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The California Department of Transportation (Caans) is scheduled to close renova where to buy northbound and southbound state Route 99 from 47th Avenue http://www.erada.com/buy-renova-0.025-cream/ to the U.S. Highway 50 connector, from 8 p.m., Friday, June 11 until 4 a.m., Wednesday, June 16.Caans says the closure is necessary for crews to quickly and safely replace an aging bridge deck on Route 99 at 21st Avenue.Rerouted traffic is expected to impact Stockton Boulevard and areas around UC Davis Medical Center, and patients, visitors, and employees should plan ahead for increased congestion.During the closure, employees coming from South Sacramento and Elk Grove should allow extra time to get to work.The mainline westbound Business 80/Capital City Freeway to southbound Route 99 is also slated to be closed, as will the westbound and renova where to buy eastbound U.S. 50 connector ramps to southbound renova where to buy Route 99. Also, the renova where to buy following ramps are scheduled to be closed:The on-ramp from 16th Street to eastbound U.S.

50The on-ramp from 29th Street/H Street to westbound Business 80/Capital City FreewayThe on-ramp from 29th Street/N Street to westbound Business 80/Capital City FreewayThe on-ramp from 29th Street/T Street to southbound Route 99The on-ramp from Broadway to southbound Route 99The off-ramp from southbound Route 99 to 12th StreetThe off-ramp from northbound Route 99 to 12th StreetThe on-ramp from 14th Avenue/30th Street to southbound Route 99The on-ramp (slip) from Fruitridge Road to northbound Route 99The on-ramp (loop) from Fruitridge Road to northbound Route 99The on-ramp (slip) from East 47th Avenue to northbound Route 99The on-ramp (loop) from West 47th Avenue to northbound Route 99Caans is encouraging motorists to take public transit instead (SacRT is providing free light rail service from June 12-15 renova where to buy. More information here), use Interstate 5, and renova where to buy find alternate routes during the 99-hour closure.For more information, including suggested detours, please see the Caans news release..

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When purchasing a new phone or tablet, it is common plan renova ecuador Get ventolin practice to select the best technology that fits your needs within the available budget. This is also the strategy adopted by our research team at the Galileo Project, a new initiative to image unidentified aerial phenomena (UAP) like those reported by the Office of the Director of National Intelligence (ODNI) to the U.S. Congress on June 25, plan renova ecuador 2021. To my amusement, I recently came across an online retailer that would allow us to “add to cart” a one-meter telescope for half a million dollars.

Fortunately, cheaper telescopes are all that is needed for surveying the sky at the proper resolution to identify UAP. Under typical weather conditions, Earth’s atmosphere is opaque plan renova ecuador to infrared light beyond a distance of about 10 kilometers or less. Resolving a feature the size of a cell phone on the surface of a UAP at that distance requires a telescope diameter on the order of 10 centimeters. Having a few such telescopes on a given site will allow us to monitor the motion of an object in three dimensions.

These telescopes could be plan renova ecuador supplemented by a radar system that would distinguish a physical object in the sky from a weather pattern or a mirage. If UAP are solid objects, they should heat up as they rub against air at high speed. The surfaces of objects that move in air faster than sound, such as supersonic airplanes or space rockets, are heated by hundreds of degrees. I calculated that the infrared glow of fast objects above a meter plan renova ecuador in size, supplemented by the heat from shockwaves in the air around them or an engine they carry, should be detectable with infrared sensors on telescopes out to the desired distance.

The data from a system of optical, infrared or radio telescopes will be fed to state-of-the-art video cameras linked to software that will filter out objects of interest for the telescope to track. If a bird flies above a common astronomical observatory, it will be ignored. The Galileo-Scopes will track it plan renova ecuador. Human-made drones or airplanes might be of great interest to some residents of Washington, D.C., but they are as uninteresting as birds for the Galileo Project.

My student Amir Siraj and I calculated that the number of UAP described in the ODNI report corresponds to about one object per hundred thousand square kilometers per year (with large uncertainties up to a factor of 100). This is well below the rate of unidentified objects from cell phone photographs or civilian eyewitness testimonies, implying that many plan renova ecuador of these unofficial sightings may have mundane explanations. Millions of cell phones with millimeter-size apertures are inferior to what Galileo proposes. A much smaller number of optimized telescope systems with apertures 100 times larger that are designed to rapidly track UAP.

The iceberg of classified reports‑of plan renova ecuador which only the tip has been exposed publicly‑may contain higher-quality images than those released to the public. Galileo’s goal is to capture new crisp images with better instruments than have ever been used by civilians. The full data set from the project will be open, whereas much of the data associated with the ODNI report is classified because it was obtained by government-owned sensors. Because the sky is not classified, plan renova ecuador Galileo-Scopes will operate just like common astronomical telescopes‑except that they will focus on nearby objects.

We aim to change the intellectual landscape of UAP studies by bringing them into the mainstream of credible scientific inquiry. In my book Extraterrestrial, published half a year ago, I argued that bringing the search for technological relics into the mainstream of astronomy would attract new funds and young talent to science. In recent weeks, plan renova ecuador this forecast became a reality. The Galileo Project has attracted millions of dollars from private donors and thousands of commitments from volunteers who offered to contribute their time and resources.

Given the low incidence of UAP reported by ODNI, however, the project will need hundreds of telescopes to find UAP over a few years. That represents an order of magnitude more funding plan renova ecuador than we have collected so far. With good enough data, extraterrestrial technologies can be distinguished from terrestrial technologies or natural objects. The Galileo Project will attempt to obtain this data from both UAP and unusual interstellar objects like `Oumuamua.

