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Vancouver, B.C buy renova canada. And Toronto, ON., December 11, 2020 buy renova canada - WELL Health Technologies Corp. (TSX.V. WELL) (the “Company” or “WELL”), a company focused on consolidating and modernizing clinical and digital assets within the primary health care sector, is pleased to announce it has partnered with Canada buy renova canada Health Infoway (“Infoway”) to integrate Infoway’s national e-prescribing service, PrescribeIT®, with WELL’s OSCAR Pro Electronic Medical Records (EMR) software. Physicians and health care practitioners using OSCAR Pro are now able to easily create, renew and cancel prescriptions electronically, while improving overall patient care through secure clinician messaging.

WELL is buy renova canada offering an end-to-end solution from virtual and on-site patient consultation to electronic prescription, resulting in a better physician and patient experience. By partnering with PrescribeIT®, health care practitioners, pharmacists and patients can have confidence that the solution ensures patient privacy and security of information. €œWe are very excited buy renova canada to launch our e-prescribing service with Infoway’s PrescribeIT®,” said Hamed Shahbazi, Chairman and CEO of WELL. €œElectronic prescriptions will be a key for making virtual visits more efficient and effective, and this integration with the WELL EMR network can help create a better patient experience. I am buy renova canada very proud of our WELL EMR Group who has worked tirelessly to successfully achieve conformance approval from Infoway and our WELL Digital Health Apps team who have made the service available through the apps.health marketplace.”PrescribeIT® enhances clinical communications, e-renewals, privacy and security.

Prescriptions can now be sent directly from within OSCAR Pro EMR in a secure electronic format to the patient's pharmacy of choice and pharmacies can electronically request prescription renewals from the patient's health care provider. Electronic prescriptions are key for virtual visits as the patient does not have to rely on faxing buy renova canada prescriptions to pharmacies. Furthermore, patient safety is increased due to prevention of data entry errors at the pharmacy and prescription fraud is decreased through direct transmission of the prescription from the prescriber to the pharmacy through the PrescribeIT® service.“We are excited about this partnership with WELL to make PrescribeIT® available to prescribers who use the OSCAR Pro EMR software,” said Jamie Bruce, Executive Vice President, Infoway. €œPrescribeIT® makes prescribing safer, more buy renova canada secure, easier and more convenient. PrescribeIT® is also an increasingly important tool in the prescriber’s virtual care toolbox.”WELL HEALTH TECHNOLOGIES CORP.Per.

“Hamed Shahbazi” Hamed ShahbaziChief Executive Officer, Chairman and DirectorAbout WELLWELL is an omni-channel digital health company whose overarching objective is to empower buy renova canada doctors to provide the best and most advanced care possible while leveraging the latest trends in digital health. As such, WELL owns and operates 25 primary health care clinics, is Canada's third largest digital Electronic Medical Records (EMR) supplier serving over 2,000 medical clinics, operates a leading national telehealth service and is a provider of digital health, billing and cybersecurity related technology solutions. WELL is an acquisitive company buy renova canada that follows a disciplined and accretive capital allocation strategy. WELL is publicly traded on the Toronto Stock Exchange under the symbol "WELL" and the Company was recognized as a TSX Venture 50 Company three years in a row in 2018, 2019 and 2020. To access the buy renova canada Company's telehealth service, visit.

Tiahealth.com or virtualclinics.ca and for corporate buy renova canada information, visit. Www.well.company.About Canada Health InfowayInfoway helps to improve the health of Canadians by working with partners to accelerate the development, adoption and effective use of digital health across Canada. Through our investments, we help deliver better quality buy renova canada and access to care and more efficient delivery of health services for patients and clinicians. Infoway is an independent, not-for-profit organization funded by the federal government. Visit www.infoway-inforoute.ca.About PrescribeIT®Canada Health Infoway is working with Health Canada, the provinces and territories, and industry stakeholders to buy renova canada develop, operate and maintain the national e-prescribing service known as PrescribeIT®.

PrescribeIT® will serve all Canadians, pharmacies and prescribers and provide safer and more effective medication management by enabling prescribers to transmit a prescription electronically between a prescriber’s electronic medical record (EMR) and the pharmacy management system (PMS) of a patient’s pharmacy of choice. PrescribeIT® will protect buy renova canada Canadians’ personal health information from being sold or used for commercial activities. Visit www.PrescribeIT.ca.Forward-Looking StatementsThis news release may contain "forward-looking statements" within the meaning of applicable Canadian securities laws, including, without limitation statements regarding. Improvement to buy renova canada overall patient care through clinical messaging. And the belief that the launch will ensure patient privacy and security of information.

Forward-looking statements are necessarily based upon a number of estimates and assumptions that, while considered reasonable buy renova canada by management, are inherently subject to significant business, economic and competitive uncertainties, and contingencies. These statements generally can be identified by the use of forward-looking words such as “may”, “should”, “will”, “could”, “intend”, “estimate”, “plan”, “anticipate”, “expect”, “believe” or “continue”, or the negative thereof or similar variations. Forward-looking statements involve known and unknown risks, uncertainties and other factors that may cause future results, performance or achievements to be buy renova canada materially different from the estimated future results, performance or achievements expressed or implied by those forward-looking statements and the forward-looking statements are not guarantees of future performance. WELL’s statements expressed or implied by these forward-looking statements are subject to a number of risks, uncertainties, and conditions, many of which are outside of WELL 's control, and undue reliance should not be placed on such statements. Forward-looking statements buy renova canada are qualified in their entirety by inherent risks and uncertainties, including.

Risks related to privacy and cyber security concerns. Risks related to compatibility between buy renova canada the two platforms and solutions. And error free adoption, use and growth of the service buy renova canada. Except as required by securities law, WELL does not assume any obligation to update or revise any forward-looking statements, whether as a result of new information, events or otherwise.Neither the TSX nor its Regulation Services Provider (as that term is defined in policies of the TSX) accepts responsibility for the adequacy or accuracy of this release.-30-For further information:Pardeep S. SanghaVP Corporate Strategy buy renova canada and Investor RelationsWELL Health Technologies Corp.604.572.6392This email address is being protected from spambots.

You need JavaScript enabled to view it.Inquiries about PrescribeIT® Tania EnsorSenior Director, Marketing, Stakeholder Relations and Reputation Management, PrescribeIT®Canada Health Infoway416.707.6285Email UsFollow @PrescribeIT_CANew survey insights released to mark Digital Health Week 2020November 16, 2020 (Toronto) — Canadians and health care providers have met the unprecedented challenge of the skin care products renova head-on by embracing change in the way health care is delivered — from in-person to virtual. This week is Digital Health Week and to mark the occasion Canada Health Infoway (Infoway) is sharing research conducted in partnership with Environics buy renova canada that digs into this substantial shift and what Canadians want for their digital health future. This latest research project, A Healthy Dialogue, is one of the largest public consultations about digital health ever conducted in Canada. The consultation reached more than 58,000 Canadians — including those underserved by the health system — who shared how they thought technology would impact their care experience.The research reveals[i]:An overwhelming majority (92%) of Canadians want technology that makes health care as convenient as other aspects of their lives.More than half (53%) of Canadians who have used health technology in the past year say it helped them avoid an in-person visit to a provider buy renova canada or an emergency room.Of those Canadians who received virtual care during the renova, 91% were satisfied with the experience, 86% agreed that virtual care tools can be important alternatives to seeing doctors in-person, and more than three-quarters (76%) are willing to use virtual care after the renova.“We’ve gone from talking about ways to further integrate digital health into everyday health care to living it. The events of the past year have accelerated our digital health progress significantly and have proven to Canadians just how important and helpful digital health can be,” says Michael Green, President and CEO of Infoway.

€œDigital Health Week is an important time to celebrate our buy renova canada progress and acknowledge the hard work of all those who have made it possible.”While technology can help reduce barriers and improve access to health care, the research also found that nearly six in 10 Canadians feel they don’t know enough about digital health apps and services. As Canada’s digital health agency, Infoway is committed to working with its partners to address these gaps through activities like Digital Health Week.About Infoway’s Commitment to ResearchA Healthy Dialogue is part of Infoway’s commitment to contributing to digital health research in Canada. To support health care organizations, clinicians, policy maker and patients, families and caregivers, Infoway conducts research into the value of digital health solutions as well as clinicians’ and Canadians’ buy renova canada attitudes and perceptions. To learn more about the results from A Healthy Dialogue, please visit https://www.infoway-inforoute.ca/en/component/edocman/resources/reports/3850-a-healthy-dialogue-executive-summary. To learn about Infoway’s other research initiatives, please visit www.infoway-inforoute.ca/en/what-we-do/research-and-insights.About Digital Health Week — #ThinkDigitalHealthDigital Health Week was created to celebrate how digital health is transforming care across the country and to increase awareness about the value and benefits of buy renova canada digital health for all Canadians.

