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We have seen anti-treatment sentiment prevail after Andrew Wakefield’s work linking autism to treatments was published. Dozens of peer-reviewed studies kamagra tablet online have found exactly the opposite. Wakefield’s paper was retracted, and he’s been resoundingly discredited as a scientist, but the damage is done. Prior to erectile dysfunction treatment, we saw measles outbreaks reach their highest numbers since measles was all but eliminated kamagra tablet online.

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But the CDC is not alone. Our top kamagra tablet online drug regulatory agency, the U.S. Food and Drug Administration (FDA), has shown inconsistency that not only affects the general public, but everyone who is involved in health care delivery. Take Aduhelm, for instance.

Several months prior to the approval of the Alzheimer’s disease drug, kamagra tablet online a group of senior FDA officials agreed that there wasn’t enough evidence for approval of the drug. The officials said the agency should require further evidence that the drug worked the way the company said it did prior to re-review or approval. This came as a blow to patients, clinicians and researchers who were incredibly hopeful for a potential treatment of such a devastating disease that lacks therapeutic options. Despite the setback, the scientific community kamagra tablet online agreed that further clinical work should be done.

Shortly after the consensus decision by advisory members and senior scientists, the FDA controversially approved the drug with no additional clinical studies and zero acknowledgment of the lack of data behind the approval. After weeks of kamagra tablet online incredible backlash and the resignation of several key advisory members, then acting FDA commissioner Janet Woodcock made a 180-degree reversal that went from making statements expressing confidence in the agency’s decision to then supporting an independent investigation that led to the approval of the drug. That flip left the medical community dumbfounded over the decision to initially approve Aduhelm, which still defies explanation. Scientists and health care professionals have long viewed institutions such as the CDC and FDA with respect.

However, the mixed messages, and the doubt they have created in our minds signal a much kamagra tablet online deeper problem that will require innovative solutions. We are entering the third year of an infectious disease war that has killed over 800,000 Americans. At the same time, many more Americans are dying from firearm injuries, drug overdoses, suicides and delayed medical care. Health care professionals are physically and emotionally exhausted and have worked through some of the darkest periods of this kamagra—whether it’s the lack of protective personal equipment (PPE), the personal kamagra tablet online sacrifice of their lives, or putting their families and loved ones at risk for contracting the kamagra.

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The leaders of government agencies and the public sector, including public and for-profit health care and research institutions, should create a rapid response system that evaluates the newest data around erectile dysfunction treatment and quickly provides feedback to best ensure the most consistent, evidence-based messaging is released to the health care workforce and the general public. Similar to the peer review process, elevating the evaluation of significant policies kamagra tablet online to a larger peer group is a strategy that may be useful. It’s also important to include frontline healthcare workers in these conversations. They are closest to the struggle and often know what the best solutions are.

As an important group of trusted professionals, public health practitioners and scientific organizations must do a better job at kamagra tablet online communicating our message, especially during a crisis where the landscape is rapidly changing. All of us are prone to mistakes, and while no one expects any individual or organization to be perfect, setting consistent expectations during a public health crisis is critical. The strategy and approach in how we communicate the message, is just as important as having the right idea..

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These and other developments towards restoring hearing in the scientific community are exciting but still preliminary. Steroids for kamagra oral jelly paypal sudden hearing loss For people who experience sudden hearing loss, steroids injected into the ear (or taken orally) can treat inflammation. If given promptly, steroids can sometimes help a person regain their hearing fully. Alternative remedies for hearing loss Alternative medicine is big business in the U.S. These days, essential oils in particular have been touted as "natural" remedies for everything from anxiety and kamagra oral jelly paypal depression to allergies and the flu kamagra.

We have even seen some claims about essential oils that help hearing loss and tinnitus. The research doesn't bear this out. We've also looked kamagra oral jelly paypal into the claims that acupuncture might help hearing loss. After reviewing the research, we found little to indicate acupuncture will restore lost hearing. It may reduce anxiety, though, which is important for people with tinnitus.

One remedy kamagra oral jelly paypal that does have some evidence behind it?. CBD oil. While the studies were small and preliminary, researchers found that CBD oil may help with tinnitus relief. A bone-anchored kamagra oral jelly paypal hearing system involvessurgery to implant a metal device intothe mastoid bone behind the ear. Surgeries for hearing loss In some cases, surgery may help improve hearing but they are rarely considered a first-line treatment in adults with mild to moderate hearing loss.

Common surgeries performed on the ears include. Cochlear implants A cochlear implant is a surgery for adults, and, more commonly, children who have kamagra oral jelly paypal no, or very little, residual hearing. It works by bypassing a severely damaged cochlea to send electrical impulses to the hearing nerves that can be translated by the brain as meaningful sound. If you have significant hearing loss, you may wonder if you can just skip hearing aids and go right to an implant. Before someone kamagra oral jelly paypal (who still has some hearing) can be considered a candidate, they must have tried hearing aids without success.

Good news. Seniors can get cochlear implants, too. Bone-anchored hearing systems kamagra oral jelly paypal Bone-anchored hearing systems, also called BAHAs, are surgically implanted devices. They're typically used for people who have hearing loss in one ear, or who have outer ear or ear canal malformations, such as microtia. Surgery involves implanting a small metal device into the mastoid bone behind the ear.

After the kamagra oral jelly paypal area has healed, the ENT or an audiologist fits the wearer with a device similar to a hearing aid hat fits snugly over the bone implant. This devices converts sound to vibrations, which stimulate sound waves in the inner ear via the implant. Stapedectomy Conductive hearing loss can result from the tiny bones of the middle ear becoming immobile and ineffective for transmitting sound to the inner ear. Otosclerosis is a common reason this can happen, and kamagra oral jelly paypal it results from extra bone material forming around the footplate of the stapes, the innermost bone of the middle ear. A stapedectomy is a procedure in which the stapes is replaced with a prosthesis.

This surgery is reserved for specific medical conditions that create conductive hearing loss and is not used for sensorineural hearing loss. Insertion of middle ear tubes Considered a minor surgery, this outpatient procedure can be done right in the ENT's kamagra oral jelly paypal (otolaryngologist) office. Middle ear, or pressure equalization (PE) tubes, are used to alleviate pressure buildup behind the eardrum in cases of middle ear or fluid that cannot drain through the Eustachian tubes. This surgery isn't used to restore hearing per se, but it does help relieve fluid buildup that may be causing temporary hearing loss. Children are the most common kamagra oral jelly paypal candidates for PE tubes because their not-yet-developed ear anatomy makes ear s more prevalent than in adults.

Middle ear s and fluid buildup usually cause some temporary conductive hearing loss that will improve post-surgery. Bottom line There are few "quick fixes" for hearing loss. In most cases, hearing aids will be the kamagra oral jelly paypal recommended treatment. If you suspect you have hearing loss and need help, find a clinic in our directory and make the call.Doorbells, washing machines, refrigerators, and sound systems have smartphone apps these days. So it should come as no surprise that many hearing aids also have apps associated with them.

Most hearing aids come with smartphoneapps to give kamagra oral jelly paypal users more control over theirdevices. €œApps are how we live our lives now,” says Shannon Basham, AuD, senior director of audiology and education at Phonak, which makes hearing aid solutions, including a hearing aid app. Apps can make something strange and new—wearing hearing aids—feel familiar, she says. They offer a wide range of useful features, and perhaps most importantly, hearing aid apps help people who wear the devices to kamagra oral jelly paypal personalize their experience, which can be deeply empowering, Basham says. “Every single person who needs a hearing aid, their hearing loss and their communication needs are so individualized,” Basham says.

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Through Bluetooth, these apps connect with the hearing aids a person is wearing, and are available on both Apple and Android phones. What features are available through apps?. Different apps offer different features, kamagra oral jelly paypal of course. But some of the features you can expect to see on many hearing aid apps include the following. You can adjust the hearing aid.

€œHearing aids are remarkable in that they can read the soundscenes and automatically adjust to the kamagra oral jelly paypal noise levels in the room,” Basham says. But if you want the flexibility to adjust the volume, treble, bass, and so on even further, apps allow you to do so through your smartphone—which can be incredibly discrete—rather than reaching up to your ear to manually push buttons. Doing this, Basham says, is analogous to adjusting your stereo settings. The homescreen for the Oticon ON appthat can be used with Oticon kamagra oral jelly paypal hearing aids. You can create and save personalized hearing programs.

For instance, if you often find hearing in a particular cafe particularly challenging, you can adjust the levels to suit your hearing, and then save it so that you can use it again the next time you’re in that environment. Some hearing kamagra oral jelly paypal aids may come with baked-in programs from your hearing care provider, as well as ones designed to mask tinnitus. You can check the device’s status. Apps often allow you to check on the battery life of your hearing aids—that way, you’ll know when they need to be recharged or replaced. Many apps kamagra oral jelly paypal also offer a “find my hearing aid” type feature to locate the device.

Apps often provide statistics—so you can see, for instance, how many hours you’ve had the hearing aids on per day/week/month. Your hearing aids can connect directly to audio. With apps, you can connect directly to audio sources, so you can stream music and TV, along with phone calls, straight to your hearing kamagra oral jelly paypal aids. You can connect to the Internet of Things. So many daily tasks travel together.

For instance, in kamagra oral jelly paypal the morning, people turn on their hearing aids, make coffee, take a shower. At night, they turn off hearing aids, turn off lights, set the alarm. You can use smart technology and IFTTT ("if this, then that") services to trigger certain events to occur when you turn your hearing aids on and off. You can review instructions and kamagra oral jelly paypal the manual. If you’re new to your hearing aids, the apps can help steer you through basic functionality—handy if you happen to need to look up how to change the batteries when you’re far from home.

You can keep a hearing journal. During check-ins, your audiologist will ask you to share about times when your hearing aid kamagra oral jelly paypal didn’t help you to your satisfaction. But remembering—and describing—these moments can be tricky. Some apps offer the ability to keep notes, so you can pinpoint the situations where you weren’t able to hear. €œThese apps allow us to get a snapshot kamagra oral jelly paypal in time of the user experience,” Basham says.

This information, in turn, can be passed along to the hearing aid professional—so that instead of verbally describing the sounds of the restaurant, the audiologist can more fully understand the soundscape. You can communicate with your audiologist or hearing care professional. Through the app, your hearing care provider can do a hearing test, adjust hearing aids, fit the hearing aid, and so much more, says Basham kamagra oral jelly paypal. €œIt’s really phenomenal during this period where people can’t be physically present for appointments,” she says. And there’s so much more that will come in future upgrades of apps.

There are no FDA-approved drugs kamagra tablet online that restore hearing loss. Another emerging area of research is gene therapy for hearing loss, though it could be many years before human testing begins. These and other developments towards restoring hearing in the scientific community are exciting but still preliminary. Steroids for sudden hearing loss For people who experience sudden hearing loss, steroids injected into the ear kamagra tablet online (or taken orally) can treat inflammation. If given promptly, steroids can sometimes help a person regain their hearing fully.

Alternative remedies for hearing loss Alternative medicine is big business in the U.S. These days, essential oils in particular have been touted as "natural" kamagra tablet online remedies for everything from anxiety and depression to allergies and the flu kamagra. We have even seen some claims about essential oils that help hearing loss and tinnitus. The research doesn't bear this out. We've also looked into the claims that acupuncture might kamagra tablet online help hearing loss.

After reviewing the research, we found little to indicate acupuncture will restore lost hearing. It may reduce anxiety, though, which is important for people with tinnitus. One remedy that does kamagra tablet online have some evidence behind it?. CBD oil. While the studies were small and preliminary, researchers found that CBD oil may help with tinnitus relief.

A bone-anchored hearing system involvessurgery to implant a metal device intothe mastoid bone behind kamagra tablet online the ear. Surgeries for hearing loss In some cases, surgery may help improve hearing but they are rarely considered a first-line treatment in adults with mild to moderate hearing loss. Common surgeries performed on the ears include. Cochlear implants A cochlear implant is a surgery for adults, and, more commonly, children who have no, or kamagra tablet online very little, residual hearing. It works by bypassing a severely damaged cochlea to send electrical impulses to the hearing nerves that can be translated by the brain as meaningful sound.

If you have significant hearing loss, you may wonder if you can just skip hearing aids and go right to an implant. Before someone (who still has some hearing) kamagra tablet online can be considered a candidate, they must have tried hearing aids without success. Good news. Seniors can get cochlear implants, too. Bone-anchored hearing systems Bone-anchored hearing systems, also called BAHAs, are surgically kamagra tablet online implanted devices.

They're typically used for people who have hearing loss in one ear, or who have outer ear or ear canal malformations, such as microtia. Surgery involves implanting a small metal device into the mastoid bone behind the ear. After the area has kamagra tablet online healed, the ENT or an audiologist fits the wearer with a device similar to a hearing aid hat fits snugly over the bone implant. This devices converts sound to vibrations, which stimulate sound waves in the inner ear via the implant. Stapedectomy Conductive hearing loss can result from the tiny bones of the middle ear becoming immobile and ineffective for transmitting sound to the inner ear.

Otosclerosis is a common kamagra tablet online reason this can happen, and it results from extra bone material forming around the footplate of the stapes, the innermost bone of the middle ear. A stapedectomy is a procedure in which the stapes is replaced with a prosthesis. This surgery is reserved for specific medical conditions that create conductive hearing loss and is not used for sensorineural hearing loss. Insertion of middle ear tubes Considered a minor surgery, this outpatient procedure kamagra tablet online can be done right in the ENT's (otolaryngologist) office. Middle ear, or pressure equalization (PE) tubes, are used to alleviate pressure buildup behind the eardrum in cases of middle ear or fluid that cannot drain through the Eustachian tubes.

This surgery isn't used to restore hearing per se, but it does help relieve fluid buildup that may be causing temporary hearing loss. Children are kamagra tablet online the most common candidates for PE tubes because their not-yet-developed ear anatomy makes ear s more prevalent than in adults. Middle ear s and fluid buildup usually cause some temporary conductive hearing loss that will improve post-surgery. Bottom line There are few "quick fixes" for hearing loss. In most cases, hearing aids will kamagra tablet online be the recommended treatment.

If you suspect you have hearing loss and need help, find a clinic in our directory and make the call.Doorbells, washing machines, refrigerators, and sound systems have smartphone apps these days. So it should come as no surprise that many hearing aids also have apps associated with them. Most hearing aids come with smartphoneapps to give users more kamagra tablet online control over theirdevices. €œApps are how we live our lives now,” says Shannon Basham, AuD, senior director of audiology and education at Phonak, which makes hearing aid solutions, including a hearing aid app. Apps can make something strange and new—wearing hearing aids—feel familiar, she says.