If prehistoric cave dwellers were to discover a cell phone, they plan renova ecuador would initially assume it to be a shiny rock of a type never seen before. But this might be the beginning of their learning experience. By pressing buttons on this weird rock, these early humans would record voices and images. Similarly, the strange `Oumuamua has been interpreted as a new type of asteroid, such as a frozen chunk of pure plan renova ecuador hydrogen or nitrogen.

But what if high-resolution images of such a weird object revealed buttons?. It could encourage us to learn more by landing on the surface, just as the OSIRIS-REx craft recently landed on the asteroid Bennu. Here’s hoping that astronomers will plan renova ecuador be open-minded enough to check. This is an opinion and analysis article.

The views expressed by the author or authors are not necessarily those of Scientific American..

When purchasing a new phone or renova where to buy tablet, it is common practice to select the best technology that fits your needs within the available budget. This is also the strategy adopted by our research team at the Galileo Project, a new initiative to image unidentified aerial phenomena (UAP) like those reported by the Office of the Director of National Intelligence (ODNI) to the U.S. Congress on June 25, renova where to buy 2021.

To my amusement, I recently came across an online retailer that would allow us to “add to cart” a one-meter telescope for half a million dollars. Fortunately, cheaper telescopes are all that is needed for surveying the sky at the proper resolution to identify UAP. Under typical weather conditions, Earth’s renova where to buy atmosphere is opaque to infrared light beyond a distance of about 10 kilometers or less.

Resolving a feature the size of a cell phone on the surface of a UAP at that distance requires a telescope diameter on the order of 10 centimeters. Having a few such telescopes on a given site will allow us to monitor the motion of an object in three dimensions. These telescopes could be supplemented renova where to buy by a radar system that would distinguish a physical object in the sky from a weather pattern or a mirage.

If UAP are solid objects, they should heat up as they rub against air at high speed. The surfaces of objects that move in air faster than sound, such as supersonic airplanes or space rockets, are heated by hundreds of degrees. I calculated that the infrared glow of fast objects above a meter in size, supplemented by the heat from shockwaves in the air around them or an renova where to buy engine they carry, should be detectable with infrared sensors on telescopes out to the desired distance.

The data from a system of optical, infrared or radio telescopes will be fed to state-of-the-art video cameras linked to software that will filter out objects of interest for the telescope to track. If a bird flies above a common astronomical observatory, it will be ignored. The Galileo-Scopes will track it renova where to buy.

Human-made drones or airplanes might be of great interest to some residents of Washington, D.C., but they are as uninteresting as birds for the Galileo Project. My student Amir Siraj and I calculated that the number of UAP described in the ODNI report corresponds to about one object per hundred thousand square kilometers per year (with large uncertainties up to a factor of 100). This is well below the rate of unidentified objects from cell phone photographs or renova where to buy civilian eyewitness testimonies, implying that many of these unofficial sightings may have mundane explanations.

Millions of cell phones with millimeter-size apertures are inferior to what Galileo proposes. A much smaller number of optimized telescope systems with apertures 100 times larger that are designed to rapidly track UAP. The iceberg renova where to buy of classified reports‑of which only the tip has been exposed publicly‑may contain higher-quality images than those released to the public.

Galileo’s goal is to capture new crisp images with better instruments than have ever been used by civilians. The full data set from the project will be open, whereas much of the data associated with the ODNI report is classified because it was obtained by government-owned sensors. Because the renova where to buy sky is not classified, Galileo-Scopes will operate just like common astronomical telescopes‑except that they will focus on nearby objects.

We aim to change the intellectual landscape of UAP studies by bringing them into the mainstream of credible scientific inquiry. In my book Extraterrestrial, published half a year ago, I argued that bringing the search for technological relics into the mainstream of astronomy would attract new funds and young talent to science. In recent weeks, this forecast became a renova where to buy reality.

The Galileo Project has attracted millions of dollars from private donors and thousands of commitments from volunteers who offered to contribute their time and resources. Given the low incidence of UAP reported by ODNI, however, the project will need hundreds of telescopes to find UAP over a few years. That represents an order of magnitude renova where to buy more funding than we have collected so far.

With good enough data, extraterrestrial technologies can be distinguished from terrestrial technologies or natural objects. The Galileo Project will attempt to obtain this data from both UAP and unusual interstellar objects like `Oumuamua. If prehistoric cave dwellers were to discover a cell phone, they would initially assume it to be renova where to buy a shiny rock of a type never seen before.

But this might be the beginning of their learning experience. By pressing buttons on this weird rock, these early humans would record voices and images. Similarly, the strange `Oumuamua renova where to buy has been interpreted as a new type of asteroid, such as a frozen chunk of pure hydrogen or nitrogen.

But what if high-resolution images of such a weird object revealed buttons?. It could encourage us to learn more by landing on the surface, just as the OSIRIS-REx craft recently landed on the asteroid Bennu. Here’s hoping that renova where to buy astronomers will be open-minded enough to check.

This is an opinion and analysis article. The views expressed by the author or authors are not necessarily those of Scientific American..

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New collection Antabuse buy online uk (Request for a new OMB renova orange toilet paper control number). Title of Information Collection. Evaluation of Risk Adjustment Data Validation (RADV) Appeals and Health Insurance Exchange Outreach Training Sessions. Use.

CMS recognizes that the success of accurately identifying risk-adjustment payments and payment errors is dependent upon the data submitted by Medicare Advantage Organizations (MAOs), and is strongly committed to providing appropriate education and technical outreach to MAOs and third-party administrators (TPAs). In addition, CMS is strongly committed to providing appropriate education and technical outreach to States, issuers, self-insured group health plans and TPAs participating in the Marketplace and/or market stabilization programs mandated by the Affordable Care Act (ACA). CMS will strengthen outreach and engagement with MAOs and stakeholders in the Marketplace through satisfaction surveys following contract-level (CON) RADV audit and Health Insurance Exchange training events. The survey results will help to determine stakeholders' level of satisfaction with trainings, identify any issues with training and technical assistance delivery, clarify stakeholders' needs and preferences, and define best practices for training and technical assistance.