Digital Health Week is supported by 60+ organizations. Join the conversation buy renova canada and share your story. #ThinkDigitalHealth.About Canada Health InfowayInfoway helps to improve the health of Canadians by working with partners to accelerate the development, adoption and effective use of digital health across Canada. Through our investments, we help deliver better quality and access to care and more efficient delivery of health services for patients and buy renova canada clinicians. Infoway is an independent, not-for-profit organization funded by the federal government.

Visit www.infoway-inforoute.ca.[i] A national survey of about 6,900 Canadians was conducted from December 2019-February 2020, pre-skin care products buy renova canada. A follow-up survey was conducted in June 2020 with about 2,200 of the original 6,900, to see if their views had shifted since the renova began.-30-Media Inquiries.

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The high cost of prescription drugs continues to be generic renova cost a top health priority for the public. Policymakers at the federal and state level are pursuing a range of options to lower drug prices for Americans, one of which would allow for the safe importation of prescription drugs from Canada and other countries, based on evidence showing that people often pay more for medications in the U.S. Than elsewhere generic renova cost. In an executive order issued July 2021, President Joe Biden directed the Food and Drug Administration (FDA) to work with states to import prescription drugs from Canada, an approach that was put into place by the previous Administration and has bipartisan support among the general public (Figure 1).Figure 1. Majority of the Public Favors Allowing Americans to Buy generic renova cost Prescription Drugs Imported from CanadaThese FAQs discuss recent efforts related to prescription drug importation, the history of this approach, challenges that previous efforts to carry out importation proposals have faced, and stakeholder views.1.

What is the current status of prescription drug importation?. Current law allows for the importation of certain drugs from Canada under defined, limited circumstances, generic renova cost and only if the Secretary of the United States Department of Health and Human Services (HHS) certifies that importation poses no threat to the health and safety of the American public and will result in significant cost savings to the American consumer. In September 2020, the Trump Administration issued a final rule and final FDA guidance, creating two new pathways for the safe importation of drugs from Canada and other countries, and then-HHS Secretary Alex Azar certified that importation of prescription drugs poses no risk to public health and safety and would result in significant cost savings.Soon after the rule was finalized, PhRMA and other parties filed a lawsuit challenging the rule based on safety and other concerns. In May 2021, the Biden Administration sought to dismiss generic renova cost this lawsuit, arguing that plaintiffs cannot show the final rule or the certification by the HHS Secretary has harmed them. Because the FDA has not authorized any state importation plan under the final rule, and there is no timeline for authorization, the Administration asserts that “possible future injuries to Plaintiffs’ members are overly speculative and not imminent.” The federal court has not yet responded to the Administration’s motion to dismiss the lawsuit.The Biden Administration’s position on this lawsuit has opened the door for states to move forward with drug importation plans, as discussed further below, and President Biden’s recent executive order directly instructs the FDA to work with states to import prescription drugs from Canada.2.

Why is importation of generic renova cost prescription drugs from Canada being considered as a way to lower drug costs in the U.S.?. Many studies have shown that people in the United States often pay more for their prescription drugs than in other developed countries, including Canada. According to one analysis of a subset of single-source brand-name drugs, Canadian drug prices are about 28% of the price in the United States, while another analysis of a broad range of drugs found that Canadian prices are 46% of those in the United States.Canada’s drug prices are generally lower than those in the United States because the Canadian government has various mechanisms to lower the cost of prescription drugs. Since 1987, the Patented Medicine generic renova cost Prices Review Board (PMPRB) has regulated the price of patented (i.e., brand-name) drugs in Canada to ensure that they are not excessive. The PMPRB reviews the prices charged for drugs, and if the Board determines the price of a drug is excessive, it can order a patentee to lower the price of a drug, including requiring a monetary payment for the excess revenue earned from the drug.3.

How does current U.S generic renova cost. Law regulate the importation of prescription drugs from other countries?. In order for a drug to be marketed in the United States, it must first receive FDA approval and meet standards set forth in the Food and Drug Cosmetic (FD&C) Act of 1938 generic renova cost. Any drug that is “unapproved,” meaning it does not meet these standards, is not eligible for importation. Currently, the generic renova cost only type of legally imported drugs are those that are.

1) manufactured in foreign FDA-inspected facilities, the subject of an FDA-approved drug application, intended for use by U.S. Consumers, and generic renova cost imported into the U.S. By the drug manufacturer, and 2) those that are U.S.-approved and manufactured in the U.S., sent abroad, then imported back into the U.S. Under rare circumstances such as for emergency medical purposes or in the case of product recalls. These importation regulations pertain only to the drug product itself, and are not related to the cost of imported products.In 2000, Congress enacted the Medicine Equity and Drug Safety (MEDS) Act, which added Section 804 to generic renova cost the FD&C Act, to allow pharmacists and wholesalers to import prescription drugs directly from certain industrialized countries, including Canada, subject to specified limitations and safeguards.

The MEDS Act allows such importation, subject to an important requirement. To do so, the HHS Secretary generic renova cost must demonstrate that the program. €œposes no additional risk to the public’s health and safety,” and “results in a significant reduction in the cost of covered products to the American consumer.”The Medicare Modernization Act of 2003 (MMA) amended the Section 804 importation language that was added by the MEDS Act. The MMA specifies that generic renova cost wholesalers and pharmacists can only import prescription drugs from Canada, not other industrialized countries. The MMA also authorizes the Secretary to terminate such importation programs if they do not meet safety standards or result in a significant reduction in costs for consumers.

The MMA also requires the HHS Secretary to issue regulations that would grant waivers to individuals to import drugs generic renova cost for personal use under certain circumstances.Importation of prescription drugs under conditions set forth first by the MEDS Act, and then by the MMA, could allow wholesalers and pharmacists to obtain FDA-approved drugs at lower prices than are available in the U.S. By purchasing them from foreign sellers, and pass these savings on to U.S. Consumers.4. Why have prescription drug importation proposals not been implemented in the past?. Up until the Trump Administration’s final rule authorizing importation of prescription drugs from Canada, no previous HHS Secretaries have certified an implementation plan for importation, primarily due to safety concerns.

According to the HHS taskforce report on drug importation issued in December 2004, the drug distribution network for prescription drugs in the U.S. Is a “closed” system that provides the American public with multiple levels of protection against receiving unsafe or poor quality medications. Importation, according to the taskforce report, would create an opening in this closed system that would increase the opportunity for counterfeit, substandard, or unapproved products to enter the supply chain, introducing additional risks to American consumers.The report also noted some potential risks and challenges with legalizing importation, including but not limited to. The increasing difficulty of monitoring and ensuring the safety of imported drugs. The additional cost and resources needed for ensuring safety, which may reduce potential savings.

The possibility that total savings would be significantly less than international price comparisons suggest. And the likelihood that there would be a reduction in research and development of new drugs. Furthermore, many former HHS Secretaries and FDA commissioners have voiced concerns in recent years about FDA’s ability to assure the safety, effectiveness, and quality of imported drugs. According to a 2017 letter to Congress signed by four former FDA commissioners:“…Allowing importation of drugs purported to be manufactured overseas in FDA-inspected facilities and drugs purported to be manufactured domestically for export to other countries and reimported from those countries to the United States cannot meet the requirements under the existing closed drug manufacturing and distribution system because the drugs could not be tracked and certified by the manufacturer…Such a program would be very different from importation of consumer products like watches or clothing, where consumers can more easily discern quality and where there are no health consequences of fake products. It could lead to a host of unintended consequences and undesirable effects, including serious harm stemming from the use of adulterated, substandard, or counterfeit drugs.

It could also undermine American confidence in what has proven to be a highly successful system for assuring drug safety.”5. What drug importation plans have been finalized?. In September 2020, the Trump Administration issued a final rule and final FDA guidance for the importation of prescription drugs. The final rule would authorize states, territories and Indian tribes, and in certain future circumstances wholesalers and pharmacists, to implement time-limited importation programs, known as Section 804 Implementation Programs or SIPs, for importation of prescription drugs from Canada only. States, territories, and Indian tribes could submit proposals to the HHS Secretary to manage these SIPs and act as SIP sponsors.In order for a proposal to be approved by HHS, a SIP sponsor would need to specify.

The drugs it seeks to import. The foreign seller in Canada that would purchase the drug directly from its manufacturer. The importer in the U.S. That would buy the drug directly from the foreign seller in Canada. The re-labeler or re-packager of the drug itself that would ensure the drug meets all labeling requirements in the U.S..