They offer a wide range of useful features, and perhaps most importantly, hearing aid apps kamagra tablet online help people who wear the devices to personalize their experience, which can be deeply empowering, Basham says. “Every single person who needs a hearing aid, their hearing loss and their communication needs are so individualized,” Basham says. Apps allow people to tailor their listening experience, instead of trying to fit into a cookie-cutter situation, she says. What kamagra tablet online is a hearing aid app?. There are a number of hearing-related apps available for smartphones, such as decibel-measuring apps that tell you how loud it is around you.

Other apps can perform a basic screening test to measure your hearing, and some let you "train" your brain with hearing exercises. But for people who wear hearing aids—or who kamagra tablet online are considering getting fitted for hearing aids—the most relevant category is apps that are made by hearing aid manufacturers. Through Bluetooth, these apps connect with the hearing aids a person is wearing, and are available on both Apple and Android phones. What features are available through apps?. Different apps offer different features, kamagra tablet online of course.

But some of the features you can expect to see on many hearing aid apps include the following. You can adjust the hearing aid. €œHearing aids are remarkable in that they can read the soundscenes and automatically adjust to the noise kamagra tablet online levels in the room,” Basham says. But if you want the flexibility to adjust the volume, treble, bass, and so on even further, apps allow you to do so through your smartphone—which can be incredibly discrete—rather than reaching up to your ear to manually push buttons. Doing this, Basham says, is analogous to adjusting your stereo settings.

The homescreen for the kamagra tablet online Oticon ON appthat can be used with Oticon hearing aids. You can create and save personalized hearing programs. For instance, if you often find hearing in a particular cafe particularly challenging, you can adjust the levels to suit your hearing, and then save it so that you can use it again the next time you’re in that environment. Some hearing aids may come with baked-in programs from your hearing care provider, as well as ones designed kamagra tablet online to mask tinnitus. You can check the device’s status.

Apps often allow you to check on the battery life of your hearing aids—that way, you’ll know when they need to be recharged or replaced. Many apps kamagra tablet online also offer a “find my hearing aid” type feature to locate the device. Apps often provide statistics—so you can see, for instance, how many hours you’ve had the hearing aids on per day/week/month. Your hearing aids can connect directly to audio. With apps, you can connect kamagra tablet online directly to audio sources, so you can stream music and TV, along with phone calls, straight to your hearing aids.

You can connect to the Internet of Things. So many daily tasks travel together. For instance, kamagra tablet online in the morning, people turn on their hearing aids, make coffee, take a shower. At night, they turn off hearing aids, turn off lights, set the alarm. You can use smart technology and IFTTT ("if this, then that") services to trigger certain events to occur when you turn your hearing aids on and off.

You can review instructions kamagra tablet online and the manual. If you’re new to your hearing aids, the apps can help steer you through basic functionality—handy if you happen to need to look up how to change the batteries when you’re far from home. You can keep a hearing journal. During check-ins, kamagra tablet online your audiologist will ask you to share about times when your hearing aid didn’t help you to your satisfaction. But remembering—and describing—these moments can be tricky.

Some apps offer the ability to keep notes, so you can pinpoint the situations where you weren’t able to hear. €œThese apps allow us to get a kamagra tablet online snapshot in time of the user experience,” Basham says. This information, in turn, can be passed along to the hearing aid professional—so that instead of verbally describing the sounds of the restaurant, the audiologist can more fully understand the soundscape. You can communicate with your audiologist or hearing care professional. Through the app, your hearing care provider can do a hearing test, adjust hearing aids, fit the hearing kamagra tablet online aid, and so much more, says Basham.

€œIt’s really phenomenal during this period where people can’t be physically present for appointments,” she says. And there’s so much more that will come in future upgrades of apps. Just as hearing aids have made leaps forward in functionality, so too will the apps. €œWith regard to hearing aid tech we’re just scratching the surface of what is possible,” Basham says. More content on apps and hearing loss.

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How to http://headsnap.net/photo-gallery/ cite can i get kamagra over the counter this article:Singh OP. Psychiatry research in India. Closing the can i get kamagra over the counter research gap. Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science. Research in can i get kamagra over the counter India in general and medical research in particular is always being criticized for lack of innovation and originality required for the delivery of health services suitable to Indian conditions.

Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism. It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, can i get kamagra over the counter The ICMR could not even list one practical application of its hundreds of research papers published in various national and international research journals which helped cure any disease, or diagnose it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of ICMR is not up to the mark and is not commensurate with the magnitude of the disease burden in India. According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases. The research conducted elsewhere may not be generalized to the Indian population owing can i get kamagra over the counter to differences in biology, health-care systems, health practices, culture, and socioeconomic standards.

Questions which are pertinent and specific to the Indian context may not be answered and will remain understudied. One of the vital elements in improving this situation is the need for relevant research base that would equip policymakers to take informed health policy decisions.The Parliamentary Standing Committee on Health and Family Welfare in the 100th report on Demand for Grants (2017–2018) of the Department of Health Research observed that “the biomedical research output needs to be augmented substantially to cater to the health challenges faced by the country.”[1]Among the various reasons, lack of fund, infrastructure, and resources is the prime cause which is glaringly evident from the inadequate budget allocation for biomedical research. While ICMR has a budget of 232 million dollars per year on health research, it is zilch in comparison to the annual budget expenditure of the National Institute of can i get kamagra over the counter Health, USA, on biomedical research which is 32 billion dollars.The lacuna of quality research is not merely due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of the factors which need our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field can i get kamagra over the counter of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research in India are conducted in medical institutions.

The majority of these are done as thesis submission for fulfillment of the requirement of PG degree. From 2015 onward, publication of papers had been made an obligatory requirement for promotion of can i get kamagra over the counter faculty to higher posts. Although it offered a unique opportunity for training of residents and stimulus for research, it failed to translate into production of quality research work as thesis was limited by time and it had to be done with other clinical and academic duties.While the top four medical colleges, namely AIIMS, New Delhi. PGIMER, Chandigarh. CMC, Vellore can i get kamagra over the counter.

And SGIMS, Lucknow are among the top ten medical institutions in terms of publication in peer-reviewed journals, around 332 (57.3%) medical colleges have no research paper published in a decade between 2004 and 2014.[2]The research in psychiatry is realistically dominated by major research institutes which are doing commendable work, but there is a substantial lack of contemporary research originating from other centers. Dr. Chittaranjan Andrade (NIMHANS, Bengaluru) and Dr. K Jacob (CMC, Vellore) recently figured in the list of top 2% psychiatry researchers in the world from India in psychiatry.[3] Most of the research conducted in the field of psychiatry are limited to caregivers' burden, pathways of care, and other topics which can be done in limited resources available to psychiatry departments. While all these areas of work are important in providing proper care and treatment, there is overabundance of research in these areas.The Government of India is aggressively looking forward to enhancing the quality of research and is embarking on an ambitious project of purchasing all major journals and providing free access to universities across the country.

The India Genome Project started in January, 2020, is a good example of collaboration. While all these actions are laudable, a lot more needs to be done. Following are some measures which will reduce the gap:Research proposals at the level of protocol can be guided and mentored by institutes. Academic committees of different zones and journals can help in this endeavorBreaking the cubicles by establishing a collaboration between medical colleges and various institutes. While there is a lack of resources available in individual departments, there are universities and institutes with excellent infrastructure.

They are not aware of the requirements of the field of psychiatry and research questions. Creation of an alliance will enhance the quality of research work. Some of such institutes include Centre for Neuroscience, Indian Institute of Science, Bengaluru. CSIR-Institute of Genomics and Integrative Biology, New Delhi. And National Institute of Biomedical Genomics, KalyaniInitiation and establishment of interactive and stable relationships between basic scientists and clinical and technological experts will enhance the quality of research work and will lead to translation of basic biomedical research into real-time applications.

For example, work on artificial intelligence for mental health. Development of Apps by IITs. Genome India Project by the Government of India, genomic institutes, and social science and economic institutes working in the field of various aspects of mental healthUtilization of underutilized, well-equipped biotechnological labs of nonmedical colleges for furthering biomedical researchMedical colleges should collaborate with various universities which have labs providing testing facilities such as spectroscopy, fluoroscopy, gamma camera, scintigraphy, positron emission tomography, single photon emission computed tomography, and photoacoustic imagingCreating an interactive, interdepartmental, intradepartmental, and interinstitutional partnershipBy developing a healthy and ethical partnership with industries for research and development of new drugs and interventions.Walking the talk – the psychiatric fraternity needs to be proactive and rather than lamenting about the lack of resource, we should rise to the occasion and come out with innovative and original research proposals. With the implementation of collaborative approach, we can not only enhance and improve the quality of our research but to an extent also mitigate the effects of resource crunch and come up as a leader in the field of biomedical research. References 1.2.Nagoba B, Davane M.

Current status of medical research in India. Where are we?. Walawalkar Int Med J 2017;4:66-71. 3.Ioannidis JP, Boyack KW, Baas J. Updated science-wide author databases of standardized citation indicators.

PLoS Biol 2020;18:e3000918. Correspondence Address:Dr. Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/indianjpsychiatry.indianjpsychiatry_1362_2Abstract Background. The burden of mental illness among the scheduled tribe (ST) population in India is not known clearly.Aim. The aim was to identify and appraise mental health research studies on ST population in India and collate such data to inform future research.Materials and Methods. Studies published between January 1980 and December 2018 on STs by following exclusion and inclusion criteria were selected for analysis. PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar were systematically searched to identify relevant studies.

Quality of the included studies was assessed using an appraisal tool to assess the quality of cross-sectional studies and Critical Appraisal Checklist developed by Critical Appraisal Skills Programme. Studies were summarized and reported descriptively.Results. Thirty-two relevant studies were found and included in the review. Studies were categorized into the following three thematic areas. Alcohol and substance use disorders, common mental disorders and sociocultural aspects, and access to mental health-care services.

Sociocultural factors play a major role in understanding and determining mental disorders.Conclusion. This study is the first of its kind to review research on mental health among the STs. Mental health research conducted among STs in India is limited and is mostly of low-to-moderate quality. Determinants of poor mental health and interventions for addressing them need to be studied on an urgent basis.Keywords. India, mental health, scheduled tribesHow to cite this article:Devarapalli S V, Kallakuri S, Salam A, Maulik PK.

Mental health research on scheduled tribes in India. Indian J Psychiatry 2020;62:617-30 Introduction Mental health is a highly neglected area particularly in low and middle-income countries (LMIC). Data from community-based studies showed that about 10% of people suffer from common mental disorders (CMDs) such as depression, anxiety, and somatic complaints.[1] A systematic review of epidemiological studies between 1960 and 2009 in India reported that about 20% of the adult population in the community are affected by psychiatric disorders in the community, ranging from 9.5 to 103/1000 population, with differences in case definitions, and methods of data collection, accounting for most of the variation in estimates.[2]The scheduled tribes (ST) population is a marginalized community and live in relative social isolation with poorer health indices compared to similar nontribal populations.[3] There are an estimated 90 million STs or Adivasis in India.[4] They constitute 8.6% of the total Indian population. The distribution varies across the states and union territories of India, with the highest percentage in Lakshadweep (94.8%) followed by Mizoram (94.4%). In northeastern states, they constitute 65% or more of the total population.[5] The ST communities are identified as culturally or ethnographically unique by the Indian Constitution.

They are populations with poorer health indicators and fewer health-care facilities compared to non-ST rural populations, even when within the same state, and often live in demarcated geographical areas known as ST areas.[4]As per the National Family Health Survey, 2015–2016, the health indicators such as infant mortality rate (IMR) is 44.4, under five mortality rate (U5MR) is 57.2, and anemia in women is 59.8 for STs – one of the most disadvantaged socioeconomic groups in India, which are worse compared to other populations where IMR is 40.7, U5MR is 49.7, and anemia in women among others is 53.0 in the same areas.[6] Little research is available on the health of ST population. Tribal mental health is an ignored and neglected area in the field of health-care services. Further, little data are available about the burden of mental disorders among the tribal communities. Health research on tribal populations is poor, globally.[7] Irrespective of the data available, it is clear that they have worse health indicators and less access to health facilities.[8] Even less is known about the burden of mental disorders in ST population. It is also found that the traditional livelihood system of the STs came into conflict with the forces of modernization, resulting not only in the loss of customary rights over the livelihood resources but also in subordination and further, developing low self-esteem, causing great psychological stress.[4] This community has poor health infrastructure and even less mental health resources, and the situation is worse when compared to other communities living in similar areas.[9],[10]Only 15%–25% of those affected with mental disorders in LMICs receive any treatment for their mental illness,[11] resulting in a large “treatment gap.”[12] Treatment gaps are more in rural populations,[13] especially in ST communities in India, which have particularly poor infrastructure and resources for health-care delivery in general, and almost no capacity for providing mental health care.[14]The aim of this systematic review was to explore the extent and nature of mental health research on ST population in India and to identify gaps and inform future research.

Materials and Methods Search strategyWe searched major databases (PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar) and made hand searches from January 1980 to December 2018 to identify relevant literature. Hand search refers to searching through medical journals which are not indexed in the major electronic databases such as Embase, for instance, searching for Indian journals in IndMed database as most of these journals are not available in major databases. Physical search refers to searching the journals that were not available online or were not available online during the study years. We used relevant Medical Subject Heading and key terms in our search strategy, as follows. €œMental health,” “Mental disorders,” “Mental illness,” “Psychiatry,” “Scheduled Tribe” OR “Tribe” OR “Tribal Population” OR “Indigenous population,” “India,” “Psych*” (Psychiatric, psychological, psychosis).Inclusion criteriaStudies published between January 1980 and December 2018 were included.

Studies on mental disorders were included only when they focused on ST population. Both qualitative and quantitative studies on mental disorders of ST population only were included in the analysis.Exclusion criteriaStudies without any primary data and which are merely overviews and commentaries and those not focused on ST population were excluded from the analysis.Data management and analysisTwo researchers (SD and SK) initially screened the title and abstract of each record to identify relevant papers and subsequently screened full text of those relevant papers. Any disagreements between the researchers were resolved by discussion or by consulting with an adjudicator (PKM). From each study, data were extracted on objectives, study design, study population, study duration, interventions (if applicable), outcomes, and results. Quality of the included studies was assessed, independently by three researchers (SD, SK, and AS), using Critical Appraisal Checklist developed by Critical Appraisal Skills Programme (CASP).[15] After a thorough qualitative assessment, all quantitative data were generated and tabulated.