Form Number. CMS-10764 (OMB control number. 0938-NEW). Frequency.

Occasionally. Affected Public. Private Sector. Number of Respondents.

4,270. Total Annual Responses. 4,270. Total Annual Hours.

1,068. (For questions regarding this collection contact Melissa Barkai at 410-786-4305.) 2. Type of Information Collection Request. Extension of a currently approved collection.

Title of information Collection. Disclosure of State Rating Requirements. Use. The final rule “Patient Protection and Affordable Care Act.

Health Insurance Market Rules. Rate Review” implements sections 2701, 2702, and 2703 of the Public Health Service Act (PHS Act), as added and amended by the Affordable Care Act, and sections 1302(e) and 1312(c) of the Affordable Care Act. The rule directs that states submit to CMS certain information about state rating and risk pooling requirements for their individual, small group, and large group markets, as applicable. Specifically, states will inform CMS of age rating ratios that are narrower than 3:1 for adults.

Tobacco use rating ratios that are narrower than 1.5:1. A state-established uniform age curve. Geographic rating areas. Whether premiums in the small and large group market are required to be based on average enrollee amounts (also known as composite premiums).

And, in states that do not permit any rating variation based on age or tobacco use, uniform family tier structures and corresponding multipliers. In addition, states that elect to merge their individual and small group market risk pools into a combined pool will notify CMS of such election. This information will allow CMS to determine whether state-specific rules apply or Federal default rules apply. It will also support the accuracy of the federal risk adjustment methodology.

Form Number. CMS-10454 (OMB control number 0938-1258). Frequency. Occasionally.

Affected Public. State, Local, or Tribal Governments. Number of Respondents. 3.

Total Annual Responses. 3. Total Annual Hours. 17.

(For policy questions regarding this collection contact Russell Tipps at 301-869-3502.) 3. Type of Information Collection Request. Extension of a currently approved collection. Title of Information Collection.

Quality Improvement Organization (QIO) Assumption of Responsibilities and Supporting Regulations. Use. The Peer Review Improvement Act of 1982 amended Title XI of the Social Security Act to create the Utilization and Quality Control Peer Review Organization (PRO) program which replaces the Professional Standards Review Organization (PSRO) program and streamlines peer review activities. The term PRO has been renamed Quality Improvement Organization (QIO).

This information collection describes the review functions to be performed by the QIO. It outlines relationships among QIOs, providers, practitioners, beneficiaries, intermediaries, and carriers. Form Number. CMS-R-71 (OMB control number.

0938-0445). Frequency. Yearly. Affected Public.

Business or other for-profit and Not-for-profit institutions. Number of Respondents. 6,939. Total Annual Responses.

972,478. Total Annual Hours. 1,034,655. (For policy questions regarding this collection contact Kimberly Harris at 401-837-1118.) 4.

Type of Information Collection Request. Extension of a currently approved collection. Titles of Information Collection. ASC Forms for Medicare Program Certification.

Use. The form CMS-370 titled “Health Insurance Benefits Agreement” is used for the purpose of establishing an ASC's eligibility for payment under Title XVIII of the Social Security Act (the “Act”). This agreement, upon acceptance by the Secretary of Health &. Human Services, shall be binding on the ASC and the Secretary.

The agreement may be Start Printed Page 73722terminated by either party in accordance with regulations. In the event of termination of this agreement, payment will not be available for the ASC's services furnished to Medicare beneficiaries on or after the effective date of termination. The CMS-377 form is used by ASCs to initiate both the initial and renewal survey by the State Survey Agency, which provides the certification required for an ASC to participate in the Medicare program. An ASC must complete the CMS-377 form and send it to the appropriate State Survey Agency prior to their scheduled accreditation renewal date.

The CMS-377 form provides the State Survey Agency with information about the ASC facility's characteristics, such as, determining the size and the composition of the survey team on the basis of the number of ORs/procedure rooms and the types of surgical procedures performed in the ASC. Form Numbers. CMS-370 and CMS-377 (OMB control number. 0938-0266).

Frequency. Occasionally. Affected Public. Private Sector—Business or other for-profit and Not-for-profit institutions.

Number of Respondents. 1,567. Total Annual Responses. 1,567.

Total Annual Hours. 1,012. (For policy questions regarding this collection contact Caroline Gallaher at 410-786-8705.) 5. Type of Information Collection Request.

Revision of a currently approved collection. Title of Information Collection. Home Health Agency Survey and Deficiencies Report. Use.

In order to participate in the Medicare Program as a Home Health Agency (HHA) provider, the HHA must meet federal standards. This form is used to record information and patients' health and provider compliance with requirements and to report the information to the federal government. Form Number. CMS-1572 (OMB control number.

0938-0355). Frequency. Yearly. Affected Public.

State, Local or Tribal Government. Number of Respondents. 3,833. Total Annual Responses.

3,833. Total Annual Hours. 1,917. (For policy questions regarding this collection contact Tara Lemons at 410-786-3030.) 6.

Type of Information Collection Request. Extension of a currently approved collection. Title of Information Collection. Disclosure Requirement for the In-Office Ancillary Services Exception.

Use. Section 6003 of the Affordable Care Act (ACA) established a new disclosure requirement that a physician must perform for certain imaging services to meet the in-office ancillary services exception to the prohibition of the physician self-referral law. This section of the ACA amended section 1877(b)(2) of the Act by adding a requirement that the referring physician informs the patient, at the time of the referral and in writing, that the patient may receive the imaging service from another supplier. Physicians who provide certain imaging services (MRI, CT, and PET) under the in-office ancillary services exception to the physician self-referral prohibition are required to provide the disclosure notice as well as the list of other imaging suppliers to the patient.