The qualifying lab that would conduct testing of the drug for authenticity and degradation. And steps that would be taken by the SIP to ensure the supply chain is secure. SIPs would initially be authorized for 2-year periods with the possibility of 2-year extensions.Each SIP sponsor would also be subject to post-importation requirements, including providing FDA with data and information on the SIP’s cost savings to American consumers.The final FDA guidance specifies how manufacturers can import and market FDA-approved drugs in the U.S. That were manufactured abroad and intended to be marketed and authorized for sale in a foreign country. Using this approach, a manufacturer may be able to obtain an additional National Drug Code (NDC) for drugs imported into the U.S.

The stated rationale is that “in recent years, multiple manufacturers have stated (either publicly or in statements to the Administration) that they wanted to offer lower cost versions but could not readily do so because they were locked into contracts with other parties in the supply chain. This pathway would highlight an opportunity for manufacturers to use importation to offer lower-cost versions of their drugs.”6. Which drugs would be covered under the new importation plans?. Under the final rule, which allows states and other entities to facilitate importation of drugs from Canada, only drugs that are currently marketed in the U.S. Would be eligible for importation.

As under current law, certain types of drugs are excluded from the definition of a prescription drug eligible for importation including. Controlled substances, biological products (including insulin), infused drugs, intravenously injected drugs, and inhaled drugs during surgery. Furthermore, drugs that are subject to risk evaluation and mitigation strategies (REMS), which are high-risk products with serious safety concerns, such as opioids, are not eligible for importation.Under the final FDA guidance, which allows manufacturers to import drugs to the U.S. That were manufactured and intended for sale in other countries (not limited to Canada), prescription drugs, including biological products excluded under the final rule, could be imported and made available to patients. These drugs must also currently be marketed in the U.S.

To be eligible.7. What is the estimated savings for these importation plans?. The potential cost savings from the final rule are unknown. In the final rule itself, and in FDA’s full final regulatory impact analysis, the Trump Administration did not provide an estimate of the expected savings. The final regulatory analysis noted that responses by other stakeholders, such as Canadian regulatory agencies and drug manufacturers, could impact the potential benefits of this program.The Trump Administration did not release an estimate of potential savings for importation in the FDA guidance for industry.8.

What are states currently doing regarding importation?. Some states have been actively pursuing legislative action to promote the importation of prescription drugs. Several states, including Florida, Vermont, Colorado, Maine, New Mexico, and New Hampshire have enacted laws establishing importation programs for prescription drugs from Canada. In order for any importation plan to go into effect, the HHS Secretary must certify that it meets the safety and cost saving requirements set forth in Section 804 of the FD&C Act. Under each state’s respective laws to establish an importation program, they are required to submit a proposal to HHS to demonstrate how its program will meet those safety and cost saving requirements.

Thus far, no state plan has been certified.Florida, Vermont, Colorado, and Maine have taken action to become the first states to implement importation plans. In August 2019, Florida officially submitted its importation proposal to HHS (predating the previous Administration’s rule for state importation plans). Under Florida’s importation plan, the program would be overseen by the state’s Agency for Health Care Administration (AHCA) through a vendor who would handle the operation of the program and ensure importers are following all state and federal laws relating to importation. Eligible importers would be limited to wholesalers or pharmacists who dispense prescription drugs on behalf of public payers, including Medicaid, the Department of Corrections, and the Department for Children and Families. In June 2020, Florida’s AHCA released an “Invitation to Negotiate” for the state’s vendor bid system, for assistance with implementation of the importation program, and in December 2020, the AHCA contracted with a vendor to administer the importation program.

The governor of Florida has called on the Biden Administration to approve the state’s plan, citing projections that it could “potentially save the state between $80 to $150 million in the first year alone.”Vermont submitted its importation proposal to HHS in November 2019. Vermont’s plan primarily differs from Florida’s in that wholesalers would import drugs on behalf of both commercial plans and public payers, rather than just public payers.Colorado submitted its importation proposal in March 2020, and in January 2021, released an invitation to negotiate with vendors to implement its importation program. Bids were due in late April and the contract is set to be awarded later in 2021. New Mexico and Maine have also submitted importation plans for HHS approval. New Hampshire is also in the process of developing importation plans for HHS approval, and according to the state’s law, New Hampshire had until February 1, 2021 to submit its plan.

North Dakota passed a bill that requires a study on the potential impacts of prescription drug importation. Other states are also considering legislation that would facilitate drug importation from Canada, but thus far, none have been approved by HHS.9. Under what circumstances can individuals legally import drugs from other countries, like Canada?. In most circumstances, it is illegal for individuals to import FDA-approved drugs from other countries for personal use. However, based on changes enacted by the MMA, personal importation of prescription drugs that have not been approved by the FDA for use in the U.S.

Is permitted on a case-by-case basis. Under this statutory authority, FDA has put out guidance that lays out certain circumstances where importation of non-FDA approved drugs for personal use might be allowed. For example, personal importation is generally allowed if the treatment is for a serious condition, there is no effective treatment available in the U.S., and there is no commercialization of the drug for U.S. Residents. Typically, only a three-month supply is allowed, and individuals most confirm in writing that the drug is for personal use and provide information about the physician responsible for their treatment.There appears to be little enforcement by the FDA of the ban against importing FDA-approved drugs for personal use.

Even if the personal importation of a drug is technically illegal, current law directs the FDA to exercise discretion in permitting personal importation of drugs when the product is “clearly for personal use, and does not appear to present an unreasonable risk to the user,” which is reinforced in FDA guidelines.The Trump Administration’s executive order from July 2020, which directed the HHS Secretary to finalize rulemaking in regard to states importing certain drugs from Canada, also directed HHS to take action to allow individuals to import prescription drugs from foreign countries as well as permit insulin products that were manufactured in the United States and sent abroad to be reimported to the United States. In response, the previous Administration issued two requests for proposals, and HHS and FDA started accepting proposals for these two pathways in September 2020. However, the Biden Administration did not receive any proposals to be implemented via either of these pathways, and in June 2021, the Biden Administration formally withdrew both requests for proposals.10. How do stakeholders and the public view these importation plans?. Many stakeholders have expressed reservations about the feasibility of the current importation plans.

Prime Minister Trudeau stated that ensuring the safe and adequate supply of prescription drugs for Canadians is his first priority. However, he also said the Canadian government will take into account the actions of the United States and may be able to provide help to the US and other countries. The Government of Canada stated that it would be unable to meet the needs of the U.S. Market without impacting access to medications for Canadians. The Canadian government also expressed concern that this policy would create drug shortages in Canada, and issued an order in November 2020 prohibiting the distribution of drugs that could cause or exacerbate a shortage.As mentioned above, industry groups such as PhRMA, as well as the Partnership for Safe Medicines and the Council for Affordable Health Coverage, sued the Trump Administration to keep the first importation plan under the final rule from going into effect, arguing that importation would weaken safeguards protecting America’s drug supply, expose Americans to substandard and counterfeit drugs, and that the additional resources required to ensure the safety of drugs from abroad would outweigh any potential savings for patients.

In addition to its lawsuit challenging the final rule, PhRMA has also filed citizens petitions challenging the state SIP applications submitted to HHS by Florida and New Mexico.Some organizations also submitted comments for the importation pathway described in the final FDA guidance. Despite their support for the flexibility to sell drugs under different NDC codes, PhRMA had specific concerns with guidance, including that NDC flexibility alone is not enough to lower prices for consumers. The American Medical Association (AMA) and APhA also expressed concern with the FDA guidance, noting the potential for unintended consequences, including increased costs for patients and patient and pharmacy confusion, leading to disruptions in patient care.Other stakeholders, however, have expressed support for allowing prescription drug importation, including AARP, the AMA, National Federation of Independent Business (NFIB), and Patients for Affordable Drugs Now, although some of these groups expressed concerns about specific aspects of the importation plan at the proposed rule stage. Patients for Affordable Drugs Now said it was pleased the Administration had opened the door for importation, but noted that it is not a solution for lowering drug prices for the majority of Americans.The American public is generally in favor of importation. According to KFF polling from October 2019, 78% of the public favors allowing Americans to buy prescription drugs imported from licensed Canadian pharmacies.

This proposal has broad support across party lines – 75% of Democrats, 82% of Independents, and 75% of Republicans favor drug importation from Canada (Figure 1). However, it not clear to what extent public opinion would shift if presented with arguments for or against importation.The American public also supports virtually all proposals to lower prescription drug costs, including the government negotiating with drug companies, and believes lowering prescription drug prices should be a top legislative priority for Congress.Many people enrolled in Medicare go without dental care, especially beneficiaries of color, according to a new KFF analysis of dental coverage and costs for people with Medicare.Almost half of all Medicare beneficiaries (47%) did not have a dental visit within the past year as of 2018, the analysis finds, with rates higher among those who are Black (68%) or Hispanic (61%) compared to White beneficiaries (42%). Rates were also higher among those who have low incomes (73%), or who are in fair or poor health (63%). The data pre-date the onset of the skin care renova and do not reflect the slump in health care utilization during the public health emergency.One reason Medicare beneficiaries do not seek care is a lack of insurance. Nearly half of all people with Medicare (47%) did not have dental coverage, as of 2019.