A narrative description of the studies is provided in [Table 1] using some broad categories. Results Search resultsOur search retrieved 2306 records (which included hand-searched articles), of which after removing duplicates, title and abstracts of 2278 records were screened. Of these, 178 studies were deemed as potentially relevant and were reviewed in detail. Finally, we excluded 146 irrelevant studies and 32 studies were included in the review [Figure 1].Quality of the included studiesSummary of quality assessment of the included studies is reported in [Table 2]. Overall, nine studies were of poor quality, twenty were of moderate quality, and three studies were of high quality.

The CASP shows that out of the 32 studies, the sample size of 21 studies was not representative, sample size of 7 studies was not justified, risk factors were not identified in 28 studies, methods used were not sufficiently described to repeat them in 24 studies, and nonresponse reasons were not addressed in 24 studies. The most common reasons for studies to be of poor-quality included sample size not justified. Sample is not representative. Nonresponse not addressed. Risk factors not measured correctly.

And methods used were not sufficiently described to repeat them. Studies under the moderate quality did not have a representative sample. Non-responders categories was not addressed. Risk factors were not measured correctly. And methods used were not sufficiently described to allow the study to be replicated by other researchers.The included studies covered three broad categories.

Alcohol and substance use disorders, CMD (depression, anxiety, stress, and suicide risk), socio-cultural aspects, and access to mental health services.Alcohol and substance use disordersFive studies reviewed the consumption of alcohol and opioid. In an ethnographic study conducted in three western districts in Rajasthan, 200 opium users were interviewed. Opium consumption was common among both younger and older males during nonharvest seasons. The common causes for using opium were relief of anxiety related to crop failure due to drought, stress, to get a high, be part of peers, and for increased sexual performance.[16]In a study conducted in Arunachal Pradesh involving a population of more than 5000 individuals, alcohol use was present in 30% and opium use in about 5% adults.[17] Contrary to that study, in Rajasthan, the prevalence of opium use was more in women and socioeconomic factors such as occupation, education, and marital status were associated with opium use.[16] The prevalence of opium use increased with age in both sexes, decreased with increasing education level, and increased with employment. It was observed that wages were used to buy opium.

In the entire region of Chamlang district of Arunachal Pradesh, female substance users were almost half of the males among ST population.[17] Types of substance used were tobacco, alcohol, and opium. Among tobacco users, oral tobacco use was higher than smoking. The prevalence of tobacco use was higher among males, but the prevalence of alcohol use was higher in females, probably due to increased access to homemade rice brew generally prepared by women. This study is unique in terms of finding a strong association with religion and culture with substance use.[18]Alcohol consumption among Paniyas of Wayanad district in Kerala is perceived as a male activity, with many younger people consuming it than earlier. A study concluded that alcohol consumption among them was less of a “choice” than a result of their conditions operating through different mechanisms.

In the past, drinking was traditionally common among elderly males, however the consumption pattern has changed as a significant number of younger men are now drinking. Drinking was clustered within families as fathers and sons drank together. Alcohol is easily accessible as government itself provides opportunities. Some employers would provide alcohol as an incentive to attract Paniya men to work for them.[19]In a study from Jharkhand, several ST community members cited reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement, as a reason for consuming alcohol. Societal acceptance of drinking alcohol and peer pressure, as well as high emotional problems, appeared to be the major etiology leading to higher prevalence of substance dependence in tribal communities.[20] Another study found high life time alcohol use prevalence, and the reasons mentioned were increased poverty, illiteracy, increased stress, and peer pressure.[21] A household survey from Chamlang district of Arunachal Pradesh revealed that there was a strong association between opium use and age, occupation, marital status, religion, and ethnicity among both the sexes of STs, particularly among Singhpho and Khamti.[15] The average age of onset of tobacco use was found to be 16.4 years for smoked and 17.5 years for smokeless forms in one study.[22]Common mental disorders and socio-cultural aspectsSuicide was more common among Idu Mishmi in Roing and Anini districts of Arunachal Pradesh state (14.2%) compared to the urban population in general (0.4%–4.2%).

Suicides were associated with depression, anxiety, alcoholism, and eating disorders. Of all the factors, depression was significantly high in people who attempted suicide.[24] About 5% out of 5007 people from thirty villages comprising ST suffered from CMDs in a study from West Godavari district in rural Andhra Pradesh. CMDs were defined as moderate/severe depression and/or anxiety, stress, and increased suicidal risk. Women had a higher prevalence of depression, but this may be due to the cultural norms, as men are less likely to express symptoms of depression or anxiety, which leads to underreporting. Marital status, education, and age were prominently associated with CMD.[14] In another study, gender, illiteracy, infant mortality in the household, having <3 adults living in the household, large family size with >four children, morbidity, and having two or more life events in the last year were associated with increased prevalence of CMD.[24] Urban and rural ST from the same community of Bhutias of Sikkim were examined, and it was found that the urban population experienced higher perceived stress compared to their rural counterparts.[25] Age, current use of alcohol, poor educational status, marital status, social groups, and comorbidities were the main determinants of tobacco use and nicotine dependence in a study from the Andaman and Nicobar Islands.[22] A study conducted among adolescents in the schools of rural areas of Ranchi district in Jharkhand revealed that about 5% children from the ST communities had emotional symptoms, 9.6% children had conduct problems, 4.2% had hyperactivity, and 1.4% had significant peer problems.[27] A study conducted among the female school teachers in Jharkhand examined the effects of stress, marital status, and ethnicity upon the mental health of school teachers.

The study found that among the three factors namely stress, marital status, and ethnicity, ethnicity was found to affect mental health of the school teachers most. It found a positive relationship between mental health and socioeconomic status, with an inverse relationship showing that as income increased, the prevalence of depression decreased.[28] A study among Ao-Nagas in Nagaland found that 74.6% of the population attributed mental health problems to psycho-social factors and a considerable proportion chose a psychiatrist or psychologist to overcome the problem. However, 15.4% attributed mental disorders to evil spirits. About 47% preferred to seek treatment with a psychiatrist and 25% preferred prayers. Nearly 10.6% wanted to seek the help of both the psychiatrist and prayer group and 4.4% preferred traditional healers.[28],[29] The prevalence of Down syndrome among the ST in Chikhalia in Barwani district of Madhya Pradesh was higher than that reported in overall India.

Three-fourth of the children were the first-born child. None of the parents of children with Down syndrome had consanguineous marriage or a history of Down syndrome, intellectual disability, or any other neurological disorder such as cerebral palsy and epilepsy in preceding generations. It is known that tribal population is highly impoverished and disadvantaged in several ways and suffer proportionately higher burden of nutritional and genetic disorders, which are potential factors for Down syndrome.[30]Access to mental health-care servicesIn a study in Ranchi district of Jharkhand, it was found that most people consulted faith healers rather than qualified medical practitioners. There are few mental health services in the regions.[31] Among ST population, there was less reliance and belief in modern medicine, and it was also not easily accessible, thus the health-care systems must be more holistic and take care of cultural and local health practices.[32]The Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health project was implemented in thirty ST villages in West Godavari District of Andhra Pradesh. The key objectives were to use task sharing, training of primary health workers, implementing evidence-based clinical decision support tools on a mobile platform, and providing mental health services to rural population.

The study included 238 adults suffering from CMD. During the intervention period, 12.6% visited the primary health-care doctors compared to only 0.8% who had sought any care for their mental disorders prior to the intervention. The study also found a significant reduction in the depression and anxiety scores at the end of intervention and improvements in stigma perceptions related to mental health.[14] A study in Gudalur and Pandalur Taluks of Nilgiri district from Tamil Nadu used low cost task shifting by providing community education and identifying and referring individuals with psychiatric problems as effective strategies for treating mental disorders in ST communities. Through the program, the health workers established a network within the village, which in turn helped the patients to interact with them freely. Consenting patients volunteered at the educational sessions to discuss their experience about the effectiveness of their treatment.

Community awareness programs altered knowledge and attitudes toward mental illness in the community.[33] A study in Nilgiri district, Tamil Nadu, found that the community had been taking responsibility of the patients with the system by providing treatment closer to home without people having to travel long distances to access care. Expenses were reduced by subsidizing the costs of medicine and ensuring free hospital admissions and referrals to the people.[34] A study on the impact of gender, socioeconomic status, and age on mental health of female factory workers in Jharkhand found that the ST women were more likely to face stress and hardship in life due to diverse economic and household responsibilities, which, in turn, severely affected their mental health.[35] Prevalence of mental health morbidity in a study from the Sunderbans delta found a positive relation with psycho-social stressors and poor quality of life. The health system in that remote area was largely managed by “quack doctors” and faith healers. Poverty, illiteracy, and detachment from the larger community helped reinforce superstitious beliefs and made them seek both mental and physical health care from faith healers.[36] In a study among students, it was found that children had difficulties in adjusting to both ethnic and mainstream culture.[27] Low family income, inadequate housing, poor sanitation, and unhealthy and unhygienic living conditions were some environmental factors contributing to poor physical and mental growth of children. It was observed that children who did not have such risk factors maintained more intimate relations with the family members.

Children belonging to the disadvantaged environment expressed their verbal, emotional need, blame, and harm avoidances more freely than their counterparts belonging to less disadvantaged backgrounds. Although disadvantaged children had poor interfamilial interaction, they had better relations with the members outside family, such as peers, friends, and neighbors.[37] Another study in Jharkhand found that epilepsy was higher among ST patients compared to non-ST patients.[31] Most patients among the ST are irregular and dropout rates are higher among them than the non-ST patients. Urbanization per se exerted no adverse influence on the mental health of a tribal community, provided it allowed preservation of ethnic and cultural practices. Women in the ST communities were less vulnerable to mental illness than men. This might be a reflection of their increased responsibilities and enhanced gender roles that are characteristic of women in many ST communities.[38] Data obtained using culturally relevant scales revealed that relocated Sahariya suffer a lot of mental health problems, which are partially explained by livelihood and poverty-related factors.

The loss of homes and displacement compromise mental health, especially the positive emotional well-being related to happiness, life satisfaction, optimism for future, and spiritual contentment. These are often not overcome even with good relocation programs focused on material compensation and livelihood re-establishment.[39] Discussion This systematic review is to our knowledge the first on mental health of ST population in India. Few studies on the mental health of ST were available. All attempts including hand searching were made to recover both published peer-reviewed papers and reports available on the website. Though we searched gray literature, it may be possible that it does not capture all articles.

Given the heterogeneity of the papers, it was not possible to do a meta-analysis, so a narrative review was done.The quality of the studies was assessed by CASP. The assessment shows that the research conducted on mental health of STs needs to be carried out more effectively. The above mentioned gaps need to be filled in future research by considering the resources effectively while conducting the studies. Mental and substance use disorders contribute majorly to the health disparities. To address this, one needs to deliver evidence-based treatments, but it is important to understand how far these interventions for the indigenous populations can incorporate cultural practices, which are essential for the development of mental health services.[30] Evidence has shown a disproportionate burden of suicide among indigenous populations in national and regional studies, and a global and systematic investigation of this topic has not been undertaken to date.

Previous reviews of suicide epidemiology among indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth, high-income countries, or regions such as Oceania or the Arctic.[46] The only studies in our review which provided data on suicide were in Idu Mishmi, an isolated tribal population of North-East India, and tribal communities from Sunderban delta.[24],[37] Some reasons for suicide in these populations could be the poor identification of existing mental disorders, increased alcohol use, extreme poverty leading to increased debt and hopelessness, and lack of stable employment opportunities.[24],[37] The traditional consumption pattern of alcohol has changed due to the reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement.[19],[20]Faith healers play a dominant role in treating mental disorders. There is less awareness about mental health and available mental health services and even if such knowledge is available, access is limited due to remoteness of many of these villages, and often it involves high out-of-pocket expenditure.[35] Practitioners of modern medicine can play a vital role in not only increasing awareness about mental health in the community, but also engaging with faith healers and traditional medicine practitioners to help increase their capacity to identify and manage CMDs that do not need medications and can be managed through simple “talk therapy.” Knowledge on symptoms of severe mental disorders can also help such faith healers and traditional medicine practitioners to refer cases to primary care doctors or mental health professionals.Remote settlements make it difficult for ST communities to seek mental health care. Access needs to be increased by using solutions that use training of primary health workers and nonphysician health workers, task sharing, and technology-enabled clinical decision support tools.[3] The SMART Mental Health project was delivered in the tribal areas of Andhra Pradesh using those principles and was found to be beneficial by all stakeholders.[14]Given the lack of knowledge about mental health problems among these communities, the government and nongovernmental organizations should collect and disseminate data on mental disorders among the ST communities. More research funding needs to be provided and key stakeholders should be involved in creating awareness both in the community and among policy makers to develop more projects for ST communities around mental health. Two recent meetings on tribal mental health – Round Table Meeting on Mental Health of ST Populations organized by the George Institute for Global Health, India, in 2017,[51] and the First National Conference on Tribal Mental Health organized by the Indian Psychiatric Society in Bhubaneswar in 2018 – have identified some key areas of research priority for mental health in ST communities.

A national-level policy on mental health of tribal communities or population is advocated which should be developed in consultation with key stakeholders. The Indian Psychiatric Society can play a role in coordinating research activities with support of the government which can ensure regular monitoring and dissemination of the research impact to the tribal communities. There is a need to understand how mental health symptoms are perceived in different ST communities and investigate the healing practices associated with distress/disaster/death/loss/disease. This could be done in the form of cross-sectional or cohort studies to generate proper evidence which could also include the information on prevalence, mental health morbidity, and any specific patterns associated with a specific disorder. Future research should estimate the prevalence of mental disorders in different age groups and gender, risk factors, and the influence of modernization.

Studies should develop a theoretical model to understand mental disorders and promote positive mental health within ST communities. Studies should also look at different ST communities as cultural differences exist across them, and there are also differences in socioeconomic status which impact on ability to access care.Research has shown that the impact and the benefits are amplified when research is driven by priorities that are identified by indigenous communities and involve their active participation. Their knowledge and perspectives are incorporated in processes and findings. Reporting of findings is meaningful to the communities. And indigenous groups and other key stakeholders are engaged from the outset.[47] Future research in India on ST communities should also adhere to these broad principles to ensure relevant and beneficial research, which have direct impact on the mental health of the ST communities.There is also a need to update literature related to mental health of ST population continuously.

Develop culturally appropriate validated instruments to measure mental morbidity relevant to ST population. And use qualitative research to investigate the perceptions and barriers for help-seeking behavior.[48] Conclusion The current review helps not only to collate the existing literature on the mental health of ST communities but also identify gaps in knowledge and provide some indications about the type of research that should be funded in future.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Gururaj G, Girish N, Isaac MK. Mental. Neurological and Substance abuse disorders.