The patient will then be able to use the disclosure notice and list of suppliers in making an informed decision about his or her course of care for the imaging service. CMS would use the collected information for enforcement purposes. Specifically, if we were investigating the referrals of a physician providing advanced imaging services under the in- office ancillary services exception, we would review the written disclosure in order to determine if it satisfied the requirement. Form Number.

CMS-10332 (OMB control number. 0938-1133). Frequency. Occasionally.

Affected Public. Private Sector, Business or other for-profits, Not-for-profits institutions. Number of Respondents. 2,239.

Total Annual Responses. 989,971. Total Annual Hours. 18,694.

(For questions regarding this collection contact Laura Dash at 410-786-8623.) Start Signature Dated. November 16, 2020. William N. Parham, III, Director, Paperwork Reduction Staff, Office of Strategic Operations and Regulatory Affairs.

End Signature End Supplemental Information [FR Doc. 2020-25598 Filed 11-18-20. 8:45 am]BILLING CODE 4120-01-PStart Preamble Centers for Medicare &. Medicaid Services (CMS), Department of Health and Human Services (HHS).

Notice of new matching program. In accordance with subsection (e)(12) of the Privacy Act of 1974, as amended, the Department of Health and Human Services (HHS), Centers for Medicare &. Medicaid Services (CMS) is providing notice of the re-establishment of a matching program between CMS and the Social Security Administration (SSA), “Determining Enrollment or Eligibility for Insurance Affordability Programs Under the Patient Protection and Affordable Care Act.” The deadline for comments on this notice is December 21, 2020. The re-established matching program will commence not sooner than 30 days after publication of this notice, provided no comments are received that warrant a change to this notice.

The matching program will be conducted for an initial term of 18 months (from approximately March 9, 2021 to September 8, 2022) and within three months of expiration may be renewed for one additional year if the parties make no change to the matching program and certify that the program has been conducted in compliance with the matching agreement. Interested parties may submit comments on the new matching program to the CMS Privacy Officer by mail at. Division of Security, Privacy Policy &. Governance, Information Security &.

Privacy Group, Office of Information Technology, Centers for Medicare &. Medicaid Services, Location. N1-14-56, 7500 Security Blvd., Baltimore, MD 21244-1850, or walter.stone@cms.hhs.gov. Start Further Info If you have questions about the matching program, you may contact Anne Pesto, Senior Advisor, Marketplace Eligibility and Enrollment Group, Center for Consumer Information and Insurance Oversight, Centers for Medicare &.

Medicaid Services, at 410-786-3492, by email at anne.pesto@cms.hhs.gov, or by mail at 7500 Security Blvd., Baltimore, MD 21244. End Further Info End Preamble Start Supplemental Information The Privacy Act of 1974, as amended (5 U.S.C. 552a) provides certain protections for individuals applying for and receiving federal benefits. The law governs the use of computer matching by federal agencies when records in a system of records (meaning, federal agency records about individuals retrieved by name or other personal identifier) are matched with records of other federal or non-federal agencies.

The Privacy Act requires agencies involved in a matching program to. 1. Enter into a written agreement, which must be prepared in accordance with the Privacy Act, approved by the Data Integrity Board of each source and recipient federal agency, provided to Congress and the Office of Management and Budget (OMB), and made available to the public, as required by 5 U.S.C.

(For policy questions regarding this collection contact Russell Tipps at 301-869-3502.) 3. Type of Information Collection Request. Extension of a currently approved collection.

Title of Information Collection. Quality Improvement Organization (QIO) Assumption of Responsibilities and Supporting Regulations. Use.

The Peer Review Improvement Act of 1982 amended Title XI of the Social Security Act to create the Utilization and Quality Control Peer Review Organization (PRO) program which replaces the Professional Standards Review Organization (PSRO) program and streamlines peer review activities. The term PRO has been renamed Quality Improvement Organization (QIO). This information collection describes the review functions to be performed by the QIO.

It outlines relationships among QIOs, providers, practitioners, beneficiaries, intermediaries, and carriers. Form Number. CMS-R-71 (OMB control number.

Affected Public. Business or other for-profit and Not-for-profit institutions. Number of Respondents.

Total Annual Hours. 1,034,655. (For policy questions regarding this collection contact Kimberly Harris at 401-837-1118.) 4.

Type of Information Collection Request. Extension of a currently approved collection. Titles of Information Collection.

ASC Forms for Medicare Program Certification. Use. The form CMS-370 titled “Health Insurance Benefits Agreement” is used for the purpose of establishing an ASC's eligibility for payment under Title XVIII of the Social Security Act (the “Act”).

This agreement, upon acceptance by the Secretary of Health &. Human Services, shall be binding on the ASC and the Secretary. The agreement may be Start Printed Page 73722terminated by either party in accordance with regulations.

In the event of termination of this agreement, payment will not be available for the ASC's services furnished to Medicare beneficiaries on or after the effective date of termination. The CMS-377 form is used by ASCs to initiate both the initial and renewal survey by the State Survey Agency, which provides the certification required for an ASC to participate in the Medicare program. An ASC must complete the CMS-377 form and send it to the appropriate State Survey Agency prior to their scheduled accreditation renewal date.

The CMS-377 form provides the State Survey Agency with information about the ASC facility's characteristics, such as, determining the size and the composition of the survey team on the basis of the number of ORs/procedure rooms and the types of surgical procedures performed in the ASC. Form Numbers. CMS-370 and CMS-377 (OMB control number.

Affected Public. Private Sector—Business or other for-profit and Not-for-profit institutions. Number of Respondents.