The others got it through Medicare Advantage (29%), private insurance (16%) and Medicaid (8%).The analysis also finds that beneficiaries can face significant out-of-pocket costs when they do seek care. Average out-of-pocket spending among Medicare beneficiaries who used any dental services was $874 in 2018, the analysis finds. One in five beneficiaries spent more than $1,000, including one in ten who spent more than $2,000.The findings come at a time when Senate Democrats are seeking to add a standard dental, vision and hearing benefit to Medicare, as part of a sweeping $3.5 trillion budget reconciliation package. If it makes it through Congress, it would be the largest expansion of Medicare benefits since the inception of Part D prescription drug coverage in 2006.The new analysis also provides an in-depth look at the scope of dental benefits available to people enrolled in Medicare Advantage plans, which have become the leading source of dental coverage among Medicare beneficiaries.In 2021, 94 percent of Medicare Advantage enrollees in individual plans are in a plan that offers access to some dental coverage. The scope of coverage varies widely across these plans.

Most Medicare Advantage enrollees with access to dental coverage have preventive benefits, such as cleanings, and access to more extensive dental benefits for services such as extractions and root canals that typically require 50 percent coinsurance for in-network care, and are subject to an annual dollar cap, the analysis finds. The average annual cap on dental benefits is about $1,300 in 2021.Among the factors policymakers likely will consider in determining whether to add a dental benefit to Medicare are the scope of covered benefits, the amount of beneficiary cost sharing for specific services, and the impact on overall Medicare spending and premiums.For more data and analyses about Medicare and dental coverage, visit kff.org.

The high cost of prescription drugs continues to be buy renova canada a top health priority for the public Best online propecia. Policymakers at the federal and state level are pursuing a range of options to lower drug prices for Americans, one of which would allow for the safe importation of prescription drugs from Canada and other countries, based on evidence showing that people often pay more for medications in the U.S. Than elsewhere buy renova canada.

In an executive order issued July 2021, President Joe Biden directed the Food and Drug Administration (FDA) to work with states to import prescription drugs from Canada, an approach that was put into place by the previous Administration and has bipartisan support among the general public (Figure 1).Figure 1. Majority of the Public Favors Allowing Americans to Buy Prescription Drugs Imported from CanadaThese FAQs discuss recent efforts related to prescription drug importation, the history of this approach, challenges that previous buy renova canada efforts to carry out importation proposals have faced, and stakeholder views.1. What is the current status of prescription drug importation?.

Current law allows for the importation of certain drugs from Canada under defined, limited circumstances, and only if the Secretary of the United States Department of Health and Human Services (HHS) certifies that importation poses no threat to the health and buy renova canada safety of the American public and will result in significant cost savings to the American consumer. In September 2020, the Trump Administration issued a final rule and final FDA guidance, creating two new pathways for the safe importation of drugs from Canada and other countries, and then-HHS Secretary Alex Azar certified that importation of prescription drugs poses no risk to public health and safety and would result in significant cost savings.Soon after the rule was finalized, PhRMA and other parties filed a lawsuit challenging the rule based on safety and other concerns. In May 2021, the Biden Administration sought to dismiss this lawsuit, arguing that plaintiffs cannot show the final rule or the buy renova canada certification by the HHS Secretary has harmed them.

Because the FDA has not authorized any state importation plan under the final rule, and there is no timeline for authorization, the Administration asserts that “possible future injuries to Plaintiffs’ members are overly speculative and not imminent.” The federal court has not yet responded to the Administration’s motion to dismiss the lawsuit.The Biden Administration’s position on this lawsuit has opened the door for states to move forward with drug importation plans, as discussed further below, and President Biden’s recent executive order directly instructs the FDA to work with states to import prescription drugs from Canada.2. Why is importation of prescription drugs from Canada buy renova canada being considered as a way to lower drug costs in the U.S.?. Many studies have shown that people in the United States often pay more for their prescription drugs than in other developed countries, including Canada.

According to one analysis of a subset of single-source brand-name drugs, Canadian drug prices are about 28% of the price in the United States, while another analysis of a broad range of drugs found that Canadian prices are 46% of those in the United States.Canada’s drug prices are generally lower than those in the United States because the Canadian government has various mechanisms to lower the cost of prescription drugs. Since 1987, the Patented Medicine Prices buy renova canada Review Board (PMPRB) has regulated the price of patented (i.e., brand-name) drugs in Canada to ensure that they are not excessive. The PMPRB reviews the prices charged for drugs, and if the Board determines the price of a drug is excessive, it can order a patentee to lower the price of a drug, including requiring a monetary payment for the excess revenue earned from the drug.3.

How does current U.S buy renova canada. Law regulate the importation of prescription drugs from other countries?. In order for a drug to be marketed in the United States, it must first receive FDA approval and meet standards set forth in the Food and Drug Cosmetic (FD&C) Act of 1938 buy renova canada.

Any drug that is “unapproved,” meaning it does not meet these standards, is not eligible for importation. Currently, the only type of legally imported drugs are buy renova canada those that are. 1) manufactured in foreign FDA-inspected facilities, the subject of an FDA-approved drug application, intended for use by U.S.

Consumers, and imported into buy renova canada the U.S. By the drug manufacturer, and 2) those that are U.S.-approved and manufactured in the U.S., sent abroad, then imported back into the U.S. Under rare circumstances such as for emergency medical purposes or in the case of product recalls.

These importation regulations pertain only to the drug product itself, and are not related to the cost of imported products.In 2000, Congress enacted the Medicine Equity and Drug Safety (MEDS) Act, which added Section 804 to the FD&C Act, to allow pharmacists and wholesalers to import prescription drugs directly from certain industrialized countries, including Canada, subject to buy renova canada specified limitations and safeguards. The MEDS Act allows such importation, subject to an important requirement. To do so, the buy renova canada HHS Secretary must demonstrate that the program.

€œposes no additional risk to the public’s health and safety,” and “results in a significant reduction in the cost of covered products to the American consumer.”The Medicare Modernization Act of 2003 (MMA) amended the Section 804 importation language that was added by the MEDS Act. The MMA specifies that wholesalers and pharmacists can only buy renova canada import prescription drugs from Canada, not other industrialized countries. The MMA also authorizes the Secretary to terminate such importation programs if they do not meet safety standards or result in a significant reduction in costs for consumers.

The MMA also requires the HHS Secretary to issue regulations that would grant waivers to individuals to import drugs for personal use under certain circumstances.Importation of prescription drugs under conditions set buy renova canada forth first by the MEDS Act, and then by the MMA, could allow wholesalers and pharmacists to obtain FDA-approved drugs at lower prices than are available in the U.S. By purchasing them from foreign sellers, and pass these savings on to U.S. Consumers.4.

Why have prescription drug importation proposals not been implemented in the past?. Up until the Trump Administration’s final rule authorizing importation of prescription drugs from Canada, no previous HHS Secretaries have certified an implementation plan for importation, primarily due to safety concerns. According to the HHS taskforce report on drug importation issued in December 2004, the drug distribution network for prescription drugs in the U.S.

Is a “closed” system that provides the American public with multiple levels of protection against receiving unsafe or poor quality medications. Importation, according to the taskforce report, would create an opening in this closed system that would increase the opportunity for counterfeit, substandard, or unapproved products to enter the supply chain, introducing additional risks to American consumers.The report also noted some potential risks and challenges with legalizing importation, including but not limited to. The increasing difficulty of monitoring and ensuring the safety of imported drugs.

The additional cost and resources needed for ensuring safety, which may reduce potential savings. The possibility that total savings would be significantly less than international price comparisons suggest. And the likelihood that there would be a reduction in research and development of new drugs.

Furthermore, many former HHS Secretaries and FDA commissioners have voiced concerns in recent years about FDA’s ability to assure the safety, effectiveness, and quality of imported drugs. According to a 2017 letter to Congress signed by four former FDA commissioners:“…Allowing importation of drugs purported to be manufactured overseas in FDA-inspected facilities and drugs purported to be manufactured domestically for export to other countries and reimported from those countries to the United States cannot meet the requirements under the existing closed drug manufacturing and distribution system because the drugs could not be tracked and certified by the manufacturer…Such a program would be very different from importation of consumer products like watches or clothing, where consumers can more easily discern quality and where there are no health consequences of fake products. It could lead to a host of unintended consequences and undesirable effects, including serious harm stemming from the use of adulterated, substandard, or counterfeit drugs.

