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Given the ongoing number of infectious cases in the community, the current lockdown will be Discover More extended for at least another two weeks until buy kamagra online australia 11:59pm on Friday, 30 July. We are constantly buy kamagra online australia reviewing the health advice and will continue to update the community if any changes are required. This means the restrictions currently in place across Greater Sydney including the Central Coast, Blue Mountains, Wollongong and Shellharbour will remain in place until this time.In these areas, online learning for students will also continue for an additional two weeks.We understand this is a difficult time for the community and appreciate their ongoing patience.

It is vital people continue to come forward for testing to help us buy kamagra online australia find any erectile dysfunction treatment cases in the community. Restrictions in regional NSW remain unchanged. Read the latest erectile dysfunction treatment information.​​Given the growing number of infectious cases in the community and unlinked cases of community transmission, erectile dysfunction treatment restrictions will be tightened across Greater Sydney including the Central Coast, Blue Mountains, Wollongong and Shellharbour.From 5pm today (Friday, 9 July) buy kamagra online australia the following additional restrictions will be in placeOutdoor public gatherings limited to two people (excluding members of the same household)People must stay in their Local Government Area or within 10kms of home for exercise and outdoor recreation, with no carpooling between non-household membersBrowsing in shops is prohibited, plus only one person per household, per day may leave the home for shoppingFunerals limited to ten people in total (this will take effect from Sunday, 11 July).The four reasons to leave your home remain in placeShopping for food or other essential goods and services (one person only)Medical care or compassionate needs (only one visitor can enter another residence to fulfil carers' responsibilities or provide care or assistance, or for compassionate reasons)Exercise with no more than 2 (unless members of the same household)Essential work, or education, where you cannot work or study from home.Restrictions in regional NSW will remain unchanged.These tightened restrictions are based on health advice from the Chief Health Officer Dr Kerry Chant.They are necessary due to the increasing number of unlinked cases in the community.

We understand this is a buy kamagra online australia difficult time for the community and businesses. We thank them for their understanding and patience. High testing numbers are key to finding unrecognised chains buy kamagra online australia of transmission in the community, so please continue to come forward for a erectile dysfunction treatment test, even if you have the mildest of symptoms.

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How to who can buy kamagra cite my blog this article:Singh OP. Psychiatry research in India. Closing the who can buy kamagra research gap.

Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science. Research in India in general and medical research in particular is always being criticized for lack of innovation and originality required who can buy kamagra 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 who can buy kamagra helped cure any disease, or diagnose it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of ICMR is not up to the mark and is not commensurate with the magnitude of the disease burden in India. According to the 12th Plan Report, the country contributes to a fifth of the world's share of diseases.

The research conducted elsewhere may not be generalized to the Indian population owing to differences in biology, health-care systems, health practices, who can buy kamagra 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 who can buy kamagra 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 who can buy kamagra information about research work happening globallyLack of promotion, motivation, commitment, and passion in the field of researchClinicians being overburdened with patientsLack of collaboration between medical colleges and established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research in India are conducted in medical institutions.

The majority of these are done as thesis submission for fulfillment of the requirement of PG degree. From 2015 onward, who can buy kamagra 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 who can buy kamagra. 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. Strategies towards a systems approach. In.

Burden of Disease in India. Equitable development – Healthy future New Delhi, India. National Commission on Macroeconomics and Health.

Ministry of Health and Family Welfare, Government of India. 2005. 2.Math SB, Srinivasaraju R.

Indian Psychiatric epidemiological studies. Learning from the past. Indian J Psychiatry 2010;52:S95-103.

3.Tewari A, Kallakuri S, Devarapalli S, Jha V, Patel A, Maulik PK. Process evaluation of the systematic medical appraisal, referral and treatment (SMART) mental health project in rural India. BMC Psychiatry 2017;17:385.

4.Ministry of Tribal Affairs, Government of India. Report of the High Level Committee on Socio-economic, Health and Educational Status of Tribal Communities of India. New Delhi.

Government of India. 2014. 5.Office of the Registrar General and Census Commissioner, Census of India.

New Delhi. Office of the Registrar General and Census Commissioner. 2011.

6.International Institute for Population Sciences and ICF. National Family Health Survey (NFHS-4), 2015-16. India, Mumbai.

International Institute for Population Sciences. 2017. 7.World Health Organization.

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[PUBMED] [Full text] 21.Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders. Findings from the Global Burden of Disease Study 2010.

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Correspondence Address:S V. Siddhardh Kumar DevarapalliGeorge Institute for Global Health, Plot No. 57, Second Floor, Corporation Bank Building, Nagarjuna Circle, Punjagutta, Hyderabad - 500 082, Telangana IndiaSource of Support.

None, Conflict of Interest. NoneDOI. 10.4103/psychiatry.IndianJPsychiatry_136_19 Figures [Figure 1] Tables [Table 1], [Table 2].

How to cite this article:Singh OP buy kamagra online australia http://bunkerhilltrading.com/product/magpul-afg1-angled-foregrip-black/. Psychiatry research in India. Closing the buy kamagra online australia research gap. Indian J Psychiatry 2020;62:615-6Research is an important aspect of the growth and development of medical science. Research in India in general and medical research in particular is always being criticized for lack of innovation and originality required for the delivery of health services suitable buy kamagra online australia to Indian conditions.