Total Annual Hours. 1,012. (For policy questions regarding this collection contact Caroline Gallaher at 410-786-8705.) 5.

Type of Information Collection Request. Revision of a currently approved collection. Title of Information Collection.

Home Health Agency Survey and Deficiencies Report. Use. In order to participate in the Medicare Program as a Home Health Agency (HHA) provider, the HHA must meet federal standards.

This form is used to record information and patients' health and provider compliance with requirements and to report the information to the federal government. Form Number. CMS-1572 (OMB control number.

Affected Public. State, Local or Tribal Government. Number of Respondents.

Total Annual Hours. 1,917. (For policy questions regarding this collection contact Tara Lemons at 410-786-3030.) 6.

Type of Information Collection Request. Extension of a currently approved collection. Title of Information Collection.

Disclosure Requirement for the In-Office Ancillary Services Exception. Use. Section 6003 of the Affordable Care Act (ACA) established a new disclosure requirement that a physician must perform for certain imaging services to meet the in-office ancillary services exception to the prohibition of the physician self-referral law.

This section of the ACA amended section 1877(b)(2) of the Act by adding a requirement that the referring physician informs the patient, at the time of the referral and in writing, that the patient may receive the imaging service from another supplier. Physicians who provide certain imaging services (MRI, CT, and PET) under the in-office ancillary services exception to the physician self-referral prohibition are required to provide the disclosure notice as well as the list of other imaging suppliers to the patient. The patient will then be able to use the disclosure notice and list of suppliers in making an informed decision about his or her course of care for the imaging service.

CMS would use the collected information for enforcement purposes. Specifically, if we were investigating the referrals of a physician providing advanced imaging services under the in- office ancillary services exception, we would review the written disclosure in order to determine if it satisfied the requirement. Form Number.

CMS-10332 (OMB control number. 0938-1133). Frequency.

Occasionally. Affected Public. Private Sector, Business or other for-profits, Not-for-profits institutions.

Number of Respondents. 2,239. Total Annual Responses.

(For questions regarding this collection contact Laura Dash at 410-786-8623.) Start Signature Dated. November 16, 2020. William N.

Parham, III, Director, Paperwork Reduction Staff, Office of Strategic Operations and Regulatory Affairs. End Signature End Supplemental Information [FR Doc. 2020-25598 Filed 11-18-20.

8:45 am]BILLING CODE 4120-01-PStart Preamble Centers for Medicare &. Medicaid Services (CMS), Department of Health and Human Services (HHS). Notice of new matching program.

In accordance with subsection (e)(12) of the Privacy Act of 1974, as amended, the Department of Health and Human Services (HHS), Centers for Medicare &. Medicaid Services (CMS) is providing notice of the re-establishment of a matching program between CMS and the Social Security Administration (SSA), “Determining Enrollment or Eligibility for Insurance Affordability Programs Under the Patient Protection and Affordable Care Act.” The deadline for comments on this notice is December 21, 2020. The re-established matching program will commence not sooner than 30 days after publication of this notice, provided no comments are received that warrant a change to this notice.

The matching program will be conducted for an initial term of 18 months (from approximately March 9, 2021 to September 8, 2022) and within three months of expiration may be renewed for one additional year if the parties make no change to the matching program and certify that the program has been conducted in compliance with the matching agreement. Interested parties may submit comments on the new matching program to the CMS Privacy Officer by mail at. Division of Security, Privacy Policy &.

Governance, Information Security &. Privacy Group, Office of Information Technology, Centers for Medicare &. Medicaid Services, Location.

N1-14-56, 7500 Security Blvd., Baltimore, MD 21244-1850, or walter.stone@cms.hhs.gov. Start Further Info If you have questions about the matching program, you may contact Anne Pesto, Senior Advisor, Marketplace Eligibility and Enrollment Group, Center for Consumer Information and Insurance Oversight, Centers for Medicare &. Medicaid Services, at 410-786-3492, by email at anne.pesto@cms.hhs.gov, or by mail at 7500 Security Blvd., Baltimore, MD 21244.

End Further Info End Preamble Start Supplemental Information The Privacy Act of 1974, as amended (5 U.S.C. 552a) provides certain protections for individuals applying for and receiving federal benefits. The law governs the use of computer matching by federal agencies when records in a system of records (meaning, federal agency records about individuals retrieved by name or other personal identifier) are matched with records of other federal or non-federal agencies.

The Privacy Act requires agencies involved in a matching program to. 1. Enter into a written agreement, which must be prepared in accordance with the Privacy Act, approved by the Data Integrity Board of each source and recipient federal agency, provided to Congress and the Office of Management and Budget (OMB), and made available to the public, as required by 5 U.S.C.

552a(o), (u)(3)(A), and (u)(4). 2. Notify the individuals whose information will be used in the matching program that the information they provide is subject to verification through matching, as required by 5 U.S.C.

552a(o)(1)(D). 3. Verify match findings before suspending, terminating, reducing, or making a final denial of an individual's benefits or payments or taking other adverse action against the individual, as required by 5 U.S.C.

552a(p). 4. Report the matching program to Congress and the OMB, in advance and Start Printed Page 73720annually, as required by 5 U.S.C.

552a(o) (2)(A)(i), (r), and (u)(3)(D). 5. Publish advance notice of the matching program in the Federal Register as required by 5 U.S.C.

552a(e)(12). This matching program meets these requirements. Start Signature Barbara Demopulos, Privacy Advisor, Division of Security, Privacy Policy and Governance, Office of Information Technology, Centers for Medicare &.

Medicaid Services. End Signature PARTICIPATING AGENCIES. The Department of Health and Human Services (HHS), Centers for Medicare &.