It could also undermine American confidence in what has proven to be a highly successful system for assuring drug safety.”5. What drug importation plans have been finalized?. In September 2020, the Trump Administration issued a final rule and final FDA guidance for the importation of prescription drugs.

The final rule would authorize states, territories and Indian tribes, and in certain future circumstances wholesalers and pharmacists, to implement time-limited importation programs, known as Section 804 Implementation Programs or SIPs, for importation of prescription drugs from Canada only. States, territories, and Indian tribes could submit proposals to the HHS Secretary to manage these SIPs and act as SIP sponsors.In order for a proposal to be approved by HHS, a SIP sponsor would need to specify. The drugs it seeks to import.

The foreign seller in Canada that would purchase the drug directly from its manufacturer. The importer in the U.S. That would buy the drug directly from the foreign seller in Canada.

The re-labeler or re-packager of the drug itself that would ensure the drug meets all labeling requirements in the U.S.. The qualifying lab that would conduct testing of the drug for authenticity and degradation. And steps that would be taken by the SIP to ensure the supply chain is secure.

SIPs would initially be authorized for 2-year periods with the possibility of 2-year extensions.Each SIP sponsor would also be subject to post-importation requirements, including providing FDA with data and information on the SIP’s cost savings to American consumers.The final FDA guidance specifies how manufacturers can import and market FDA-approved drugs in the U.S. That were manufactured abroad and intended to be marketed and authorized for sale in a foreign country. Using this approach, a manufacturer may be able to obtain an additional National Drug Code (NDC) for drugs imported into the U.S.

The stated rationale is that “in recent years, multiple manufacturers have stated (either publicly or in statements to the Administration) that they wanted to offer lower cost versions but could not readily do so because they were locked into contracts with other parties in the supply chain. This pathway would highlight an opportunity for manufacturers to use importation to offer lower-cost versions of their drugs.”6. Which drugs would be covered under the new importation plans?.

Under the final rule, which allows states and other entities to facilitate importation of drugs from Canada, only drugs that are currently marketed in the U.S. Would be eligible for importation. As under current law, certain types of drugs are excluded from the definition of a prescription drug eligible for importation including.

Controlled substances, biological products (including insulin), infused drugs, intravenously injected drugs, and inhaled drugs during surgery. Furthermore, drugs that are subject to risk evaluation and mitigation strategies (REMS), which are high-risk products with serious safety concerns, such as opioids, are not eligible for importation.Under the final FDA guidance, which allows manufacturers to import drugs to the U.S. That were manufactured and intended for sale in other countries (not limited to Canada), prescription drugs, including biological products excluded under the final rule, could be imported and made available to patients.

These drugs must also currently be marketed in the U.S. To be eligible.7. What is the estimated savings for these importation plans?.

The potential cost savings from the final rule are unknown. In the final rule itself, and in FDA’s full final regulatory impact analysis, the Trump Administration did not provide an estimate of the expected savings. The final regulatory analysis noted that responses by other stakeholders, such as Canadian regulatory agencies and drug manufacturers, could impact the potential benefits of this program.The Trump Administration did not release an estimate of potential savings for importation in the FDA guidance for industry.8.

What are states currently doing regarding importation?. Some states have been actively pursuing legislative action to promote the importation of prescription drugs. Several states, including Florida, Vermont, Colorado, Maine, New Mexico, and New Hampshire have enacted laws establishing importation programs for prescription drugs from Canada.

In order for any importation plan to go into effect, the HHS Secretary must certify that it meets the safety and cost saving requirements set forth in Section 804 of the FD&C Act. Under each state’s respective laws to establish an importation program, they are required to submit a proposal to HHS to demonstrate how its program will meet those safety and cost saving requirements. Thus far, no state plan has been certified.Florida, Vermont, Colorado, and Maine have taken action to become the first states to implement importation plans.

In August 2019, Florida officially submitted its importation proposal to HHS (predating the previous Administration’s rule for state importation plans). Under Florida’s importation plan, the program would be overseen by the state’s Agency for Health Care Administration (AHCA) through a vendor who would handle the operation of the program and ensure importers are following all state and federal laws relating to importation. Eligible importers would be limited to wholesalers or pharmacists who dispense prescription drugs on behalf of public payers, including Medicaid, the Department of Corrections, and the Department for Children and Families.

In June 2020, Florida’s AHCA released an “Invitation to Negotiate” for the state’s vendor bid system, for assistance with implementation of the importation program, and in December 2020, the AHCA contracted with a vendor to administer the importation program. The governor of Florida has called on the Biden Administration to approve the state’s plan, citing projections that it could “potentially save the state between $80 to $150 million in the first year alone.”Vermont submitted its importation proposal to HHS in November 2019. Vermont’s plan primarily differs from Florida’s in that wholesalers would import drugs on behalf of both commercial plans and public payers, rather than just public payers.Colorado submitted its importation proposal in March 2020, and in January 2021, released an invitation to negotiate with vendors to implement its importation program.

Bids were due in late April and the contract is set to be awarded later in 2021. New Mexico and Maine have also submitted importation plans for HHS approval. New Hampshire is also in the process of developing importation plans for HHS approval, and according to the state’s law, New Hampshire had until February 1, 2021 to submit its plan.

North Dakota passed a bill that requires a study on the potential impacts of prescription drug importation. Other states are also considering legislation that would facilitate drug importation from Canada, but thus far, none have been approved by HHS.9. Under what circumstances can individuals legally import drugs from other countries, like Canada?.

In most circumstances, it is illegal for individuals to import FDA-approved drugs from other countries for personal use. However, based on changes enacted by the MMA, personal importation of prescription drugs that have not been approved by the FDA for use in the U.S. Is permitted on a case-by-case basis.

Under this statutory authority, FDA has put out guidance that lays out certain circumstances where importation of non-FDA approved drugs for personal use might be allowed. For example, personal importation is generally allowed if the treatment is for a serious condition, there is no effective treatment available in the U.S., and there is no commercialization of the drug for U.S. Residents.

Typically, only a three-month supply is allowed, and individuals most confirm in writing that the drug is for personal use and provide information about the physician responsible for their treatment.There appears to be little enforcement by the FDA of the ban against importing FDA-approved drugs for personal use. Even if the personal importation of a drug is technically illegal, current law directs the FDA to exercise discretion in permitting personal importation of drugs when the product is “clearly for personal use, and does not appear to present an unreasonable risk to the user,” which is reinforced in FDA guidelines.The Trump Administration’s executive order from July 2020, which directed the HHS Secretary to finalize rulemaking in regard to states importing certain drugs from Canada, also directed HHS to take action to allow individuals to import prescription drugs from foreign countries as well as permit insulin products that were manufactured in the United States and sent abroad to be reimported to the United States. In response, the previous Administration issued two requests for proposals, and HHS and FDA started accepting proposals for these two pathways in September 2020.

However, the Biden Administration did not receive any proposals to be implemented via either of these pathways, and in June 2021, the Biden Administration formally withdrew both requests for proposals.10. How do stakeholders and the public view these importation plans?. Many stakeholders have expressed reservations about the feasibility of the current importation plans.

Prime Minister Trudeau stated that ensuring the safe and adequate supply of prescription drugs for Canadians is his first priority. However, he also said the Canadian government will take into account the actions of the United States and may be able to provide help to the US and other countries. The Government of Canada stated that it would be unable to meet the needs of the U.S.

Market without impacting access to medications for Canadians. The Canadian government also expressed concern that this policy would create drug shortages in Canada, and issued an order in November 2020 prohibiting the distribution of drugs that could cause or exacerbate a shortage.As mentioned above, industry groups such as PhRMA, as well as the Partnership for Safe Medicines and the Council for Affordable Health Coverage, sued the Trump Administration to keep the first importation plan under the final rule from going into effect, arguing that importation would weaken safeguards protecting America’s drug supply, expose Americans to substandard and counterfeit drugs, and that the additional resources required to ensure the safety of drugs from abroad would outweigh any potential savings for patients. In addition to its lawsuit challenging the final rule, PhRMA has also filed citizens petitions challenging the state SIP applications submitted to HHS by Florida and New Mexico.Some organizations also submitted comments for the importation pathway described in the final FDA guidance.

Despite their support for the flexibility to sell drugs under different NDC codes, PhRMA had specific concerns with guidance, including that NDC flexibility alone is not enough to lower prices for consumers. The American Medical Association (AMA) and APhA also expressed concern with the FDA guidance, noting the potential for unintended consequences, including increased costs for patients and patient and pharmacy confusion, leading to disruptions in patient care.Other stakeholders, however, have expressed support for allowing prescription drug importation, including AARP, the AMA, National Federation of Independent Business (NFIB), and Patients for Affordable Drugs Now, although some of these groups expressed concerns about specific aspects of the importation plan at the proposed rule stage. Patients for Affordable Drugs Now said it was pleased the Administration had opened the door for importation, but noted that it is not a solution for lowering drug prices for the majority of Americans.The American public is generally in favor of importation.