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Correspondence Address:S V. Siddhardh Kumar DevarapalliGeorge Institute for Global Health, Plot No. 57, Second Floor, Corporation Bank Building, Nagarjuna Circle, Punjagutta, Hyderabad - 500 082, Telangana IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/psychiatry.IndianJPsychiatry_136_19 Figures [Figure 1] Tables [Table 1], [Table 2].

How to cite this kamagra tablet online article:Singh OP. Psychiatry research in India. Closing the kamagra tablet online research gap. Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science. Research in India in general and kamagra tablet online medical research in particular is always being criticized for lack of innovation and originality required for the delivery of health services suitable to Indian conditions.

Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism. It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list one practical application of its hundreds of research papers published in various national and international research journals which helped cure any disease, or diagnose it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of kamagra tablet online ICMR is not up to the mark and is not commensurate with the magnitude of the disease burden in India. According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases. The research conducted elsewhere may not be generalized to the Indian population owing to differences in biology, health-care systems, health practices, culture, kamagra tablet online and socioeconomic standards.

Questions which are pertinent and specific to the Indian context may not be answered and will remain understudied. One of the vital elements in improving this situation is the need for relevant research base that would equip policymakers to take informed health policy decisions.The Parliamentary Standing Committee on Health and Family Welfare in the 100th report on Demand for Grants (2017–2018) of the Department of Health Research observed that “the biomedical research output needs to be augmented substantially to cater to the health challenges faced by the country.”[1]Among the various reasons, lack of fund, infrastructure, and resources is the prime cause which is glaringly evident from the inadequate budget allocation for biomedical research. While ICMR has kamagra tablet online a budget of 232 million dollars per year on health research, it is zilch in comparison to the annual budget expenditure of the National Institute of Health, USA, on biomedical research which is 32 billion dollars.The lacuna of quality research is not merely due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of the factors which need our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due to lack of interdisciplinary technological kamagra tablet online support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research in India are conducted in medical institutions.

The majority of these are done as thesis submission for fulfillment of the requirement of PG degree. From 2015 onward, publication of papers had been made an obligatory requirement kamagra tablet online for promotion of faculty to higher posts. Although it offered a unique opportunity for training of residents and stimulus for research, it failed to translate into production of quality research work as thesis was limited by time and it had to be done with other clinical and academic duties.While the top four medical colleges, namely AIIMS, New Delhi. PGIMER, Chandigarh. CMC, Vellore kamagra tablet online.

And SGIMS, Lucknow are among the top ten medical institutions in terms of publication in peer-reviewed journals, around 332 (57.3%) medical colleges have no research paper published in a decade between 2004 and 2014.[2]The research in psychiatry is realistically dominated by major research institutes which are doing commendable work, but there is a substantial lack of contemporary research originating from other centers. Dr. Chittaranjan Andrade (NIMHANS, Bengaluru) and Dr. K Jacob (CMC, Vellore) recently figured in the list of top 2% psychiatry researchers in the world from India in psychiatry.[3] Most of the research conducted in the field of psychiatry are limited to caregivers' burden, pathways of care, and other topics which can be done in limited resources available to psychiatry departments. While all these areas of work are important in providing proper care and treatment, there is overabundance of research in these areas.The Government of India is aggressively looking forward to enhancing the quality of research and is embarking on an ambitious project of purchasing all major journals and providing free access to universities across the country.

The India Genome Project started in January, 2020, is a good example of collaboration. While all these actions are laudable, a lot more needs to be done. Following are some measures which will reduce the gap:Research proposals at the level of protocol can be guided and mentored by institutes. Academic committees of different zones and journals can help in this endeavorBreaking the cubicles by establishing a collaboration between medical colleges and various institutes. While there is a lack of resources available in individual departments, there are universities and institutes with excellent infrastructure.

They are not aware of the requirements of the field of psychiatry and research questions. Creation of an alliance will enhance the quality of research work. Some of such institutes include Centre for Neuroscience, Indian Institute of Science, Bengaluru. CSIR-Institute of Genomics and Integrative Biology, New Delhi. And National Institute of Biomedical Genomics, KalyaniInitiation and establishment of interactive and stable relationships between basic scientists and clinical and technological experts will enhance the quality of research work and will lead to translation of basic biomedical research into real-time applications.

For example, work on artificial intelligence for mental health. Development of Apps by IITs. Genome India Project by the Government of India, genomic institutes, and social science and economic institutes working in the field of various aspects of mental healthUtilization of underutilized, well-equipped biotechnological labs of nonmedical colleges for furthering biomedical researchMedical colleges should collaborate with various universities which have labs providing testing facilities such as spectroscopy, fluoroscopy, gamma camera, scintigraphy, positron emission tomography, single photon emission computed tomography, and photoacoustic imagingCreating an interactive, interdepartmental, intradepartmental, and interinstitutional partnershipBy developing a healthy and ethical partnership with industries for research and development of new drugs and interventions.Walking the talk – the psychiatric fraternity needs to be proactive and rather than lamenting about the lack of resource, we should rise to the occasion and come out with innovative and original research proposals. With the implementation of collaborative approach, we can not only enhance and improve the quality of our research but to an extent also mitigate the effects of resource crunch and come up as a leader in the field of biomedical research. References 1.2.Nagoba B, Davane M.

Current status of medical research in India. Where are we?. Walawalkar Int Med J 2017;4:66-71. 3.Ioannidis JP, Boyack KW, Baas J. Updated science-wide author databases of standardized citation indicators.

PLoS Biol 2020;18:e3000918. Correspondence Address:Dr. Om Prakash SinghAA 304, Ashabari Apartments, O/31, Baishnabghata, Patuli Township, Kolkata - 700 094, West Bengal IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/indianjpsychiatry.indianjpsychiatry_1362_2Abstract Background. The burden of mental illness among the scheduled tribe (ST) population in India is not known clearly.Aim. The aim was to identify and appraise mental health research studies on ST population in India and collate such data to inform future research.Materials and Methods. Studies published between January 1980 and December 2018 on STs by following exclusion and inclusion criteria were selected for analysis. PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar were systematically searched to identify relevant studies.

Quality of the included studies was assessed using an appraisal tool to assess the quality of cross-sectional studies and Critical Appraisal Checklist developed by Critical Appraisal Skills Programme. Studies were summarized and reported descriptively.Results. Thirty-two relevant studies were found and included in the review. Studies were categorized into the following three thematic areas. Alcohol and substance use disorders, common mental disorders and sociocultural aspects, and access to mental health-care services.

Sociocultural factors play a major role in understanding and determining mental disorders.Conclusion. This study is the first of its kind to review research on mental health among the STs. Mental health research conducted among STs in India is limited and is mostly of low-to-moderate quality. Determinants of poor mental health and interventions for addressing them need to be studied on an urgent basis.Keywords. India, mental health, scheduled tribesHow to cite this article:Devarapalli S V, Kallakuri S, Salam A, Maulik PK.

Mental health research on scheduled tribes in India. Indian J Psychiatry 2020;62:617-30 Introduction Mental health is a highly neglected area particularly in low and middle-income countries (LMIC). Data from community-based studies showed that about 10% of people suffer from common mental disorders (CMDs) such as depression, anxiety, and somatic complaints.[1] A systematic review of epidemiological studies between 1960 and 2009 in India reported that about 20% of the adult population in the community are affected by psychiatric disorders in the community, ranging from 9.5 to 103/1000 population, with differences in case definitions, and methods of data collection, accounting for most of the variation in estimates.[2]The scheduled tribes (ST) population is a marginalized community and live in relative social isolation with poorer health indices compared to similar nontribal populations.[3] There are an estimated 90 million STs or Adivasis in India.[4] They constitute 8.6% of the total Indian population. The distribution varies across the states and union territories of India, with the highest percentage in Lakshadweep (94.8%) followed by Mizoram (94.4%). In northeastern states, they constitute 65% or more of the total population.[5] The ST communities are identified as culturally or ethnographically unique by the Indian Constitution.

They are populations with poorer health indicators and fewer health-care facilities compared to non-ST rural populations, even when within the same state, and often live in demarcated geographical areas known as ST areas.[4]As per the National Family Health Survey, 2015–2016, the health indicators such as infant mortality rate (IMR) is 44.4, under five mortality rate (U5MR) is 57.2, and anemia in women is 59.8 for STs – one of the most disadvantaged socioeconomic groups in India, which are worse compared to other populations where IMR is 40.7, U5MR is 49.7, and anemia in women among others is 53.0 in the same areas.[6] Little research is available on the health of ST population. Tribal mental health is an ignored and neglected area in the field of health-care services. Further, little data are available about the burden of mental disorders among the tribal communities. Health research on tribal populations is poor, globally.[7] Irrespective of the data available, it is clear that they have worse health indicators and less access to health facilities.[8] Even less is known about the burden of mental disorders in ST population. It is also found that the traditional livelihood system of the STs came into conflict with the forces of modernization, resulting not only in the loss of customary rights over the livelihood resources but also in subordination and further, developing low self-esteem, causing great psychological stress.[4] This community has poor health infrastructure and even less mental health resources, and the situation is worse when compared to other communities living in similar areas.[9],[10]Only 15%–25% of those affected with mental disorders in LMICs receive any treatment for their mental illness,[11] resulting in a large “treatment gap.”[12] Treatment gaps are more in rural populations,[13] especially in ST communities in India, which have particularly poor infrastructure and resources for health-care delivery in general, and almost no capacity for providing mental health care.[14]The aim of this systematic review was to explore the extent and nature of mental health research on ST population in India and to identify gaps and inform future research.

Materials and Methods Search strategyWe searched major databases (PubMed, PsychINFO, Embase, Sociofile, Cinhal, and Google Scholar) and made hand searches from January 1980 to December 2018 to identify relevant literature. Hand search refers to searching through medical journals which are not indexed in the major electronic databases such as Embase, for instance, searching for Indian journals in IndMed database as most of these journals are not available in major databases. Physical search refers to searching the journals that were not available online or were not available online during the study years. We used relevant Medical Subject Heading and key terms in our search strategy, as follows. €œMental health,” “Mental disorders,” “Mental illness,” “Psychiatry,” “Scheduled Tribe” OR “Tribe” OR “Tribal Population” OR “Indigenous population,” “India,” “Psych*” (Psychiatric, psychological, psychosis).Inclusion criteriaStudies published between January 1980 and December 2018 were included.

Studies on mental disorders were included only when they focused on ST population. Both qualitative and quantitative studies on mental disorders of ST population only were included in the analysis.Exclusion criteriaStudies without any primary data and which are merely overviews and commentaries and those not focused on ST population were excluded from the analysis.Data management and analysisTwo researchers (SD and SK) initially screened the title and abstract of each record to identify relevant papers and subsequently screened full text of those relevant papers. Any disagreements between the researchers were resolved by discussion or by consulting with an adjudicator (PKM). From each study, data were extracted on objectives, study design, study population, study duration, interventions (if applicable), outcomes, and results. Quality of the included studies was assessed, independently by three researchers (SD, SK, and AS), using Critical Appraisal Checklist developed by Critical Appraisal Skills Programme (CASP).[15] After a thorough qualitative assessment, all quantitative data were generated and tabulated.

A narrative description of the studies is provided in [Table 1] using some broad categories. Results Search resultsOur search retrieved 2306 records (which included hand-searched articles), of which after removing duplicates, title and abstracts of 2278 records were screened. Of these, 178 studies were deemed as potentially relevant and were reviewed in detail. Finally, we excluded 146 irrelevant studies and 32 studies were included in the review [Figure 1].Quality of the included studiesSummary of quality assessment of the included studies is reported in [Table 2]. Overall, nine studies were of poor quality, twenty were of moderate quality, and three studies were of high quality.

The CASP shows that out of the 32 studies, the sample size of 21 studies was not representative, sample size of 7 studies was not justified, risk factors were not identified in 28 studies, methods used were not sufficiently described to repeat them in 24 studies, and nonresponse reasons were not addressed in 24 studies. The most common reasons for studies to be of poor-quality included sample size not justified. Sample is not representative. Nonresponse not addressed. Risk factors not measured correctly.

And methods used were not sufficiently described to repeat them. Studies under the moderate quality did not have a representative sample. Non-responders categories was not addressed. Risk factors were not measured correctly. And methods used were not sufficiently described to allow the study to be replicated by other researchers.The included studies covered three broad categories.

Alcohol and substance use disorders, CMD (depression, anxiety, stress, and suicide risk), socio-cultural aspects, and access to mental health services.Alcohol and substance use disordersFive studies reviewed the consumption of alcohol and opioid. In an ethnographic study conducted in three western districts in Rajasthan, 200 opium users were interviewed. Opium consumption was common among both younger and older males during nonharvest seasons. The common causes for using opium were relief of anxiety related to crop failure due to drought, stress, to get a high, be part of peers, and for increased sexual performance.[16]In a study conducted in Arunachal Pradesh involving a population of more than 5000 individuals, alcohol use was present in 30% and opium use in about 5% adults.[17] Contrary to that study, in Rajasthan, the prevalence of opium use was more in women and socioeconomic factors such as occupation, education, and marital status were associated with opium use.[16] The prevalence of opium use increased with age in both sexes, decreased with increasing education level, and increased with employment. It was observed that wages were used to buy opium.

In the entire region of Chamlang district of Arunachal Pradesh, female substance users were almost half of the males among ST population.[17] Types of substance used were tobacco, alcohol, and opium. Among tobacco users, oral tobacco use was higher than smoking. The prevalence of tobacco use was higher among males, but the prevalence of alcohol use was higher in females, probably due to increased access to homemade rice brew generally prepared by women. This study is unique in terms of finding a strong association with religion and culture with substance use.[18]Alcohol consumption among Paniyas of Wayanad district in Kerala is perceived as a male activity, with many younger people consuming it than earlier. A study concluded that alcohol consumption among them was less of a “choice” than a result of their conditions operating through different mechanisms.