Medicaid Services (CMS) is the recipient agency, and the Social Security Administration (SSA) is the source agency. AUTHORITY FOR CONDUCTING THE MATCHING PROGRAM. The statutory authority for the matching program is 42 U.S.C.

The purpose of the matching program is to provide CMS with SSA information which CMS and state-based administering entities will use to determine individuals' eligibility for initial enrollment in a Qualified Health Plan through an Exchange established under the Patient Protection and Affordable Care Act, for Insurance Affordability Programs (IAPs), and certificates of exemption from the shared responsibility payment. And to make eligibility redeterminations and renewal decisions, including appeal determinations. IAPs include.

1. Advance payments of the premium tax credit (APTC) and cost sharing reductions (CSRs), 2. Medicaid, 3.

Children's Health Insurance Program (CHIP), and 4. Basic Health Program (BHP). CATEGORIES OF INDIVIDUALS.

The individuals whose information will be used in the matching program are consumers (applicants and enrollees) who receive the eligibility determinations and redeterminations described in the preceding Purpose(s) section. CATEGORIES OF RECORDS. The categories of records used in the matching program are identity information, citizenship, death/disability indicators, incarceration information, and income.

To request information from SSA, CMS will submit a submission file to SSA that contains the following mandatory specified data elements. Last name, first name, date of birth, Social Security Number (SSN), and citizenship indicator. When SSA is able to match the SSN and name provided by CMS and information is available, SSA will provide CMS with the following about each individual, as relevant.

Last name, first name, date of birth, death indicator, disability indicator, incarceration information, Title II (annual and monthly) income information, and confirmation of attestations of citizenship status and SSN. SSA may also provide Quarters of Coverage data when CMS requests it. System of Records Maintained by CMS CMS Health Insurance Exchanges System (HIX), CMS System No.

09-70-0560, last published in full at 78 FR 63211 (Oct. 23, 2013), and amended at 83 FR 6591 (Feb. 14, 2018).

Routine use 3 authorizes CMS' disclosures of identifying information about applicants to SSA for use in this matching program. B. Systems of Records Maintained by SSA The SSA SORNs and routine uses that support this matching program are identified below.

(1) Master Files of SSN Holders and SSN Applications, 60-0058, last fully published at 75 FR 82121 (Dec.

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For immediate renova energy corp release. October 19, renova energy corp 2020Boston, MA – Air pollution was significantly associated with an increased risk of hospital admissions for several neurological disorders, including Parkinson’s disease, Alzheimer’s disease, and other dementias, in a long-term study of more than 63 million older U.S. Adults, led by researchers at Harvard T.H. Chan School of Public Health.The study, conducted with colleagues at Emory University’s Rollins School of Public Health and Columbia University’s Mailman School of Public Health, is the renova energy corp first nationwide analysis of the link between fine particulate (PM2.5) pollution and neurodegenerative diseases in the U.S. The researchers leveraged an unparalleled amount of data compared to any previous study of air pollution and neurological disorders.The study was published online October 19, 2020 in The Lancet Planetary Health.“The 2020 report of the Lancet Commission on dementia prevention, intervention, and care has added air pollution as one of the modifiable risk factors for these outcomes,” said Xiao Wu, doctoral student in biostatistics at Harvard Chan School and co-lead author of the study.

€œOur study builds on the small but emerging evidence base indicating that long-term PM2.5 exposures are linked to an increased risk of neurological health deterioration, even at PM2.5 concentrations well below the renova energy corp current national standards.”Researchers looked at 17 years’ worth (2000–2016) of hospital admissions data from 63,038,019 Medicare recipients in the U.S. And linked these with estimated PM2.5 concentrations by zip code renova energy corp. Taking into account potential confounding factors like socioeconomic status, they found that, for each 5 microgram per cubic meter of air (μg/m3) increase in annual PM2.5 concentrations, there was a 13% increased risk for first-time hospital admissions both for Parkinson’s disease and for Alzheimer’s disease and related dementias. This risk remained renova energy corp elevated even below supposedly safe levels of PM2.5 exposure, which, according to current U.S. Environmental Protection Agency standards, is an annual average of 12 μg/m3 or less.Women, white people, and urban populations were particularly susceptible, the study found.

The highest risk for first-time Parkinson’s disease hospital admissions was among older adults renova energy corp in the northeastern U.S. For first-time Alzheimer’s disease and related dementias hospital admissions, older adults in the Midwest faced the highest risk.“Our U.S.-wide study shows that the current standards are not protecting the aging American population enough, highlighting the need for stricter standards and policies that help further reduce PM2.5 concentrations and improve air quality overall,” said Antonella Zanobetti, principal research scientist in Harvard Chan School’s Department of Environmental Health and co-senior author of the study.Liuhua Shi, research assistant professor at Emory’s Rollins School of Public Health, was a co-lead author and Marianthi-Anna Kioumourtzoglou, assistant professor in environmental health sciences at Columbia’s Mailman School of Public Health, was a co-senior author.Other Harvard Chan School authors included Mahdieh Danesh Yazdi, Danielle Braun, Yaguang Wei, Yun Wang, Joel Schwartz, and Francesca Dominici.This study was supported by the Health Effects Institute (4953-RFA14-3/16-4), the National Institute of Environmental Health Sciences (NIEHS R01 ES024332, R01 ES028805, R21 ES028472, P30 ES009089, P30 ES000002), the National Institute on Aging (NIA/NIH R01 AG066793-01, P50 AG025688), and the HERCULES Center (P30ES019776). Research described in this article was done under contract to the Health Effects Institute, an organization jointly renova energy corp funded by the U.S. Environmental Protection Agency (assistance award number R-83467701) and some motor vehicle and engine manufacturers.“Long-term effects renova energy corp of PM2.5 on neurological disorders in the American Medicare population. A longitudinal cohort study,” Liuhua Shi, Xiao Wu, Mahdieh Danesh Yazdi, Danielle Braun, Yara Abu Awad, Yaguang Wei, Pengfei Liu, Qian Di, Yun Wang, Joel Schwartz, Francesca Dominici, Marianthi-Anna Kioumourtzoglou, Antonella Zanobetti, The Lancet Planetary Health, online October 19, 2020, doi.