According to KFF polling from October 2019, 78% of the public favors allowing Americans to buy prescription drugs imported from licensed Canadian pharmacies. This proposal has broad support across party lines – 75% of Democrats, 82% of Independents, and 75% of Republicans favor drug importation from Canada (Figure 1). However, it not clear to what extent public opinion would shift if presented with arguments for or against importation.The American public also supports virtually all proposals to lower prescription drug costs, including the government negotiating with drug companies, and believes lowering prescription drug prices should be a top legislative priority for Congress.Many people enrolled in Medicare go without dental care, especially beneficiaries of color, according to a new KFF analysis of dental coverage and costs for people with Medicare.Almost half of all Medicare beneficiaries (47%) did not have a dental visit within the past year as of 2018, the analysis finds, with rates higher among those who are Black (68%) or Hispanic (61%) compared to White beneficiaries (42%).

Rates were also higher among those who have low incomes (73%), or who are in fair or poor health (63%). The data pre-date the onset of the skin care renova and do not reflect the slump in health care utilization during the public health emergency.One reason Medicare beneficiaries do not seek care is a lack of insurance. Nearly half of all people with Medicare (47%) did not have dental coverage, as of 2019.

The others got it through Medicare Advantage (29%), private insurance (16%) and Medicaid (8%).The analysis also finds that beneficiaries can face significant out-of-pocket costs when they do seek care. Average out-of-pocket spending among Medicare beneficiaries who used any dental services was $874 in 2018, the analysis finds. One in five beneficiaries spent more than $1,000, including one in ten who spent more than $2,000.The findings come at a time when Senate Democrats are seeking to add a standard dental, vision and hearing benefit to Medicare, as part of a sweeping $3.5 trillion budget reconciliation package.

If it makes it through Congress, it would be the largest expansion of Medicare benefits since the inception of Part D prescription drug coverage in 2006.The new analysis also provides an in-depth look at the scope of dental benefits available to people enrolled in Medicare Advantage plans, which have become the leading source of dental coverage among Medicare beneficiaries.In 2021, 94 percent of Medicare Advantage enrollees in individual plans are in a plan that offers access to some dental coverage. The scope of coverage varies widely across these plans. Most Medicare Advantage enrollees with access to dental coverage have preventive benefits, such as cleanings, and access to more extensive dental benefits for services such as extractions and root canals that typically require 50 percent coinsurance for in-network care, and are subject to an annual dollar cap, the analysis finds.

The average annual cap on dental benefits is about $1,300 in 2021.Among the factors policymakers likely will consider in determining whether to add a dental benefit to Medicare are the scope of covered benefits, the amount of beneficiary cost sharing for specific services, and the impact on overall Medicare spending and premiums.For more data and analyses about Medicare and dental coverage, visit kff.org.

Renova spa los cabos

NSW recorded 1,257 new locally acquired cases of More Info skin care products in the 24 hours renova spa los cabos to 8pm last night. Three new cases renova spa los cabos were acquired overseas in the 24 hours to 8pm last night, and 22 previously reported cases have been excluded following further investigation. The total number of cases in NSW renova spa los cabos since the beginning of the renova is 44,485. Sadly, NSW Health has been notified of the deaths of seven people who had skin care products.A man in his 90s from Dubbo died at the St Mary’s Villa Aged Care Facility, renova spa los cabos where he acquired his .

A man in his 80s from Sydney’s renova spa los cabos inner city died at St Vincent’s Hospital. A woman renova spa los cabos in her 60s from south western Sydney died at Campbelltown Hospital. A man in his 80s died at Nepean Hospital. He acquired his at the renova spa los cabos Hawkesbury Living Aged Care Facility in Sydney’s north west.

His is the second death linked to an outbreak at this facility.A man in renova spa los cabos his 90s from south western Sydney died at Liverpool Hospital. A woman in her 90s from Sydney’s inner renova spa los cabos west died at Concord Hospital. A man in his 80s from south western Sydney died at Sutherland renova spa los cabos Hospital. There have been 184 skin care products related deaths in NSW since 16 June 2021, and 240 in total since the start of the renova.There have been 38,856 locally acquired cases reported since 16 June 2021, when the first renova spa los cabos case in this outbreak was reported.

There are currently 1,189 skin care products renova spa los cabos cases admitted to hospital, with 222 people in intensive care, 94 of whom require ventilation.There were 137,668 skin care products tests reported to 8pm last night, compared with the previous day’s total of 105,505. Confirmed cases (including interstate residents in NSW health care facilities) 44,485 Deaths (in NSW from confirmed cases) 240 Total tests carried out14,944,905 Total vaccinations administered in NSW8,189,640 NSW Health administered 21,892 skin care products treatments in the 24 hours to 8pm last night, including 5,973 at the vaccination centre at Sydney Olympic Park.Across NSW, 78.5 per cent of the over-16 population has received a first dose skin care products treatment, and 46.2 per cent are fully vaccinated to 11:59pm on Saturday, 11 September 2021.The total number of treatments administered in NSW is now 8,189,640 with 3,030,040 doses administered by NSW Health to 8pm last night and 5,159,600 administered by the GP network and other providers to 11:59pm on Saturday 11 September 2021. Of the 1,257 locally acquired cases reported to 8pm last night, 427 are from South Western Sydney Local Health District (LHD), 314 are from Western Sydney LHD, 181 are from Sydney LHD, 127 are from South Eastern Sydney LHD, 78 are from Nepean Blue Mountains LHD, 27 are from Illawarra Shoalhaven LHD, 22 are from Northern Sydney LHD, 18 are from Hunter New England LHD, 16 are from Central Coast LHD, 12 are from Western NSW LHD, eight are in correctional settings, seven are from Far West LHD, two are from Southern LHD, 18 cases are yet to be assigned to an LHD.From today, people across NSW who have received both doses of a skin care products treatment will renova spa los cabos be allowed more freedoms. For those who live outside the LGAs of concern, up to five fully vaccinated adults can engage renova spa los cabos in outdoor recreation in a person's LGA or within 5km of home.

Children aged 12 and under will not be counted in this total.For those who live in the LGAs of concern, a household with all adults renova spa los cabos vaccinated will be able to engage in outdoor recreation (including picnics) for up to two hours within the existing rules (outside of curfew hours and within 5km of home). This is in addition to the ability to engage in outdoor exercise.People who live alone in the LGAs of concern can gather with one other adult to participate in outdoor recreation within the same existing renova spa los cabos rules. NSW Health's ongoing renova spa los cabos sewage surveillance program has recently detected fragments of the renova that causes skin care products at the Yass and Eden treatment plants in Southern NSW Local Health District (LHD), at the Tamworth treatment plant in Hunter New England LHD, at the Dunbogan and Karuah treatment plants in Mid North Coast LHD, at Gerroa treatment plant in Illawarra Shoalhaven LHD and Brooklyn treatment plant in Northern Sydney LHD.No recent cases have been identified in these locations, so everyone is urged to monitor for the onset of symptoms, and if they appear, to immediately be tested and isolate until a negative result is received.If you are directed to get tested for skin care products‑19 or self-isolate at any time, you must follow the rules whether or not the venue or exposure setting is listed on the NSW Health website.It remains vital that anyone who has any symptoms or is a close or casual contact of a person with skin care products, isolates and is tested immediately. When testing clinics are busy, please ensure you stay in line, identify yourself to staff and tell them that you have symptoms or are a contact of a case.Please check the NSW Government website regularly, and follow the relevant health advice if you have attended a venue of concern or travelled on a public transport route at the same time as a confirmed case of skin care products.

This list is being updated regularly as case investigations proceed.There are 500 skin care products testing locations across NSW, many of which are open seven renova spa los cabos days a week. To find your renova spa los cabos nearest clinic visit skin care products clinics or contact your GP. Likely source of confirmed skin care products cases in NSWOverseas 3 11 renova spa los cabos 3,439 Interstate 0 0 96 Locally acquired 1,257 9,717 40,950 Note. Case counts reported for renova spa los cabos a particular day may vary over time due to ongoing investigations and case review.