In the past, drinking was traditionally common among elderly males, however the consumption pattern has changed as a significant number of younger men are now drinking. Drinking was clustered within families as fathers and sons drank together. Alcohol is easily accessible as government itself provides opportunities. Some employers would provide alcohol as an incentive to attract Paniya men to work for them.[19]In a study from Jharkhand, several ST community members cited reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement, as a reason for consuming alcohol. Societal acceptance of drinking alcohol and peer pressure, as well as high emotional problems, appeared to be the major etiology leading to higher prevalence of substance dependence in tribal communities.[20] Another study found high life time alcohol use prevalence, and the reasons mentioned were increased poverty, illiteracy, increased stress, and peer pressure.[21] A household survey from Chamlang district of Arunachal Pradesh revealed that there was a strong association between opium use and age, occupation, marital status, religion, and ethnicity among both the sexes of STs, particularly among Singhpho and Khamti.[15] The average age of onset of tobacco use was found to be 16.4 years for smoked and 17.5 years for smokeless forms in one study.[22]Common mental disorders and socio-cultural aspectsSuicide was more common among Idu Mishmi in Roing and Anini districts of Arunachal Pradesh state (14.2%) compared to the urban population in general (0.4%–4.2%).

Suicides were associated with depression, anxiety, alcoholism, and eating disorders. Of all the factors, depression was significantly high in people who attempted suicide.[24] About 5% out of 5007 people from thirty villages comprising ST suffered from CMDs in a study from West Godavari district in rural Andhra Pradesh. CMDs were defined as moderate/severe depression and/or anxiety, stress, and increased suicidal risk. Women had a higher prevalence of depression, but this may be due to the cultural norms, as men are less likely to express symptoms of depression or anxiety, which leads to underreporting. Marital status, education, and age were prominently associated with CMD.[14] In another study, gender, illiteracy, infant mortality in the household, having <3 adults living in the household, large family size with >four children, morbidity, and having two or more life events in the last year were associated with increased prevalence of CMD.[24] Urban and rural ST from the same community of Bhutias of Sikkim were examined, and it was found that the urban population experienced higher perceived stress compared to their rural counterparts.[25] Age, current use of alcohol, poor educational status, marital status, social groups, and comorbidities were the main determinants of tobacco use and nicotine dependence in a study from the Andaman and Nicobar Islands.[22] A study conducted among adolescents in the schools of rural areas of Ranchi district in Jharkhand revealed that about 5% children from the ST communities had emotional symptoms, 9.6% children had conduct problems, 4.2% had hyperactivity, and 1.4% had significant peer problems.[27] A study conducted among the female school teachers in Jharkhand examined the effects of stress, marital status, and ethnicity upon the mental health of school teachers.

The study found that among the three factors namely stress, marital status, and ethnicity, ethnicity was found to affect mental health of the school teachers most. It found a positive relationship between mental health and socioeconomic status, with an inverse relationship showing that as income increased, the prevalence of depression decreased.[28] A study among Ao-Nagas in Nagaland found that 74.6% of the population attributed mental health problems to psycho-social factors and a considerable proportion chose a psychiatrist or psychologist to overcome the problem. However, 15.4% attributed mental disorders to evil spirits. About 47% preferred to seek treatment with a psychiatrist and 25% preferred prayers. Nearly 10.6% wanted to seek the help of both the psychiatrist and prayer group and 4.4% preferred traditional healers.[28],[29] The prevalence of Down syndrome among the ST in Chikhalia in Barwani district of Madhya Pradesh was higher than that reported in overall India.

Three-fourth of the children were the first-born child. None of the parents of children with Down syndrome had consanguineous marriage or a history of Down syndrome, intellectual disability, or any other neurological disorder such as cerebral palsy and epilepsy in preceding generations. It is known that tribal population is highly impoverished and disadvantaged in several ways and suffer proportionately higher burden of nutritional and genetic disorders, which are potential factors for Down syndrome.[30]Access to mental health-care servicesIn a study in Ranchi district of Jharkhand, it was found that most people consulted faith healers rather than qualified medical practitioners. There are few mental health services in the regions.[31] Among ST population, there was less reliance and belief in modern medicine, and it was also not easily accessible, thus the health-care systems must be more holistic and take care of cultural and local health practices.[32]The Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health project was implemented in thirty ST villages in West Godavari District of Andhra Pradesh. The key objectives were to use task sharing, training of primary health workers, implementing evidence-based clinical decision support tools on a mobile platform, and providing mental health services to rural population.

The study included 238 adults suffering from CMD. During the intervention period, 12.6% visited the primary health-care doctors compared to only 0.8% who had sought any care for their mental disorders prior to the intervention. The study also found a significant reduction in the depression and anxiety scores at the end of intervention and improvements in stigma perceptions related to mental health.[14] A study in Gudalur and Pandalur Taluks of Nilgiri district from Tamil Nadu used low cost task shifting by providing community education and identifying and referring individuals with psychiatric problems as effective strategies for treating mental disorders in ST communities. Through the program, the health workers established a network within the village, which in turn helped the patients to interact with them freely. Consenting patients volunteered at the educational sessions to discuss their experience about the effectiveness of their treatment.

Community awareness programs altered knowledge and attitudes toward mental illness in the community.[33] A study in Nilgiri district, Tamil Nadu, found that the community had been taking responsibility of the patients with the system by providing treatment closer to home without people having to travel long distances to access care. Expenses were reduced by subsidizing the costs of medicine and ensuring free hospital admissions and referrals to the people.[34] A study on the impact of gender, socioeconomic status, and age on mental health of female factory workers in Jharkhand found that the ST women were more likely to face stress and hardship in life due to diverse economic and household responsibilities, which, in turn, severely affected their mental health.[35] Prevalence of mental health morbidity in a study from the Sunderbans delta found a positive relation with psycho-social stressors and poor quality of life. The health system in that remote area was largely managed by “quack doctors” and faith healers. Poverty, illiteracy, and detachment from the larger community helped reinforce superstitious beliefs and made them seek both mental and physical health care from faith healers.[36] In a study among students, it was found that children had difficulties in adjusting to both ethnic and mainstream culture.[27] Low family income, inadequate housing, poor sanitation, and unhealthy and unhygienic living conditions were some environmental factors contributing to poor physical and mental growth of children. It was observed that children who did not have such risk factors maintained more intimate relations with the family members.

Children belonging to the disadvantaged environment expressed their verbal, emotional need, blame, and harm avoidances more freely than their counterparts belonging to less disadvantaged backgrounds. Although disadvantaged children had poor interfamilial interaction, they had better relations with the members outside family, such as peers, friends, and neighbors.[37] Another study in Jharkhand found that epilepsy was higher among ST patients compared to non-ST patients.[31] Most patients among the ST are irregular and dropout rates are higher among them than the non-ST patients. Urbanization per se exerted no adverse influence on the mental health of a tribal community, provided it allowed preservation of ethnic and cultural practices. Women in the ST communities were less vulnerable to mental illness than men. This might be a reflection of their increased responsibilities and enhanced gender roles that are characteristic of women in many ST communities.[38] Data obtained using culturally relevant scales revealed that relocated Sahariya suffer a lot of mental health problems, which are partially explained by livelihood and poverty-related factors.

The loss of homes and displacement compromise mental health, especially the positive emotional well-being related to happiness, life satisfaction, optimism for future, and spiritual contentment. These are often not overcome even with good relocation programs focused on material compensation and livelihood re-establishment.[39] Discussion This systematic review is to our knowledge the first on mental health of ST population in India. Few studies on the mental health of ST were available. All attempts including hand searching were made to recover both published peer-reviewed papers and reports available on the website. Though we searched gray literature, it may be possible that it does not capture all articles.

Given the heterogeneity of the papers, it was not possible to do a meta-analysis, so a narrative review was done.The quality of the studies was assessed by CASP. The assessment shows that the research conducted on mental health of STs needs to be carried out more effectively. The above mentioned gaps need to be filled in future research by considering the resources effectively while conducting the studies. Mental and substance use disorders contribute majorly to the health disparities. To address this, one needs to deliver evidence-based treatments, but it is important to understand how far these interventions for the indigenous populations can incorporate cultural practices, which are essential for the development of mental health services.[30] Evidence has shown a disproportionate burden of suicide among indigenous populations in national and regional studies, and a global and systematic investigation of this topic has not been undertaken to date.

Previous reviews of suicide epidemiology among indigenous populations have tended to be less comprehensive or not systematic, and have often focused on subpopulations such as youth, high-income countries, or regions such as Oceania or the Arctic.[46] The only studies in our review which provided data on suicide were in Idu Mishmi, an isolated tribal population of North-East India, and tribal communities from Sunderban delta.[24],[37] Some reasons for suicide in these populations could be the poor identification of existing mental disorders, increased alcohol use, extreme poverty leading to increased debt and hopelessness, and lack of stable employment opportunities.[24],[37] The traditional consumption pattern of alcohol has changed due to the reasons associated with social enhancement and coping with distressing emotions rather than individual enhancement.[19],[20]Faith healers play a dominant role in treating mental disorders. There is less awareness about mental health and available mental health services and even if such knowledge is available, access is limited due to remoteness of many of these villages, and often it involves high out-of-pocket expenditure.[35] Practitioners of modern medicine can play a vital role in not only increasing awareness about mental health in the community, but also engaging with faith healers and traditional medicine practitioners to help increase their capacity to identify and manage CMDs that do not need medications and can be managed through simple “talk therapy.” Knowledge on symptoms of severe mental disorders can also help such faith healers and traditional medicine practitioners to refer cases to primary care doctors or mental health professionals.Remote settlements make it difficult for ST communities to seek mental health care. Access needs to be increased by using solutions that use training of primary health workers and nonphysician health workers, task sharing, and technology-enabled clinical decision support tools.[3] The SMART Mental Health project was delivered in the tribal areas of Andhra Pradesh using those principles and was found to be beneficial by all stakeholders.[14]Given the lack of knowledge about mental health problems among these communities, the government and nongovernmental organizations should collect and disseminate data on mental disorders among the ST communities. More research funding needs to be provided and key stakeholders should be involved in creating awareness both in the community and among policy makers to develop more projects for ST communities around mental health. Two recent meetings on tribal mental health – Round Table Meeting on Mental Health of ST Populations organized by the George Institute for Global Health, India, in 2017,[51] and the First National Conference on Tribal Mental Health organized by the Indian Psychiatric Society in Bhubaneswar in 2018 – have identified some key areas of research priority for mental health in ST communities.

A national-level policy on mental health of tribal communities or population is advocated which should be developed in consultation with key stakeholders. The Indian Psychiatric Society can play a role in coordinating research activities with support of the government which can ensure regular monitoring and dissemination of the research impact to the tribal communities. There is a need to understand how mental health symptoms are perceived in different ST communities and investigate the healing practices associated with distress/disaster/death/loss/disease. This could be done in the form of cross-sectional or cohort studies to generate proper evidence which could also include the information on prevalence, mental health morbidity, and any specific patterns associated with a specific disorder. Future research should estimate the prevalence of mental disorders in different age groups and gender, risk factors, and the influence of modernization.

Studies should develop a theoretical model to understand mental disorders and promote positive mental health within ST communities. Studies should also look at different ST communities as cultural differences exist across them, and there are also differences in socioeconomic status which impact on ability to access care.Research has shown that the impact and the benefits are amplified when research is driven by priorities that are identified by indigenous communities and involve their active participation. Their knowledge and perspectives are incorporated in processes and findings. Reporting of findings is meaningful to the communities. And indigenous groups and other key stakeholders are engaged from the outset.[47] Future research in India on ST communities should also adhere to these broad principles to ensure relevant and beneficial research, which have direct impact on the mental health of the ST communities.There is also a need to update literature related to mental health of ST population continuously.

Develop culturally appropriate validated instruments to measure mental morbidity relevant to ST population. And use qualitative research to investigate the perceptions and barriers for help-seeking behavior.[48] Conclusion The current review helps not only to collate the existing literature on the mental health of ST communities but also identify gaps in knowledge and provide some indications about the type of research that should be funded in future.Financial support and sponsorshipNil.Conflicts of interestThere are no conflicts of interest. References 1.Gururaj G, Girish N, Isaac MK. Mental. Neurological and Substance abuse disorders.

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Indian J Psychiatry 2010;52:S95-103. 3.Tewari A, Kallakuri S, Devarapalli S, Jha V, Patel A, Maulik PK. Process evaluation of the systematic medical appraisal, referral and treatment (SMART) mental health project in rural India. BMC Psychiatry 2017;17:385. 4.Ministry of Tribal Affairs, Government of India.

Report of the High Level Committee on Socio-economic, Health and Educational Status of Tribal Communities of India. New Delhi. Government of India. 2014. 5.Office of the Registrar General and Census Commissioner, Census of India.

New Delhi. Office of the Registrar General and Census Commissioner. 2011. 6.International Institute for Population Sciences and ICF. National Family Health Survey (NFHS-4), 2015-16.

India, Mumbai. International Institute for Population Sciences. 2017. 7.World Health Organization. The World Health Report 2001-Mental Health.

New Understanding, New Hope. Geneva, Switzerland. World Health Organization. 2001. 8.Demyttenaere K, Bruffaerts R, Posada-Villa J, Gasquet I, Kovess V, Lepine JP, et al.

Prevalence, severity, and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. JAMA 2004;291:2581-90. 9.Ministry of Health and Family Welfare, Government of India and Ministry of Tribal Affairs, Report of the Expert Committee on Tribal Health. Tribal Health in India – Bridging the Gap and a Roadmap for the Future. New Delhi.

Government of India. 2013. 10.Government of India, Rural Health Statistics 2016-17. Ministry of Health and Family Welfare Statistics Division. 2017.

11.Ormel J, VonKorff M, Ustun TB, Pini S, Korten A, Oldehinkel T. Common mental disorders and disability across cultures. Results from the WHO Collaborative Study on Psychological Problems in General Health Care. JAMA 1994;272:1741-8. 12.Thornicroft G, Brohan E, Rose D, Sartorius N, Leese M, INDIGO Study Group.

Global pattern of experienced and anticipated discrimination against people with schizophrenia. A cross-sectional survey. Lancet 2009;373:408-15. 13.Armstrong G, Kermode M, Raja S, Suja S, Chandra P, Jorm AF. A mental health training program for community health workers in India.

Impact on knowledge and attitudes. Int J Ment Health Syst 2011;5:17. 14.Maulik PK, Kallakuri S, Devarapalli S, Vadlamani VS, Jha V, Patel A. Increasing use of mental health services in remote areas using mobile technology. A pre-post evaluation of the SMART Mental Health project in rural India.

J Global Health 2017;7:1-13. 15.16.Ganguly KK, Sharma HK, Krishnamachari KA. An ethnographic account of opium consumers of Rajasthan (India). Socio-medical perspective. Addiction 1995;90:9-12.

17.Chaturvedi HK, Mahanta J. Sociocultural diversity and substance use pattern in Arunachal Pradesh, India. Drug Alcohol Depend 2004;74:97-104. 18.Chaturvedi HK, Mahanta J, Bajpai RC, Pandey A. Correlates of opium use.