Https://doi.org/10.1016/S2542-5196(20)30227-8Photo. IStock/hapabapaVisit the Harvard Chan School website for the latest news, press releases, and multimedia offerings.Nicole Rura617.221.4241nrura@hsph.harvard.edu###Harvard T.H. Chan School of Public Health brings together dedicated experts from many disciplines to educate new generations of global health leaders and produce powerful ideas that improve the lives and health of people everywhere. As a community of leading scientists, educators, and students, we work together to take innovative ideas from the laboratory to people’s lives—not only making scientific breakthroughs, but also working to change individual behaviors, public policies, and health care practices. Each year, more than 400 faculty members at Harvard Chan School teach 1,000-plus full-time students from around the world and train thousands more through online and executive education courses.

Founded in 1913 as the Harvard-MIT School of Health Officers, the School is recognized as America’s oldest professional training program in public health.CORVALLIS, Ore. €“ Oregon State University scientists have developed a method that could potentially predict the cancer-causing potential of chemicals released into the air during wildfires and fossil fuel combustion. The research, which was recently published in the journal Toxicology in Vitro, was conducted as a part of the OSU Superfund Research Program. The findings are important for agencies that regulate air pollution caused by these chemicals, known as polycyclic aromatic hydrocarbons (PAHs). It also could help medical researchers who study patients with conditions such as asthma.

PAHs are a class of chemicals that occur naturally in coal, crude oil and gasoline. They also are produced when coal, oil, gas, wood, garbage and tobacco are burned. At high levels, as was the case during recent wildfires in the western United States, when PAHs are inhaled they can be harmful to human health. Despite PAHs being the first class of chemicals identified as cancer-causing, little is known about the carcinogenic potential of the more than 1,500 PAHs. Part of the challenge is that PAHs usually occur as a mixture of chemicals, making it difficult to tease apart roles of individual chemicals in the mixture.

The OSU researchers, led by Susan Tilton, an associate professor in the Department of Environmental and Molecular Toxicology in the College of Agricultural Sciences, have been studying PAHs for over six years. They previously developed a system to predict whether tumors formed in mice exposed to certain PAHs. The current research translates that approach using human bronchial cells. The researchers treated the cells with individual PAHs and then used computational analysis to look at changes across thousands of genes simultaneously to identify gene signatures. They then looked for gene signatures consistent across the different chemicals with similar carcinogenic potential.

€œThose with similar carcinogenic potential are the ones we can focus on,” Tilton said. €œPotentially, in the future we wouldn’t need to look at thousands and thousands of genes. Once we tested enough chemicals and felt very confident about this we could drill down and look at a select handful of genes in order to make these types of predictions.” In the future, the researchers plan to expand the number of chemicals that they test, particularly chemicals whose carcinogenic potential is not well understood. They also want to study lung cells from people with pre-existing conditions, such as asthma and chronic obstructive pulmonary disease, to see if they are particularly sensitive to certain chemicals. Co-authors of the paper were Yvonne Chang, Celine Thanh Thu Huynh, Kelley M.

Bastin, Brianna N. Rivera, Lisbeth K. Siddens, all of Oregon State..

For immediate http://www.em-jacques-prevert-schiltigheim.ac-strasbourg.fr/?slideshow=noel release renova where to buy. October 19, 2020Boston, MA – Air pollution was significantly associated with an increased risk of hospital admissions renova where to buy for several neurological disorders, including Parkinson’s disease, Alzheimer’s disease, and other dementias, in a long-term study of more than 63 million older U.S. Adults, led by researchers at Harvard T.H.

Chan School of Public Health.The study, conducted with colleagues at Emory University’s Rollins School of Public Health and Columbia University’s Mailman School of Public Health, is the first nationwide analysis of the link between fine particulate (PM2.5) pollution and neurodegenerative diseases in renova where to buy the U.S. The researchers leveraged an unparalleled amount of data compared to any previous study of air pollution and neurological disorders.The study was published online October 19, 2020 in The Lancet Planetary Health.“The 2020 report of the Lancet Commission on dementia prevention, intervention, and care has added air pollution as one of the modifiable risk factors for these outcomes,” said Xiao Wu, doctoral student in biostatistics at Harvard Chan School and co-lead author of the study. €œOur study builds on the small but emerging evidence base indicating that long-term PM2.5 exposures are linked to an increased risk of neurological health deterioration, even at PM2.5 concentrations well below the current national standards.”Researchers looked at 17 years’ worth (2000–2016) of hospital admissions renova where to buy data from 63,038,019 Medicare recipients in the U.S.

And linked these with estimated PM2.5 renova where to buy concentrations by zip code. Taking into account potential confounding factors like socioeconomic status, they found that, for each 5 microgram per cubic meter of air (μg/m3) increase in annual PM2.5 concentrations, there was a 13% increased risk for first-time hospital admissions both for Parkinson’s disease and for Alzheimer’s disease and related dementias. This risk remained elevated even below supposedly safe levels of PM2.5 exposure, which, according to renova where to buy current U.S.