*notified from 8pm 11 September 2021 to 8pm 12 September 2021 **from 8pm 6 September 2021 to 8pm 12 September 2021skin care products vaccination updateNSW Health renova spa los cabos – first doses11,900 1,969,449 NSW Health – second doses 9,992 1,060,591 *notified from 8pm 11 September 2021 to 8pm 12 September 2021 All providers – first doses78.5% All providers – fully vaccinated 46.2%*to 11.59pm 11 September 2021A video of today's press conference will be uploaded to skin care products (skin care) - press conferences and video updates.NSW recorded 1,262 new locally acquired cases of skin care products in the 24 hours to 8pm last night.No new cases were acquired overseas in the 24 hours to 8pm last night, and 15 previously reported cases have been excluded following further investigation. The total number of cases in NSW since the beginning of the renova is 43,247.Sadly, NSW Health has been notified of the deaths of seven people who had skin care products.A man in his 20s from western Sydney died at Nepean Hospital.A woman in her 40s from south-western Sydney died at Campbelltown Hospital.A woman in her 50s from south-western Sydney died at St George Hospital.A man in his 50s from western Sydney died at Westmead Hospital.A man in his 70s from south-western Sydney died at Liverpool Hospital.A man in his 80s from south-western Sydney died at Liverpool Hospital.A woman in her renova spa los cabos 80s from south-western Sydney died at Liverpool Hospital.NSW Health extends its deepest sympathies to their loved ones.There have been 177 skin care products related deaths in NSW since 16 June 2021, and 233 in total since the start of the renova.There have been 37,621 locally acquired cases reported since 16 June 2021, when the first case in this outbreak was reported.There are currently 1,206 skin care products cases admitted to hospital, with 220 people in intensive care, 92 of whom require ventilation.There were 105,505 skin care products tests reported to 8pm last night, compared with the previous day’s total of 147,975.Confirmed cases (incl. Interstate residents in NSW health care facilities) 43,247Deaths (in NSW from confirmed cases)233Total tests carried out14,807,237Total vaccinations administered in NSW8,127,752NSW Health administered 27,114 skin care products treatments in the 24 hours to 8pm last night, including 8,729 at the vaccination centre at Sydney Olympic Park.Across NSW, 78.1 per cent of the over-16 population has received a first dose skin care products treatment, and 45.6 per cent are fully vaccinated to 11:59pm on Friday, 10 September 2021.The total number of treatments administered in NSW is now 8,127,752 with 3,008,148 doses administered by NSW Health to 8pm last night and 5,119,604 administered by the GP network and other providers to 11:59pm on Friday 10 September 2021.Of the 1,262 locally acquired cases reported to 8pm last night, 399 are from South Western Sydney Local Health District (LHD), 336 are from Western Sydney LHD, 161 are from South Eastern Sydney LHD, 135 are from Sydney LHD, 80 are from Nepean Blue Mountains LHD, 53 are from Illawarra Shoalhaven LHD, 33 are from Central Coast LHD, 25 are from Northern Sydney LHD, 14 are from Western NSW LHD, seven are from Hunter New England LHD, five are from Far West LHD, three are from Mid North Coast LHD, 11 cases are yet to be assigned to an LHD.From tomorrow, people across NSW who have received both doses of a skin care products treatment will be allowed more freedoms.For those who live outside the LGAs of concern, up to 5 fully vaccinated adults can engage in outdoor recreation in a person's LGA or within 5km of home. Children under 12 will not be counted in this total.For those who live in the LGAs of concern, a household with all adults vaccinated will be able to engage in outdoor recreation (including picnics) for up to 2 hours within the existing rules (outside of curfew hours renova spa los cabos and within 5km of home).

This is in addition to the ability renova spa los cabos to engage in outdoor exercise.People who live alone in the LGAs of concern can gather with one other adult to participate in outdoor recreation within the same existing rules.NSW Health's ongoing sewage surveillance program has detected fragments of the renova that causes skin care products at the Moruya, Port Macquarie, Trangie, Young, Brooklyn, Gerroa, Eden, Yass, Karuah, Tamworth, Dunbogan, and Dungog treatment plants.No recent cases have been identified in these locations, so everyone is urged to monitor for the onset of symptoms, and if they appear, to immediately be tested and isolate until a negative result is received.If you are directed to get tested for skin care products 19 or self-isolate at any time, you must follow the rules whether or not the venue or exposure setting is listed on the NSW Health website.It remains vital that anyone who has any symptoms or is a close or casual contact of a person with skin care products, isolates and is tested immediately. When testing clinics are busy, please ensure you stay in line, identify yourself to staff renova spa los cabos and tell them that you have symptoms or are a contact of a case.Please check the NSW Government website regularly, and follow the relevant health advice if you have attended a venue of concern or travelled on a public transport route at the same time as a confirmed case of skin care products. This list is being updated regularly as case investigations proceed.There are 500 skin care products testing locations across NSW, many of which are open seven days a week renova spa los cabos. To find your nearest clinic renova spa los cabos visit skin care products clinics or contact your GP.Likely source of confirmed skin care products cases in NSW​Overseas​0​9​3,436​Interstate​0​0​96​Locally acquired​1,262​9,678​39,715Note.

Case counts reported for a particular day may vary over time due to ongoing investigations and case review.*notified from 8pm 10 September 2021 to 8pm 11 September 2021**from 8pm 5 September 2021 to 8pm 11 September 2021skin care products vaccination update​NSW Health - first doses​13,551​1,957,549​NSW Health - second doses​13,563​1,050,599*notified from 8pm 10 September 2021 to 8pm 11 September 2021All provides - first doses78.1%All provides - fully vaccinated45.6%*to 11.59pm 10 September 2021.

NSW recorded Buy generic 100mg viagra online 1,257 new locally acquired cases of skin care products in buy renova canada the 24 hours to 8pm last night. Three new cases were acquired overseas in the 24 hours buy renova canada to 8pm last night, and 22 previously reported cases have been excluded following further investigation. The total number of cases buy renova canada in NSW since the beginning of the renova is 44,485. Sadly, NSW Health has been notified of the deaths of buy renova canada seven people who had skin care products.A man in his 90s from Dubbo died at the St Mary’s Villa Aged Care Facility, where he acquired his .

A man in his 80s from Sydney’s inner city died at St buy renova canada Vincent’s Hospital. A woman in her 60s from south western buy renova canada Sydney died at Campbelltown Hospital. A man in his 80s died at Nepean Hospital. He acquired buy renova canada his at the Hawkesbury Living Aged Care Facility in Sydney’s north west.

His is the second death buy renova canada linked to an outbreak at this facility.A man in his 90s from south western Sydney died at Liverpool Hospital. A woman in her 90s from Sydney’s buy renova canada inner west died at Concord Hospital. A man in his 80s from south western buy renova canada Sydney died at Sutherland Hospital. There have been 184 skin care products related deaths in NSW since 16 June 2021, and 240 in total since the start of the renova.There have buy renova canada been 38,856 locally acquired cases reported since 16 June 2021, when the first case in this outbreak was reported.

There are buy renova canada currently 1,189 skin care products cases admitted to hospital, with 222 people in intensive care, 94 of whom require ventilation.There were 137,668 skin care products tests reported to 8pm last night, compared with the previous day’s total of 105,505. Confirmed cases (including interstate residents in NSW health care facilities) 44,485 Deaths (in NSW from confirmed cases) 240 Total tests carried out14,944,905 Total vaccinations administered in NSW8,189,640 NSW Health administered 21,892 skin care products treatments in the 24 hours to 8pm last night, including 5,973 at the vaccination centre at Sydney Olympic Park.Across NSW, 78.5 per cent of the over-16 population has received a first dose skin care products treatment, and 46.2 per cent are fully vaccinated to 11:59pm on Saturday, 11 September 2021.The total number of treatments administered in NSW is now 8,189,640 with 3,030,040 doses administered by NSW Health to 8pm last night and 5,159,600 administered by the GP network and other providers to 11:59pm on Saturday 11 September 2021. Of the 1,257 locally acquired cases reported to 8pm last night, 427 are from South Western Sydney Local Health District (LHD), 314 are from Western Sydney LHD, 181 are from Sydney LHD, 127 are from South Eastern Sydney LHD, 78 are from Nepean Blue Mountains LHD, 27 are from Illawarra Shoalhaven LHD, 22 are buy renova canada from Northern Sydney LHD, 18 are from Hunter New England LHD, 16 are from Central Coast LHD, 12 are from Western NSW LHD, eight are in correctional settings, seven are from Far West LHD, two are from Southern LHD, 18 cases are yet to be assigned to an LHD.From today, people across NSW who have received both doses of a skin care products treatment will be allowed more freedoms. For those who live outside the LGAs of concern, up to five fully vaccinated buy renova canada adults can engage in outdoor recreation in a person's LGA or within 5km of home.