Retrospective analysis of a survey of tribal communities in Arunachal Pradesh, India. BMC Public Health 2013;13:325. 19.Mohindra KS, Narayana D, Anushreedha SS, Haddad S. Alcohol use and its consequences in South India. Views from a marginalised tribal population.

Drug Alcohol Depend 2011;117:70-3. 20.Sreeraj VS, Prasad S, Khess CR, Uvais NA. Reasons for substance use. A comparative study of alcohol use in tribals and non-tribals. Indian J Psychol Med 2012;34:242-6.

[PUBMED] [Full text] 21.Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders. Findings from the Global Burden of Disease Study 2010. Lancet 2013;382:1575-86. 22.Janakiram C, Joseph J, Vasudevan S, Taha F, DeepanKumar CV, Venkitachalam R.

Prevalence and dependancy of tobacco use in an indigenous population of Kerala, India. Oral Hygiene and Health 2016;4:1 23.Manimunda SP, Benegal V, Sugunan AP, Jeemon P, Balakrishna N, Thennarusu K, et al. Tobacco use and nicotine dependency in a cross-sectional representative sample of 18,018 individuals in Andaman and Nicobar Islands, India. BMC Public Health 2012;12:515. 24.Singh PK, Singh RK, Biswas A, Rao VR.

High rate of suicide attempt and associated psychological traits in an isolated tribal population of North-East India. J Affect Dis 2013;151:673-8. 25.Sushila J. Perception of Illness and Health Care among Bhils. A Study of Udaipur District in Southern Rajasthan.

2005. 26.Sobhanjan S, Mukhopadhyay B. Perceived psychosocial stress and cardiovascular risk. Observations among the Bhutias of Sikkim, India. Stress Health 2008;24:23-34.

27.Ali A, Eqbal S. Mental Health status of tribal school going adolescents. A study from rural community of Ranchi, Jharkhand. Telangana J Psychiatry 2016;2:38-41. 28.Diwan R.

Stress and mental health of tribal and non tribal female school teachers in Jharkhand, India. Int J Sci Res Publicat 2012;2:2250-3153. 29.Longkumer I, Borooah PI. Knowledge about attitudes toward mental disorders among Nagas in North East India. IOSR J Humanities Soc Sci 2013;15:41-7.

30.Lakhan R, Kishore MT. Down syndrome in tribal population in India. A field observation. J Neurosci Rural Pract 2016;7:40-3. [PUBMED] [Full text] 31.Nizamie HS, Akhtar S, Banerjee S, Goyal N.

Health care delivery model in epilepsy to reduce treatment gap. WHO study from a rural tribal population of India. Epilepsy Res Elsevier 2009;84:146-52. 32.Prabhakar H, Manoharan R. The Tribal Health Initiative model for healthcare delivery.

A clinical and epidemiological approach. Natl Med J India 2005;18:197-204. 33.Nimgaonkar AU, Menon SD. A task shifting mental health program for an impoverished rural Indian community. Asian J Psychiatr 2015;16:41-7.

34.Yalsangi M. Evaluation of a Community Mental Health Programme in a Tribal Area- South India. Achutha Menon Centre For Health Sciences Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Working Paper No 12. 2012. 35.Tripathy P, Nirmala N, Sarah B, Rajendra M, Josephine B, Shibanand R, et al.

Effect of a participatory intervention with women's groups on birth outcomes and maternal depression in Jharkhand and Orissa, India. A cluster-randomised controlled trial. Lancet 2010;375:1182-92. 36.Aparajita C, Anita KM, Arundhati R, Chetana P. Assessing Social-support network among the socio culturally disadvantaged children in India.

Early Child Develop Care 1996;121:37-47. 37.Chowdhury AN, Mondal R, Brahma A, Biswas MK. Eco-psychiatry and environmental conservation. Study from Sundarban Delta, India. Environ Health Insights 2008;2:61-76.

38.Jeffery GS, Chakrapani U. Eco-psychiatry and Environmental Conservation. Study from Sundarban Delta, India. Working Paper- Research Gate.net. September, 2016.

39.Ozer S, Acculturation, adaptation, and mental health among Ladakhi College Students a mixed methods study of an indigenous population. J Cross Cultl Psychol 2015;46:435-53. 40.Giri DK, Chaudhary S, Govinda M, Banerjee A, Mahto AK, Chakravorty PK. Utilization of psychiatric services by tribal population of Jharkhand through community outreach programme of RINPAS. Eastern J Psychiatry 2007;10:25-9.

41.Nandi DN, Banerjee G, Chowdhury AN, Banerjee T, Boral GC, Sen B. Urbanization and mental morbidity in certain tribal communities in West Bengal. Indian J Psychiatry 1992;34:334-9. [PUBMED] [Full text] 42.Hackett RJ, Sagdeo D, Creed FH. The physical and social associations of common mental disorder in a tribal population in South India.

Soc Psychiatry Psychiatr Epidemiol 2007;42:712-5. 43.Raina SK, Raina S, Chander V, Grover A, Singh S, Bhardwaj A. Development of a cognitive screening instrument for tribal elderly population of Himalayan region in northern India. J Neurosci Rural Pract 2013;4:147-53. [PUBMED] [Full text] 44.Raina SK, Raina S, Chander V, Grover A, Singh S, Bhardwaj A.

Identifying risk for dementia across populations. A study on the prevalence of dementia in tribal elderly population of Himalayan region in Northern India. Ann Indian Acad Neurol 2013;16:640-4. [PUBMED] [Full text] 45.Raina SK, Chander V, Raina S, Kumar D. Feasibility of using everyday abilities scale of India as alternative to mental state examination as a screen in two-phase survey estimating the prevalence of dementia in largely illiterate Indian population.

Indian J Psychiatry 2016;58:459-61. [PUBMED] [Full text] 46.Diwan R. Mental health of tribal male-female factory workers in Jharkhand. IJAIR 2012;2278:234-42. 47.Banerjee T, Mukherjee SP, Nandi DN, Banerjee G, Mukherjee A, Sen B, et al.

Psychiatric morbidity in an urbanized tribal (Santal) community - A field survey. Indian J Psychiatry 1986;28:243-8. [PUBMED] [Full text] 48.Leske S, Harris MG, Charlson FJ, Ferrari AJ, Baxter AJ, Logan JM, et al. Systematic review of interventions for Indigenous adults with mental and substance use disorders in Australia, Canada, New Zealand and the United States. Aust N Z J Psychiatry 2016;50:1040-54.

49.Pollock NJ, Naicker K, Loro A, Mulay S, Colman I. Global incidence of suicide among Indigenous peoples. A systematic review. BMC Med 2018;16:145. 50.Silburn K, et al.

Evaluation of the Cooperative Research Centre for Aboriginal Health (Australian institute for primary care, trans.). Melbourne. LaTrobe University. 2010. 51.

Correspondence Address:S V. Siddhardh Kumar DevarapalliGeorge Institute for Global Health, Plot No. 57, Second Floor, Corporation Bank Building, Nagarjuna Circle, Punjagutta, Hyderabad - 500 082, Telangana IndiaSource of Support. None, Conflict of Interest. NoneDOI.

10.4103/psychiatry.IndianJPsychiatry_136_19 Figures [Figure 1] Tables [Table 1], [Table 2].

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Today, under the leadership kamagra side effects long term of President How to get prescribed zithromax Trump, the U.S. Department of Health and Human Services (HHS), through the Assistant Secretary for Health (ASH), issued guidance* under the Public Readiness and Emergency Preparedness Act (PREP Act) authorizing qualified pharmacy technicians and State-authorized pharmacy interns to administer childhood treatments, erectile dysfunction treatment kamagra side effects long term treatments when made available, and erectile dysfunction treatment tests, all subject to several requirements. This guidance clarifies that the pharmacy intern must be authorized by the State or board of pharmacy in the State in which the practical pharmacy internship occurs, but this authorization need not take the form of a license from, or registration with, the State board of pharmacy."Pharmacists and their staff are critical to the erectile dysfunction treatment response," said Assistant Secretary for Health ADM Brett P. Giroir, M.D kamagra side effects long term.

"Together with pediatricians and family physicians, they are ensuring that Americans receive the treatments they need where they need it."Childhood and erectile dysfunction treatmentsOn September 3, 2020, the Assistant Secretary for Health issued guidance authorizing state-licensed pharmacists to order and administer, and state-licensed or registered pharmacy interns acting under the supervision of the qualified pharmacist to administer, to persons ages three or older, erectile dysfunction treatment vaccinations that have been authorized or licensed by the Food and Drug Administration (FDA), provided that certain conditions are met—thereby making them “covered persons” under the PREP Act with respect to this activity. This guidance authorizes both qualified pharmacy technicians and State-authorized pharmacy interns acting under the supervision of a qualified pharmacist to administer to FDA-authorized or FDA-licensed erectile dysfunction treatments to persons ages three or older and to administer FDA-authorized or FDA-licensed kamagra side effects long term ACIP-recommended treatments to persons ages three through 18 according to ACIP’s standard immunization schedule, if the requirements listed below are satisfied. The vaccination must be ordered by the supervising qualified pharmacist. The supervising qualified pharmacist must be kamagra side effects long term readily and immediately available to the immunizing qualified pharmacy technicians.

The treatment must be FDA-authorized or FDA-licensed. In the case of a erectile dysfunction treatment, the vaccination must be ordered and administered kamagra side effects long term according to ACIP’s erectile dysfunction treatment recommendation(s). In the case of a childhood treatment, the vaccination must be ordered and administered according to ACIP’s standard immunization schedule. The qualified kamagra side effects long term pharmacy technician or State-authorized pharmacy intern must complete a practical training program that is approved by the Accreditation Council for Pharmacy Education (ACPE).

This training program must include a hands-on injection technique and the recognition and treatment of emergency reactions to treatments. The qualified kamagra side effects long term pharmacy technician or State-authorized pharmacy intern must have a current certificate in basic cardiopulmonary resuscitation. The qualified pharmacy technician must complete a minimum of two hours of ACPE-approved, immunization-related continuing pharmacy education during the relevant State licensing period(s). The supervising qualified pharmacist must comply with recordkeeping and kamagra side effects long term reporting requirements of the jurisdiction in which he or she administers treatments, including informing the patient’s primary care provider when available and submitting the required immunization information to the State or local immunization information system (treatment registry).

The supervising pharmacist is responsible for complying with requirements related to reporting adverse events. The supervising qualified pharmacist must review the treatment registry or other vaccination records prior to ordering the vaccination to be administered by the kamagra side effects long term qualified pharmacy technician or State-authorized pharmacy intern. The qualified pharmacy technician and State-authorized pharmacy intern must, if the patient is 18 years of age or younger, inform the patient and the adult caregiver accompanying the patient of the importance of a well-child visit with a pediatrician or other licensed primary care provider and refer patients as appropriate. The supervising qualified pharmacist must comply with any applicable requirements (or conditions of use) as set forth in the CDC’s erectile dysfunction treatment vaccination provider agreement and any other federal requirements that apply to the administration of erectile dysfunction treatment(s).erectile dysfunction treatment Testing This guidance also authorizes qualified pharmacy technicians and State-authorized pharmacy interns to administer erectile dysfunction treatment tests, including serology tests, that the FDA has approved, cleared, or authorized.Information kamagra side effects long term on the Third Amendment to the PREP Act declaration.Information on Operation Warp SpeedClinical resources on treatments, including continuing education training on best practices* Persons using assistive technology may not be able to fully access information in this file.

For assistance, please contact the Office of the Assistant Secretary for Health at ashmedia@hhs.gov.This story also ran on Fortune. This story can be republished for free (details). Donella Pogue has trouble finding dentists in her rural area willing to accommodate her 21-year-old son, Justin, kamagra side effects long term who is 6 feet, 8 inches tall, is on the autism spectrum and has difficulty sitting still when touched.And this summer, he had a cavity and his face swelled. Pogue, of Bristol, New York, reached out to the Eastman Institute for Oral Health in Rochester, which offers teledentistry.Dr. Adela Planerova looked into kamagra side effects long term his mouth from 28 miles away as Pogue pointed her laptop’s camera into her son’s mouth. Planerova determined they did not need to make an emergency one-hour drive to her clinic.

Instead, the dentist prescribed antibiotics and anti-inflammatory drugs, and weeks later he had surgery.Teledentistry allows dental professionals like Planerova to remotely review records and diagnose patients over kamagra side effects long term video. Some smile about its promise, seeing it as a way to become more efficient, to reach the one-third of U.S. Adults who federal figures from 2017 estimate hadn’t seen a dentist in the previous year and to practice more safely during the kamagra.But others see it as lesser-quality care that’s cheaper for dental professionals to provide, allowing them to make more money kamagra side effects long term. At the same time, widespread adoption is hindered by issues such as spotty internet and insurance companies unwilling to reimburse for teledentistry procedures.

Don't Miss A Story kamagra side effects long term Subscribe to KHN’s free Weekly Edition newsletter. Dr. Christina Carter, an orthodontist in Morristown, New Jersey, said teledentistry has its place but kamagra side effects long term shouldn’t replace time in the dental chair.“It cannot be used for a full diagnosis because we need other tools, like X-rays,” she said. €œWe have all tried to see things on our phone or even on a Zoom call, and there is still just a different feel.”Still, as the kamagra curbs in-person visits and reduces dentists’ revenue, more dentists are seeking guidance from Dr.

Nathan Suter, a leading teledentistry advocate who owns kamagra side effects long term the consulting company Access Teledentistry. Since March, he said, he’s done webinars for about 9,000 dental professionals, up from fewer than 1,000 in the three years before the kamagra.Teledentistry providers trace the practice to 1994, when the Army launched a pilot program in which health care providers used an intra-oral camera to take photos of a patient’s mouth at a fort in Georgia and then sent them over the internet to a dental clinic at a fort 120 miles away.Over the next two decades, dentists in upstate New York and the San Francisco Bay Area led teledentistry pilot programs for underserved children, some of whom were in preschool and already had cavities. The number of children who completed the prescribed kamagra side effects long term dental treatment rose significantly.Supporters say teledentistry can help reach the 43% of rural Americans who lack access to dental care. Medicaid and the Children’s Health Insurance Program will pay for many dental procedures for those enrolled in those programs, but only 38% of dentists participate in those programs, according to the American Dental Association.