Even the Indian Council of Medical Research (ICMR) which is a centrally funded frontier organization for conducting medical research couldn't avert criticism. It has been criticized heavily for not producing quality research papers which are pioneering, ground breaking, or pragmatic solutions for health issues plaguing India. In the words of a leading daily, The ICMR could not even list one practical application of its hundreds of research papers published in various national and international research journals which helped cure any disease, or diagnose it with better accuracy or in less time, or even one new basic, applied or clinical research or innovation that opened a new frontier of scientific knowledge.[1]This clearly indicates that the health research output of ICMR is not up to the mark and is not commensurate with the magnitude of the disease burden in India buy kamagra online australia. 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 buy kamagra online australia 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 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 kamagra online australia 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 buy kamagra online australia being overburdened with patientsLack of collaboration between medical colleges and established research institutesLack of continuity of research in successive batches of postgraduate (PG) students, leading to wastage of previous research and resourcesDifficulty in the application of basic biomedical research into pragmatic intervention solutions due to lack of interdisciplinary technological support/collaboration between basic scientists, clinicians, and technological experts.Majority of the biomedical research in India are conducted in medical institutions.

The majority of these are done as thesis submission for fulfillment of the requirement of PG degree. From 2015 onward, publication of papers had been made an obligatory requirement buy kamagra online australia 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 kamagra online australia.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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A saying often attributed to George Bernard Shaw is ‘The single biggest problem in communication is the illusion that it has taken place.’ While it has been debated who originally made kamagra canada buy this statement, this expression has been used across several industries in different ways.1–4 Communication is an essential aspect of patient safety. One could kamagra canada buy argue for expanding this proverb to emphasise the importance of recognising that communication at key moments is intrinsically valuable. The biggest problems in communication are the illusion that it has taken place and the assumption that it is not necessary.Over the past 100 years, cognitive aids for crisis events during patient care have been called for, developed, refined and examined.5–12 While much of this literature comes from high-risk industries and medical simulation, there is increasing supporting evidence from healthcare on how these tools can act as cognitive aids in clinical settings. Regarding terminology, we cite a review article on kamagra canada buy emergency manuals (EMs). €˜EMs are context-relevant sets of cognitive aids, such kamagra canada buy as crisis checklists, that are intended to provide professionals with key information for managing rare emergency events.

Synonyms and related terms include crisis checklists. Emergency checklists and cognitive aids, a much broader term, although often also used to describe tools for use during emergency events specifically.’13 Published accounts from healthcare professionals who experienced real-life events have described the power of these tools to prevent errors of omission, commission and lapses in communication.14–18 kamagra canada buy These events can be both common in large health systems and rare at the level of the individual clinician.10 It is also hard to predict when they will occur. These attributes create a meaningful role to study crisis checklists, EMs and other cognitive aids using medical simulation, particularly in healthcare settings (such as the emergency department (ED)) where they have been understudied.In this issue of BMJ Quality and Safety, Dryver et al make a major contribution to the expanding scope of these evidence-based tools into the realm of emergency medicine.19 In a simulation-based multi-institutional, multidisciplinary randomised controlled trial on the use of medical crisis checklists in the ED, the authors evaluated resuscitation teams in performing indicated emergency interventions during simulated medical crisis events (eg, anaphylactic shock, status epilepticus), with or without access to a crisis checklist for that scenario. Emergency medicine resuscitation teams, comprised kamagra canada buy of physicians (mainly residents), nurses, nursing assistants and medical secretaries, participated in these simulations. They took place kamagra canada buy during the teams’ clinical shift in the ED setting, with access to their usual equipment, medications and cognitive aids.

The checklist for each scenario was displayed on large wall-mounted or television screens and outlined possible interventions to consider during the management of that particular crisis, including for instance medications with their indication, contraindication and risks as well as dose and route of administration. The authors found, among other findings, a notable and significant difference in kamagra canada buy the median percentage of indicated emergency interventions when the checklists were available. 38.8% without checklist access and 85.7% with checklist access (p<0.001). They also found that kamagra canada buy the vast majority of participants (94%) agreed that they would use the checklists if faced with a similar case during actual patient care. Consistent with findings from prior studies in the New England Journal of Medicine (studying operating room teams) kamagra canada buy and the Journal of Critical Care (studying intensive care unit teams), Dryver et al have demonstrated yet another setting (the ED) where crisis checklists, EMs and other critical event cognitive aids may be beneficial.10 20The study should be interpreted in the context of its study design, strengths and limitations.