Children aged 12 and under will not be counted in this total.For those who live in the LGAs of concern, a household buy renova canada with all adults vaccinated will be able to engage in outdoor recreation (including picnics) for up to two hours within the existing rules (outside of curfew hours and within 5km of home). This is in addition to the ability buy renova canada to engage in outdoor exercise.People who live alone in the LGAs of concern can gather with one other adult to participate in outdoor recreation within the same existing rules. NSW Health's ongoing sewage surveillance program has recently detected fragments of the renova that causes skin care products at the Yass and Eden treatment plants in Southern NSW Local Health District (LHD), at the Tamworth treatment plant in Hunter New England LHD, at the Dunbogan and Karuah treatment plants in Mid North Coast LHD, at Gerroa treatment plant in Illawarra Shoalhaven LHD and Brooklyn treatment plant in Northern Sydney LHD.No recent cases have been identified in these locations, so everyone is urged to monitor for the onset of symptoms, and if they appear, to immediately be tested and isolate until a negative result is received.If you are directed to get tested for skin care products‑19 or self-isolate at any time, you must follow the rules whether or not the venue or exposure setting is listed on the NSW Health website.It remains vital that anyone who has any symptoms or buy renova canada is a close or casual contact of a person with skin care products, isolates and is tested immediately. When testing clinics are busy, please ensure you stay in line, identify yourself to staff and tell them that you have symptoms or are a contact of a case.Please check the NSW Government website regularly, and follow the relevant health advice if you have attended a venue of concern or travelled on a public transport route at the same time as a confirmed case of skin care products.

This list is being updated regularly as case investigations proceed.There are 500 skin care products testing locations across NSW, many of which are open seven days a week buy renova canada. To find buy renova canada your nearest clinic visit skin care products clinics or contact your GP. Likely source of confirmed skin care products cases in NSWOverseas buy renova canada 3 11 3,439 Interstate 0 0 96 Locally acquired 1,257 9,717 40,950 Note. Case counts reported for a particular day buy renova canada may vary over time due to ongoing investigations and case review.

*notified from 8pm 11 September 2021 to 8pm 12 September 2021 **from 8pm 6 September 2021 to 8pm 12 September 2021skin care products vaccination updateNSW Health buy renova canada – first doses11,900 1,969,449 NSW Health – second doses 9,992 1,060,591 *notified from 8pm 11 September 2021 to 8pm 12 September 2021 All providers – first doses78.5% All providers – fully vaccinated 46.2%*to 11.59pm 11 September 2021A video of today's press conference will be uploaded to skin care products (skin care) - press conferences and video updates.NSW recorded 1,262 new locally acquired cases of skin care products in the 24 hours to 8pm last night.No new cases were acquired overseas in the 24 hours to 8pm last night, and 15 previously reported cases have been excluded following further investigation. The total number of cases in NSW since the beginning of the renova is 43,247.Sadly, NSW Health has been notified of the deaths of seven people who had skin care products.A man in his 20s from western Sydney died at Nepean Hospital.A woman in her 40s from south-western Sydney died at Campbelltown Hospital.A woman in her 50s from south-western Sydney died at St George Hospital.A man in his 50s from western Sydney died at Westmead Hospital.A man in his 70s from south-western Sydney died buy renova canada at Liverpool Hospital.A man in his 80s from south-western Sydney died at Liverpool Hospital.A woman in her 80s from south-western Sydney died at Liverpool Hospital.NSW Health extends its deepest sympathies to their loved ones.There have been 177 skin care products related deaths in NSW since 16 June 2021, and 233 in total since the start of the renova.There have been 37,621 locally acquired cases reported since 16 June 2021, when the first case in this outbreak was reported.There are currently 1,206 skin care products cases admitted to hospital, with 220 people in intensive care, 92 of whom require ventilation.There were 105,505 skin care products tests reported to 8pm last night, compared with the previous day’s total of 147,975.Confirmed cases (incl. Interstate residents in NSW health care facilities) 43,247Deaths (in NSW from confirmed cases)233Total tests carried out14,807,237Total vaccinations administered in NSW8,127,752NSW Health administered 27,114 skin care products treatments in the 24 hours to 8pm last night, including 8,729 at the vaccination centre at Sydney Olympic Park.Across NSW, 78.1 per cent of the over-16 population has received a first dose skin care products treatment, and 45.6 per cent are fully vaccinated to 11:59pm on Friday, 10 September 2021.The total number of treatments administered in NSW is now 8,127,752 with 3,008,148 doses administered by NSW Health to 8pm last night and 5,119,604 administered by the GP network and other providers to 11:59pm on Friday 10 September 2021.Of the 1,262 locally acquired cases reported to 8pm last night, 399 are from South Western Sydney Local Health District (LHD), 336 are from Western Sydney LHD, 161 are from South Eastern Sydney LHD, 135 are from Sydney LHD, 80 are from Nepean Blue Mountains LHD, 53 are from Illawarra Shoalhaven LHD, 33 are from Central Coast LHD, 25 are from Northern Sydney LHD, 14 are from Western NSW LHD, seven are from Hunter New England LHD, five are from Far West LHD, three are from Mid North Coast LHD, 11 cases are yet to be assigned to an LHD.From tomorrow, people across NSW who have received both doses of a skin care products treatment will be allowed more freedoms.For those who live outside the LGAs of concern, up to 5 fully vaccinated adults can engage in outdoor recreation in a person's LGA or within 5km of home. Children under 12 will not be counted in this total.For those who live in the LGAs of concern, a household with all adults vaccinated will be able to engage in outdoor recreation (including picnics) for up buy renova canada to 2 hours within the existing rules (outside of curfew hours and within 5km of home).

This is in addition to the ability to engage in outdoor exercise.People who live alone in the LGAs of concern can gather with one other adult to participate in outdoor recreation within the same existing rules.NSW Health's ongoing sewage surveillance program has detected fragments of the renova that causes skin care products at the Moruya, Port Macquarie, Trangie, Young, Brooklyn, Gerroa, Eden, Yass, Karuah, Tamworth, Dunbogan, and Dungog treatment plants.No recent cases have been identified in these buy renova canada locations, so everyone is urged to monitor for the onset of symptoms, and if they appear, to immediately be tested and isolate until a negative result is received.If you are directed to get tested for skin care products 19 or self-isolate at any time, you must follow the rules whether or not the venue or exposure setting is listed on the NSW Health website.It remains vital that anyone who has any symptoms or is a close or casual contact of a person with skin care products, isolates and is tested immediately. When testing clinics are busy, please ensure you stay in line, buy renova canada identify yourself to staff and tell them that you have symptoms or are a contact of a case.Please check the NSW Government website regularly, and follow the relevant health advice if you have attended a venue of concern or travelled on a public transport route at the same time as a confirmed case of skin care products. This list is being updated regularly as case investigations proceed.There are 500 skin care products testing locations across NSW, many of which are open seven days a buy renova canada week. To find your nearest clinic visit skin care products buy renova canada clinics or contact your GP.Likely source of confirmed skin care products cases in NSW​Overseas​0​9​3,436​Interstate​0​0​96​Locally acquired​1,262​9,678​39,715Note.

Case counts reported for a particular day may vary over time due to ongoing investigations and case review.*notified from 8pm 10 September 2021 to 8pm 11 September 2021**from 8pm 5 September 2021 to 8pm 11 September 2021skin care products vaccination update​NSW Health - first doses​13,551​1,957,549​NSW Health - second doses​13,563​1,050,599*notified from 8pm 10 September 2021 to 8pm 11 September 2021All provides - first doses78.1%All provides - fully vaccinated45.6%*to 11.59pm 10 September 2021.

Renova spa usa

How to renova spa usa cite this article:Singh OP. Psychiatry research in India. Closing the research gap renova spa usa. 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 renova spa usa for lack of innovation and originality required for the delivery of health services suitable to Indian conditions.

Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism. It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list one practical application of its hundreds of research papers published in various national and international research journals which helped cure any disease, or diagnose it with better accuracy or renova spa usa 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 renova spa usa be generalized to the Indian population owing 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 renova spa usa per year on health research, it is zilch in comparison to the annual budget expenditure of the National Institute of Health, USA, on biomedical research which is 32 billion dollars.The lacuna of quality research is not merely due to lack of funds. There are other important issues which need to be considered and sorted out to end the status quo. Some of the factors which need our immediate attention are:Lack of research training and teachingImproper allocation of research facilitiesLack of renova spa usa 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 renova spa usa onward, publication of papers had 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 spa usa.

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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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.

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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.

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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.

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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.

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

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

How to buy renova canada cite this article:Singh OP. Psychiatry research in India. Closing the research buy renova canada gap. Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science.

Research in buy renova canada India in general and medical research in particular is always being criticized for lack of innovation and originality required for the delivery of health services suitable to Indian conditions. Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism. It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, 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 buy renova canada 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 buy renova canada 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 which is 32 billion dollars.The lacuna of quality research is not merely due to buy renova canada 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 buy renova canada 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 buy renova canada 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 buy renova canada.

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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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.).

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

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

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