One reason kamagra side effects long term. Medicaid typically reimburses at a significantly lower rate than those of private insurance plans.Teledentistry could help dentists treat more patients and make more money a number of ways. If dentists remotely review data captured by hygienists, they can see more patients kamagra side effects long term. Because video appointments save them time, dentists then have room for the people “who need the more expensive services” while also focusing on preventive care, said Kirill Zaydenman, vice president of innovation for DentaQuest, an administrator of dental insurance and oral health care provider.Donella Pogue says that teledentistry was the best option for her 21-year-old son, Justin, when he had a cavity this summer that caused his face to swell.

Justin has special needs kamagra side effects long term and was able to see the dentist from the comfort of home. (Donella Pogue)But dentists have not widely adopted teledentistry — mainly because they’ve kamagra side effects long term had difficulty getting insurers to pay for it, said Dr. Dorota Kopycka-Kedzierawski, a Rochester dentist. That’s partly because kamagra side effects long term of insurers’ concerns about fraud.

Dr. Paul Glassman, who started the Virtual Dental Home project to reach underserved preschool children in the Bay Area, considers those fears “completely incorrect.”“If you want to bill for something you didn’t do,” he said, “you can do that just as easily in an in-person environment as you can using teledentistry.”Since March, as the kamagra descended, most, if not all, private dental plans have been reimbursing kamagra side effects long term for teledentistry, said Tom Meyers, vice president of public policy for America’s Health Insurance Plans, a trade organization. And all state Medicaid programs now reimburse for teledentistry in some form, Glassman said, though policies differ by state and some practices may not be covered in some places.But teledentistry isn’t reimbursable under Medicare. (Most dentistry isn’t.) Another obstacle to kamagra side effects long term widespread adoption.

Some dentists and lawmakers connect teledentistry to companies offering at-home teeth aligners with little or no in-person contact with a dentist. Glassman has kamagra side effects long term promoted teledentistry throughout the United States and reviewed proposed legislation or regulations in states such as Idaho, Massachusetts and Texas. He said he hears concerns from dentists about the lack of an in-person exam during which X-rays are taken. Such concerns are reflected in some legislation.SmileDirectClub, an at-home teeth-aligner company, has argued in statehouse kamagra side effects long term testimony that in-person care is not always needed.

The company opposed a 2019 bill in Texas that aimed to improve access to dentistry in rural areas because it included a number of restrictions on teledentistry, including one that would have required an in-person dentist’s examination if a teledentistry provider treated that patient for more than 12 months.SmileDirect’s attorney argued at a hearing the rule “could interrupt the course of a patient’s treatment.”The measure failed.Proponents argue teledentistry isn’t just about making more money. Pogue, the New York woman, said it was the best option for her son with special needs.“He is really afraid of dentistry, so when he goes kamagra side effects long term to see someone, he is really tense and really jumpy, so that’s another reason the teledentistry was nice was because he was in my bedroom doing it, so he was really comfortable,” said Pogue, 53, whose son is covered by Medicaid.A few weeks later, Justin did have to have surgery, which went “perfect,” his mom said.Some dentists say teledentistry faces particular stumbling blocks in rural areas. Dr. Mack Taylor, kamagra side effects long term 36, a dentist who grew up in the small town of Dexter, Missouri, now practices in a health center just down the road.

Twenty years ago, he said, Dexter had eight dentists. Now there are only three.Technology is kamagra side effects long term a major obstacle for local residents, many of whom lack reliable internet service. Taylor recently applied for a U.S. Department of Agriculture grant that would give him $26,500 to buy equipment so that, for example, a hygienist can take kamagra side effects long term photos inside the mouths of nursing home residents and send them to Taylor to review.“It’s not like medicine where you can discuss someone’s ailments and have a good idea what’s going on,” Taylor said.

€œMaybe all you can tell me is ‘I have a broken tooth,’ but I can’t physically see what’s going on and prescribe the right treatment.” Related Topics erectile dysfunction treatment Dental Health Telemedicine.

Today, under kamagra tablet online the leadership of you can check here President Trump, the U.S. Department of Health and Human Services (HHS), through the Assistant Secretary for Health (ASH), issued guidance* under the Public Readiness and Emergency Preparedness Act (PREP Act) authorizing qualified pharmacy technicians kamagra tablet online and State-authorized pharmacy interns to administer childhood treatments, erectile dysfunction treatments when made available, and erectile dysfunction treatment tests, all subject to several requirements. This guidance clarifies that the pharmacy intern must be authorized by the State or board of pharmacy in the State in which the practical pharmacy internship occurs, but this authorization need not take the form of a license from, or registration with, the State board of pharmacy."Pharmacists and their staff are critical to the erectile dysfunction treatment response," said Assistant Secretary for Health ADM Brett P. Giroir, M.D kamagra tablet online. "Together with pediatricians and family physicians, they are ensuring that Americans receive the treatments they need where they need it."Childhood and erectile dysfunction treatmentsOn September 3, 2020, the Assistant Secretary for Health issued guidance authorizing state-licensed pharmacists to order and administer, and state-licensed or registered pharmacy interns acting under the supervision of the qualified pharmacist to administer, to persons ages three or older, erectile dysfunction treatment vaccinations that have been authorized or licensed by the Food and Drug Administration (FDA), provided that certain conditions are met—thereby making them “covered persons” under the PREP Act with respect to this activity.

This guidance authorizes both qualified pharmacy technicians and State-authorized pharmacy interns acting kamagra tablet online under the supervision of a qualified pharmacist to administer to FDA-authorized or FDA-licensed erectile dysfunction treatments to persons ages three or older and to administer FDA-authorized or FDA-licensed ACIP-recommended treatments to persons ages three through 18 according to ACIP’s standard immunization schedule, if the requirements listed below are satisfied. The vaccination must be ordered by the supervising qualified pharmacist. The supervising qualified pharmacist kamagra tablet online must be readily and immediately available to the immunizing qualified pharmacy technicians. The treatment must be FDA-authorized or FDA-licensed. In the kamagra tablet online case of a erectile dysfunction treatment, the vaccination must be ordered and administered according to ACIP’s erectile dysfunction treatment recommendation(s).

In the case of a childhood treatment, the vaccination must be ordered and administered according to ACIP’s standard immunization schedule. The qualified pharmacy technician or State-authorized pharmacy intern must complete a practical training program that is approved by the Accreditation Council for Pharmacy kamagra tablet online Education (ACPE). This training program must include a hands-on injection technique and the recognition and treatment of emergency reactions to treatments. The qualified pharmacy technician or State-authorized pharmacy intern must have a current certificate in kamagra tablet online basic cardiopulmonary resuscitation. The qualified pharmacy technician must complete a minimum of two hours of ACPE-approved, immunization-related continuing pharmacy education during the relevant State licensing period(s).

The supervising qualified pharmacist must comply with kamagra tablet online recordkeeping and reporting requirements of the jurisdiction in which he or she administers treatments, including informing the patient’s primary care provider when available and submitting the required immunization information to the State or local immunization information system (treatment registry). The supervising pharmacist is responsible for complying with requirements related to reporting adverse events. The supervising qualified pharmacist kamagra tablet online must review the treatment registry or other vaccination records prior to ordering the vaccination to be administered by the qualified pharmacy technician or State-authorized pharmacy intern. The qualified pharmacy technician and State-authorized pharmacy intern must, if the patient is 18 years of age or younger, inform the patient and the adult caregiver accompanying the patient of the importance of a well-child visit with a pediatrician or other licensed primary care provider and refer patients as appropriate. The supervising qualified pharmacist must comply with any applicable requirements (or conditions of use) as set forth in the CDC’s erectile dysfunction treatment vaccination provider agreement and any other federal requirements that apply to the administration of erectile dysfunction treatment(s).erectile dysfunction treatment Testing This guidance also authorizes qualified pharmacy technicians and State-authorized pharmacy interns to administer erectile dysfunction treatment tests, including serology tests, that the FDA has approved, cleared, or authorized.Information on the Third Amendment to the PREP Act declaration.Information on Operation Warp SpeedClinical resources on treatments, including continuing education training on best practices* Persons using kamagra tablet online assistive technology may not be able to fully access information in this file.

For assistance, please contact the Office of the Assistant Secretary for Health at ashmedia@hhs.gov.This story also ran on Fortune. This story can be republished for free (details). Donella Pogue has trouble finding dentists in her rural area willing to accommodate her 21-year-old son, Justin, who is 6 feet, 8 inches tall, is on the autism spectrum and has difficulty kamagra tablet online sitting still when touched.And this summer, he had a cavity and his face swelled. Pogue, of Bristol, New York, reached out to the Eastman Institute for Oral Health in Rochester, which offers teledentistry.Dr. Adela Planerova looked into his mouth from 28 miles away kamagra tablet online as Pogue pointed her laptop’s camera into her son’s mouth. Planerova determined they did not need to make an emergency one-hour drive to her clinic. Instead, the dentist prescribed kamagra tablet online antibiotics and anti-inflammatory drugs, and weeks later he had surgery.Teledentistry allows dental professionals like Planerova to remotely review records and diagnose patients over video.

Some smile about its promise, seeing it as a way to become more efficient, to reach the one-third of U.S. Adults who federal figures from 2017 estimate hadn’t seen a dentist in the previous year and to practice more kamagra tablet online safely during the kamagra.But others see it as lesser-quality care that’s cheaper for dental professionals to provide, allowing them to make more money. At the same time, widespread adoption is hindered by issues such as spotty internet and insurance companies unwilling to reimburse for teledentistry procedures. Don't Miss A Story Subscribe kamagra tablet online to KHN’s free Weekly Edition newsletter. Dr.

Christina Carter, an orthodontist in kamagra tablet online Morristown, New Jersey, said teledentistry has its place but shouldn’t replace time in the dental chair.“It cannot be used for a full diagnosis because we need other tools, like X-rays,” she said. €œWe have all tried to see things on our phone or even on a Zoom call, and there is still just a different feel.”Still, as the kamagra curbs in-person visits and reduces dentists’ revenue, more dentists are seeking guidance from Dr. Nathan Suter, a leading kamagra tablet online teledentistry advocate who owns the consulting company Access Teledentistry. Since March, he said, he’s done webinars for about 9,000 dental professionals, up from fewer than 1,000 in the three years before the kamagra.Teledentistry providers trace the practice to 1994, when the Army launched a pilot program in which health care providers used an intra-oral camera to take photos of a patient’s mouth at a fort in Georgia and then sent them over the internet to a dental clinic at a fort 120 miles away.Over the next two decades, dentists in upstate New York and the San Francisco Bay Area led teledentistry pilot programs for underserved children, some of whom were in preschool and already had cavities. The number of children who completed kamagra tablet online the prescribed dental treatment rose significantly.Supporters say teledentistry can help reach the 43% of rural Americans who lack access to dental care.

Medicaid and the Children’s Health Insurance Program will pay for many dental procedures for those enrolled in those programs, but only 38% of dentists participate in those programs, according to the American Dental Association. One reason kamagra tablet online. Medicaid typically reimburses at a significantly lower rate than those of private insurance plans.Teledentistry could help dentists treat more patients and make more money a number of ways. If dentists remotely review data captured by hygienists, they can kamagra tablet online see more patients. Because video appointments save them time, dentists then have room for the people “who need the more expensive services” while also focusing on preventive care, said Kirill Zaydenman, vice president of innovation for DentaQuest, an administrator of dental insurance and oral health care provider.Donella Pogue says that teledentistry was the best option for her 21-year-old son, Justin, when he had a cavity this summer that caused his face to swell.

Justin has special needs and was kamagra tablet online able to see the dentist from the comfort of home. (Donella Pogue)But dentists have not widely adopted teledentistry — mainly because they’ve had kamagra tablet online difficulty getting insurers to pay for it, said Dr. Dorota Kopycka-Kedzierawski, a Rochester dentist. That’s partly because of insurers’ concerns about fraud kamagra tablet online. Dr.

Paul Glassman, who started the Virtual Dental Home kamagra tablet online project to reach underserved preschool children in the Bay Area, considers those fears “completely incorrect.”“If you want to bill for something you didn’t do,” he said, “you can do that just as easily in an in-person environment as you can using teledentistry.”Since March, as the kamagra descended, most, if not all, private dental plans have been reimbursing for teledentistry, said Tom Meyers, vice president of public policy for America’s Health Insurance Plans, a trade organization. And all state Medicaid programs now reimburse for teledentistry in some form, Glassman said, though policies differ by state and some practices may not be covered in some places.But teledentistry isn’t reimbursable under Medicare. (Most dentistry isn’t.) Another obstacle to kamagra tablet online widespread adoption. Some dentists and lawmakers connect teledentistry to companies offering at-home teeth aligners with little or no in-person contact with a dentist. Glassman has kamagra tablet online promoted teledentistry throughout the United States and reviewed proposed legislation or regulations in states such as Idaho, Massachusetts and Texas.

He said he hears concerns from dentists about the lack of an in-person exam during which X-rays are taken. Such concerns are reflected in some legislation.SmileDirectClub, an at-home teeth-aligner company, has argued kamagra tablet online in statehouse testimony that in-person care is not always needed. The company opposed a 2019 bill in Texas that aimed to improve access to dentistry in rural areas because it included a number of restrictions on teledentistry, including one that would have required an in-person dentist’s examination if a teledentistry provider treated that patient for more than 12 months.SmileDirect’s attorney argued at a hearing the rule “could interrupt the course of a patient’s treatment.”The measure failed.Proponents argue teledentistry isn’t just about making more money. Pogue, the New York woman, said it was the best option for her son with special needs.“He is really afraid of dentistry, so when kamagra tablet online he goes to see someone, he is really tense and really jumpy, so that’s another reason the teledentistry was nice was because he was in my bedroom doing it, so he was really comfortable,” said Pogue, 53, whose son is covered by Medicaid.A few weeks later, Justin did have to have surgery, which went “perfect,” his mom said.Some dentists say teledentistry faces particular stumbling blocks in rural areas. Dr.

Mack Taylor, 36, a dentist who grew up in the small town of Dexter, Missouri, now practices in a health center just down the kamagra tablet online road. Twenty years ago, he said, Dexter had eight dentists. Now there are only three.Technology is a kamagra tablet online major obstacle for local residents, many of whom lack reliable internet service. Taylor recently applied for a U.S. Department of Agriculture grant that would give him $26,500 to buy equipment so kamagra tablet online that, for example, a hygienist can take photos inside the mouths of nursing home residents and send them to Taylor to review.“It’s not like medicine where you can discuss someone’s ailments and have a good idea what’s going on,” Taylor said.

€œMaybe all you can tell me is ‘I have a broken tooth,’ but I can’t physically see what’s going on and prescribe the right treatment.” Related Topics erectile dysfunction treatment Dental Health Telemedicine.