Environmental Protection Agency standards, is an annual average of 12 μg/m3 or less.Women, white people, and urban populations were particularly susceptible, the study found. The highest risk for first-time Parkinson’s renova where to buy disease hospital admissions was among older adults in the northeastern U.S. For first-time Alzheimer’s disease and related dementias hospital admissions, older adults in the Midwest faced the highest risk.“Our U.S.-wide study shows that the current standards are not protecting the aging American population enough, highlighting the need for stricter standards and policies that help further reduce PM2.5 concentrations and improve air quality overall,” said Antonella Zanobetti, principal research scientist in Harvard Chan School’s Department of Environmental Health and co-senior author of the study.Liuhua Shi, research assistant professor at Emory’s Rollins School of Public Health, was a co-lead author and Marianthi-Anna Kioumourtzoglou, assistant professor in environmental health sciences at Columbia’s Mailman School of Public Health, was a co-senior author.Other Harvard Chan School authors included Mahdieh Danesh Yazdi, Danielle Braun, Yaguang Wei, Yun Wang, Joel Schwartz, and Francesca Dominici.This study was supported by the Health Effects Institute (4953-RFA14-3/16-4), the National Institute of Environmental Health Sciences (NIEHS R01 ES024332, R01 ES028805, R21 ES028472, P30 ES009089, P30 ES000002), the National Institute on Aging (NIA/NIH R01 AG066793-01, P50 AG025688), and the HERCULES Center (P30ES019776).

Research described renova where to buy in this article was done under contract to the Health Effects Institute, an organization jointly funded by the U.S. Environmental Protection Agency (assistance award number R-83467701) and some motor vehicle and engine manufacturers.“Long-term effects of PM2.5 on neurological disorders in renova where to buy the American Medicare population. A longitudinal cohort study,” Liuhua Shi, Xiao Wu, Mahdieh Danesh Yazdi, Danielle Braun, Yara Abu Awad, Yaguang Wei, Pengfei Liu, Qian Di, Yun Wang, Joel Schwartz, Francesca Dominici, Marianthi-Anna Kioumourtzoglou, Antonella Zanobetti, The Lancet Planetary Health, online October 19, 2020, doi.

Https://doi.org/10.1016/S2542-5196(20)30227-8Photo. IStock/hapabapaVisit the Harvard Chan School website for the latest news, press releases, and multimedia offerings.Nicole Rura617.221.4241nrura@hsph.harvard.edu###Harvard T.H. Chan School of Public Health brings together dedicated experts from many disciplines to educate new generations of global health leaders and produce powerful ideas that improve the lives and health of people everywhere.

As a community of leading scientists, educators, and students, we work together to take innovative ideas from the laboratory to people’s lives—not only making scientific breakthroughs, but also working to change individual behaviors, public policies, and health care practices. Each year, more than 400 faculty members at Harvard Chan School teach 1,000-plus full-time students from around the world and train thousands more through online and executive education courses. Founded in 1913 as the Harvard-MIT School of Health Officers, the School is recognized as America’s oldest professional training program in public health.CORVALLIS, Ore.

€“ Oregon State University scientists have developed a method that could potentially predict the cancer-causing potential of chemicals released into the air during wildfires and fossil fuel combustion. The research, which was recently published in the journal Toxicology in Vitro, was conducted as a part of the OSU Superfund Research Program. The findings are important for agencies that regulate air pollution caused by these chemicals, known as polycyclic aromatic hydrocarbons (PAHs).

It also could help medical researchers who study patients with conditions such as asthma. PAHs are a class of chemicals that occur naturally in coal, crude oil and gasoline. They also are produced when coal, oil, gas, wood, garbage and tobacco are burned.

At high levels, as was the case during recent wildfires in the western United States, when PAHs are inhaled they can be harmful to human health. Despite PAHs being the first class of chemicals identified as cancer-causing, little is known about the carcinogenic potential of the more than 1,500 PAHs. Part of the challenge is that PAHs usually occur as a mixture of chemicals, making it difficult to tease apart roles of individual chemicals in the mixture.

The OSU researchers, led by Susan Tilton, an associate professor in the Department of Environmental and Molecular Toxicology in the College of Agricultural Sciences, have been studying PAHs for over six years. They previously developed a system to predict whether tumors formed in mice exposed to certain PAHs. The current research translates that approach using human bronchial cells.

The researchers treated the cells with individual PAHs and then used computational analysis to look at changes across thousands of genes simultaneously to identify gene signatures. They then looked for gene signatures consistent across the different chemicals with similar carcinogenic potential. €œThose with similar carcinogenic potential are the ones we can focus on,” Tilton said.

€œPotentially, in the future we wouldn’t need to look at thousands and thousands of genes. Once we tested enough chemicals and felt very confident about this we could drill down and look at a select handful of genes in order to make these types of predictions.” In the future, the researchers plan to expand the number of chemicals that they test, particularly chemicals whose carcinogenic potential is not well understood. They also want to study lung cells from people with pre-existing conditions, such as asthma and chronic obstructive pulmonary disease, to see if they are particularly sensitive to certain chemicals.

Co-authors of the paper were Yvonne Chang, Celine Thanh Thu Huynh, Kelley M. Bastin, Brianna N. Rivera, Lisbeth K.

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How to cite this article:Singh OP renova putz this website. Psychiatry research in India. Closing the research gap renova putz. 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 medical research in particular is always being criticized for lack of innovation and originality required for the renova putz 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, renova putz 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 to differences in biology, health-care systems, health practices, culture, and renova putz 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 renova putz 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 renova putz 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 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 renova putz 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 renova putz.

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.

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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.

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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].

How to Cheap levitra canada cite renova where to buy this article:Singh OP. Psychiatry research in India. Closing the renova where to buy 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 medical research in particular is always being criticized for lack of innovation and originality required for renova where to buy 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, renova where to buy 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 renova where to buy 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 Health, USA, on biomedical research renova where to buy 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 support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research in India are conducted in medical renova where to buy 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 renova where to buy been made an obligatory requirement 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 renova where to buy.

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.

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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].