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Drawing on kamagra london next day delivery peer-reviewed and grey literature, Powell et al argue the dominant narrative of personal self-care during the erectile dysfunction treatment kamagra must be supplemented with a collectivist approach that addresses structural inequalities and fosters a more equitable society.Compliance with self-care and risk mitigation strategies to tackle erectile dysfunction treatment has been chequered in the UK, fuelled partly by social media hoaxes and misinformation, kamagra denialism, and policy leaders contravening their own her latest blog public health messaging. Exploring individual non-compliance, and reflecting on wider societal inequities that can impact it, can help build critical normative resilience to future kamagras.From the outset, erectile dysfunction treatment public health messaging was, and remains, primarily aimed at modifying individual lifestyles and behaviours to flatten the kamagra london next day delivery infectivity curve by following ‘common sense’ approaches captured by the hands–face–space mantra.1 A culture of practice and new social norms of acceptable behaviour subsequently emerged,2 with concordance premised on cooperation between the public and government. However, as the kamagra worsened and movement restrictions continued, norms were contested by a small but vocal segment of society.This normative contestation was founded on conflict between individual agency, government paternalism and regulatory diktat, and echoed Kant’s epistemology of auism and the need to sacrifice individual liberties for the ‘greater good’ kamagra london next day delivery.

This conflict was exacerbated by multiple lockdowns that significantly impacted individuals’ daily lives, and dissidence within a post-Brexit body politic characterised by distrust of politicians3 and strong personal beliefs about rights, responsibilities and kamagra london next day delivery sovereignty.Émile Durkeim's sociological concept of anomie, however, widens our understanding further. Anomie characterises a dissolution or absence of established moral values, standards or mores that create a resulting normlessness.4 5 Discordance between personal and group norms—the absence of kamagra london next day delivery a shared social ethic—weakens communal bonds, impacting individual stress, frustration, anxiety, confusion and powerlessness. During erectile dysfunction treatment, segments of society experienced powerlessness and loss of agency as daily routines were disrupted and further compounded by financial and mental distress as morbidity and mortality data dominated daily news headlines.A visible minority began disregarding public health messaging, challenging norms needed to ensure a successful preventative response to the kamagra (eg, kamagra london next day delivery hoarding of restricted supermarket items).

That such behaviour was limited to a relative minority neither undermines the existence of anomie—self-interest remains juxtaposed to collective duty—nor weakens the contestation of existing dominant normative paradigms.6 Contesting ideas can reach a tipping point of popularity, establishing a new dominant social norm.7 This can trigger detrimental behaviour (eg, for rates) if the once dominant paradigm supported laudable public health messaging.In addressing this threat, it is vital to reinforce public health messaging by bolstering the underpinning social norms. Durkheim’s remedy was moral education, by which the collective consciousness—shared knowledge, ideas, beliefs and attitudes—is nurtured by supporting the collectivist tendencies of individuals,8 which can be achieved by various means.9 While using kamagra london next day delivery injunctions against those who transgress (eg, monetary fines) can supplement positive public health measures, Durkheim crucially counselled that the imposition of norms does not bind individuals to the collective as strongly as consensus. Such a didactic approach can undermine solidarity, potentially nurturing a scapegoat culture that can exacerbate existing and historical inequities (eg, enforcing treatment uptake among ethnic minority populations).Indeed, disruption of the social order, and the emergence of new policy prescriptions to tackle the kamagra, re-exposed chronic inequalities.10 11 ‘Stay at home’ kamagra london next day delivery advice had different connotations to a large segment of society.

Those who were victims of domestic abuse, or struggling to pay the rent, provide for their family, or who could not afford broadband, a personal laptop or access kamagra london next day delivery to a garden.An effective public health strategy is a holistic one that creates an open and inclusive dialogue with diverse community groups to identify shared values. This inclusive dialogue can help kamagra london next day delivery create a normative system that encourages the adoption and diffusion of initiatives addressing structural inequalities and injustices.Scrutiny of the UK’s response to erectile dysfunction treatment has made the case for self-care as a public health measure to tackle communicable diseases, while also highlighting its limitations vis-à-vis individual rights and responsibilities and extant structural inequalities. These challenges kamagra london next day delivery have not undermined the self-care agenda.

Rather, they have highlighted the need to reinforce it, to shore up the normative elements that underpin it to ensure success.Although the sustained adoption of health-seeking behaviours is crucial, individual self-care alone is insufficient to tackle the kamagra. Societal responsibility is also required whereby (1) individuals act in responsible and rational ways to prevent erectile dysfunction treatment spread until pharmacological interventions to prevent or kamagra london next day delivery manage the kamagra become widely available and (2) communities and governing institutions work together to build a more equal society. In the UK, the current political climate is characterised by discourse in which individuals are the source kamagra london next day delivery of, and the solution to, social problems.

Policies and practices continue to focus kamagra london next day delivery on individual rather than collective responsibility. Both aspects need to be addressed when kamagra london next day delivery tackling national emergencies, including global kamagras. As Durkheim recognised,12 social justice and equality are necessary to sustain solidarity—they are the bond connecting individuals in society that ensures stability and social order.Key messagesSelf-care has been, and continues to be, critical to tackling the erectile dysfunction treatment kamagra.The concept of anomie—an uprooting, kamagra london next day delivery dissolution or absence of established moral values, guiding standards, or social mores, creating normlessness—cannot be overlooked when planning an integrated social response.The dominant narrative of personal self-care must be supplemented with a collectivist approach that addresses structural inequalities for the future.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsRAP's and AE-O's independent contribution to this article is supported by the National Institute for Health Research Applied Research Collaboration Northwest London.

The views expressed in this publication are those of RAP and AE-O and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.The Global Burden of Disease Study reported that from 1990 to 2019, cardiovascular diseases (CVDs) emerged as a leading cause of disability-adjusted life-years (DALYs) in South Asians of both genders (15.2% of total DALYs in men and 11.9% in women).1 South Asia is largely rural with a population of approximately 1.2 billion people and projected to remain rural through to 2050, with a similar number of people.2 In 2014, the multi-country Prospective Urban Rural Epidemiology (PURE) cohort study found that rural South Asians experienced higher incidence rates for CVD mortality and morbidity (7.2 per 1000 person-years) compared with their urban counterparts (5.6 per 1000 person-years), from myocardial infarction, heart failure and stroke.3 This is despite rural South Asians having a comparatively better CVD risk profile, an INTERHEART risk score of 7.6 compared with 9.1.3 Over the past 30 years (1985–2017), the increase in age-standardised mean body mass index (BMI) in the adult rural population has outpaced urban counterparts.4 It follows that ….

Drawing on peer-reviewed and grey literature, Powell et al argue the dominant narrative of personal self-care during the erectile dysfunction treatment kamagra Can i buy antabuse over the counter must be supplemented with a collectivist approach that addresses structural inequalities and fosters a more equitable society.Compliance with self-care and risk mitigation strategies to tackle kamagra tablet online erectile dysfunction treatment has been chequered in the UK, fuelled partly by social media hoaxes and misinformation, kamagra denialism, and policy leaders contravening their own public health messaging. Exploring individual non-compliance, and reflecting on wider societal inequities that can impact it, can help build critical normative resilience to future kamagras.From the kamagra tablet online outset, erectile dysfunction treatment public health messaging was, and remains, primarily aimed at modifying individual lifestyles and behaviours to flatten the infectivity curve by following ‘common sense’ approaches captured by the hands–face–space mantra.1 A culture of practice and new social norms of acceptable behaviour subsequently emerged,2 with concordance premised on cooperation between the public and government. However, as the kamagra worsened and movement restrictions continued, kamagra tablet online norms were contested by a small but vocal segment of society.This normative contestation was founded on conflict between individual agency, government paternalism and regulatory diktat, and echoed Kant’s epistemology of auism and the need to sacrifice individual liberties for the ‘greater good’. This conflict was exacerbated by multiple lockdowns that significantly impacted individuals’ kamagra tablet online daily lives, and dissidence within a post-Brexit body politic characterised by distrust of politicians3 and strong personal beliefs about rights, responsibilities and sovereignty.Émile Durkeim's sociological concept of anomie, however, widens our understanding further.

Anomie characterises a dissolution or absence of established moral values, standards or mores that create a resulting normlessness.4 5 Discordance between personal and group norms—the absence of a shared kamagra tablet online social ethic—weakens communal bonds, impacting individual stress, frustration, anxiety, confusion and powerlessness. During erectile dysfunction treatment, segments of society experienced powerlessness and loss of agency as daily routines were disrupted and further compounded by financial and mental distress as morbidity and mortality data dominated daily news headlines.A visible minority began disregarding public health messaging, challenging norms needed to ensure a successful preventative response to the kamagra (eg, hoarding of restricted supermarket items) kamagra tablet online. That such behaviour was limited to a relative minority neither undermines the existence of anomie—self-interest remains juxtaposed to collective duty—nor weakens the contestation of existing dominant normative paradigms.6 Contesting ideas can reach a tipping point of popularity, establishing a new dominant social norm.7 This can trigger detrimental behaviour (eg, for rates) if the once dominant paradigm supported laudable public health messaging.In addressing this threat, it is vital to reinforce public health messaging by bolstering the underpinning social norms. Durkheim’s remedy was moral education, by which the collective consciousness—shared knowledge, ideas, beliefs and attitudes—is nurtured by supporting the collectivist tendencies of individuals,8 which can be achieved by various means.9 While using injunctions against those who transgress (eg, monetary fines) can supplement positive public health kamagra tablet online measures, Durkheim crucially counselled that the imposition of norms does not bind individuals to the collective as strongly as consensus.

Such a didactic approach can undermine solidarity, potentially nurturing a scapegoat culture that can exacerbate existing and historical inequities (eg, kamagra tablet online enforcing treatment uptake among ethnic minority populations).Indeed, disruption of the social order, and the emergence of new policy prescriptions to tackle the kamagra, re-exposed chronic inequalities.10 11 ‘Stay at home’ advice had different connotations to a large segment of society. Those who were victims of domestic abuse, or struggling to pay the rent, provide for their family, or who could not afford broadband, kamagra tablet online a personal laptop or access to a garden.An effective public health strategy is a holistic one that creates an open and inclusive dialogue with diverse community groups to identify shared values. This inclusive dialogue can help create a normative system that encourages the adoption and diffusion of initiatives addressing structural inequalities and injustices.Scrutiny of the UK’s response to erectile dysfunction treatment has made the case for self-care as a public health measure to tackle communicable diseases, while also highlighting its limitations vis-à-vis individual rights and responsibilities kamagra tablet online and extant structural inequalities. These challenges have not undermined the kamagra tablet online self-care agenda.

Rather, they have highlighted the need to reinforce it, to shore up the normative elements that underpin it to ensure success.Although the sustained adoption of health-seeking behaviours is crucial, individual self-care alone is insufficient to tackle the kamagra. Societal responsibility is also required whereby (1) individuals act in responsible and rational ways to prevent erectile dysfunction treatment spread until pharmacological interventions to prevent or manage the kamagra become widely available and (2) communities kamagra tablet online and governing institutions work together to build a more equal society. In the UK, the current political climate is kamagra tablet online characterised by discourse in which individuals are the source of, and the solution to, social problems. Policies and practices continue to focus on individual rather than kamagra tablet online collective responsibility.

Both aspects need to be kamagra tablet online addressed when tackling national emergencies, including global kamagras. As Durkheim recognised,12 social justice and equality are necessary to sustain solidarity—they are the bond connecting individuals in society that ensures stability and social order.Key messagesSelf-care has been, and continues to be, critical to tackling the erectile dysfunction treatment kamagra.The concept of anomie—an uprooting, dissolution or absence of established moral values, guiding standards, or social mores, creating normlessness—cannot be overlooked when planning an integrated social response.The kamagra tablet online dominant narrative of personal self-care must be supplemented with a collectivist approach that addresses structural inequalities for the future.Ethics statementsPatient consent for publicationNot required.AcknowledgmentsRAP's and AE-O's independent contribution to this article is supported by the National Institute for Health Research Applied Research Collaboration Northwest London. The views expressed in this publication are those of RAP and AE-O and not necessarily those of the National Institute for Health Research or the Department of Health and Social Care.The Global Burden of Disease Study reported that from 1990 to 2019, cardiovascular diseases (CVDs) emerged as a leading cause of disability-adjusted life-years (DALYs) in South Asians of both genders (15.2% of total DALYs in men and 11.9% in women).1 South Asia is largely rural with a population of approximately 1.2 billion people and projected to remain rural through to 2050, with a similar number of people.2 In 2014, the multi-country Prospective Urban Rural Epidemiology (PURE) cohort study found that rural South Asians experienced higher incidence rates for CVD mortality and morbidity (7.2 per 1000 person-years) compared with their urban counterparts (5.6 per 1000 person-years), from myocardial infarction, heart failure and stroke.3 This is despite rural South Asians having a comparatively better CVD risk profile, an INTERHEART risk score of 7.6 compared with 9.1.3 Over the past 30 years (1985–2017), the increase in age-standardised mean body mass index (BMI) in the adult rural population has outpaced urban counterparts.4 It follows that ….

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The winner of the selection kamagra tablet online process, Dr Martin Khechara FIBMS has now been matched with 'The Naked Scientists' podcast for the placement. Martin is a microbiologist who has previously worked at Porton Down and is now a Senior Lecturer in Biomedical Science at the University of Wolverhampton. He is also the Associate Professor for Public Engagement in STEM. As part of this, Martin is leading a public engagement group called kamagra tablet online ‘Science Shack’ which provides engaging and educational science experiences for schools and the wider community. Firstly, Martin attended three training sessions in November.

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The course is available via the Academy’s mobile learning app, which is available for download from both the Google Play and Apple App stores. What does Augmented Reality (AR) mean?. Augmented reality is a technology that superimposes a kamagra tablet online computer-generated image on a user’s real-world view. In the case of this PPE course, learners can project the 3D animated nurse in the room or space where they are with their smartphone. Viewing the experience on their smartphone screens, they can explore what the nurse is doing by moving 360 degrees around him.

Why use Augmented Reality for kamagra tablet online this purpose?. While there are already a number of PPE courses online, the augmented reality technology used by the WHO Academy takes the learning experience to a new, more engaging and interactive level, which studies have shown can help individuals learn faster and retain more of what they have learned. How do I access the course?. You will need kamagra tablet online a smartphone that has access to the internet. As a first step, you will have to download the WHO Academy App from the Apple App Store or Google Play Store.

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