The study was conducted using in situ simulation, that is, the performance of medical simulation in a clinical care area pertaining to the events being studied. When done safely, this method provides opportunities for participants to practise the management of critical events in the actual location where they may encounter them during actual patient care situations.21–23 kamagra canada buy It is also a multi-institutional study that involved two EDs from an academic centre. One from a rural community hospital, and one from a large community hospital. The checklists were tailored to the medications available at kamagra canada buy each institution’s ED location as opposed to a generic pocket-card cognitive aid. The value of kamagra canada buy such local customisation has been noted across several publications on crisis checklists and EMs, also highlighting the broader factors to consider (in addition to medication details) such as the medium used (eg, paper vs digital, tablet vs computer), device models and settings (eg, transcutaneous pacemakers settings, defibrillator settings), and methods to call for help (eg, local emergency phone numbers).10 12 24This study focused on the presence or absence of a readily displayed checklist with a medical crisis made readily apparent from the simulated scenario’s introduction.

It was not aimed to evaluate the ability of teams to correctly diagnose the critical event of interest. While the authors note that this allowed the simulations to focus on treatment, other studies on crisis checklists/EMs have intentionally included scenarios where the diagnosis was unclear or not within the EM available.10 25 One simulation-based study that included scenarios not within the EM available showed variable usage of the EMs (‘with some teams not using the [emergency manual] at all’) and variable impact on team performance.25 Future studies on the use of ED crisis checklists by resuscitation teams may want to factor in the complexity kamagra canada buy of an undifferentiated medical scenario, where a patient may present with an unknown diagnosis, or where a clinical presentation may be confounded by comorbidities.Not only the range of care settings expands where cognitive aids are considered beneficial when dealing with crisis situations, ongoing work also extends the use of such tools temporally. (1) preventing the kamagra canada buy crisis and/or its manifestations from occurring in the first place, and (2) dealing with the aftermath of the crisis event. The WHO Safe Surgery Saves Lives Surgical Safety Checklist is a well-known example of the first category, containing a set of evidence-based processes of care meant to be carried out at key pause points during surgery. This tool includes a pause-point to allow anticipated critical events to be reviewed, as well as processes that could lead to a critical event if missed (eg, reviewing allergies, confirming counts are correct towards the end of a procedure).26 A systematic review of articles describing the actual use of surgical safety checklists found that they were associated with increased detection of potential safety hazards, decreased surgical complications and improved staff communication.27 Regarding the second category, dealing with the aftermath of a crisis, critical event debriefing is a long-standing practice that has been noted for its potential benefits to healthcare professionals at the individual, team and systems level.28–33 It can help mitigate the negative impact of crisis events on healthcare providers, offer opportunities for education and learning, and serve as a vehicle to identify systems gaps in overall quality and safety.33 34 Something as simple as a well-timed drop of WATER (Welfare check, kamagra canada buy Acute/short-term corrections, Team reactions and reflection, Education, and Resource awareness/longer term needs), the beginnings of a cognitive aid in itself, can have a meaningful ripple effect if used when indicated (figure 1).

Several cognitive aids for various forms of debriefing have been described. The Promoting Excellence And Reflective Learning in Simulation (PEARLS) debriefing tool was developed based on experiences in medical simulation.35 Versions of PEARLS have been adapted for healthcare debriefing and systems-focused debriefing.32 36 The Debriefing In-Situ Conversation after Emergent Resuscitation Now tool was developed in the study of resuscitations at a paediatric ED.37 An adapted version was created during the erectile dysfunction treatment kamagra for end-of-shift debriefing in EDs (Debriefing In Situ erectile dysfunction treatment to Encourage Reflection and Plus-Delta in Healthcare After Shifts End).38 There is a large body of literature from medical simulation and other disciplines supporting critical event debriefing.33 34 Considerations to avoid psychological iatrogenic effects from debriefing (such as customisation to local culture and available resources/debriefing training) have been noted.33 34 39 Future research, both via simulation and after real events, can help inform ways to improve the quality and frequency of debriefing after the very events that have been studied with crisis checklists and kamagra canada buy EMs.40Elements to consider for debriefing just after a perioperative critical event. These elements are not meant kamagra canada buy to be comprehensive. Customisation to local culture and available resources is essential.33 34 The responsibility for interpretation/application lies with the reader. Image.

Restivo D. Water Drop impact on water surface. Available at https://commons.wikimedia.org/wiki/File:Water_drop_impact_on_a_water-surface_-_(5).jpg. Accessed 13 Feb 2021. With permission via Creative Commons CC BY-SA 2.0 License (https://creativecommons.org/licenses/by-sa/2.0/legalcode).

QI, quality improvement." data-icon-position data-hide-link-title="0">When translating these interventions from medical simulation to the point of care, there are many lessons to be learnt from the implementation sciences. Editorials and perspective pieces have called for checklists to be viewed within a broader sociocultural or sociotechnical context, including factors such as team training and thoughtful implementation.41 42 Original research on team training initiatives that include surgical safety checklists has been associated with improved patient outcomes.43 Crisis checklists and EMs are substantially less effective if they are sitting in a drawer collecting dust during an emergency. To minimise the likelihood of this happening, it is important that their implementation is approached with the same rigour as all good quality improvement work. Including conducting a needs assessment, customising the cognitive aids, obtaining key stakeholder buy-in, establishing implementation champions, developing training programmes, evaluation and ongoing measurement and iterative improvement, which all have been well described.11 44 45 As another example of an implementation framework, the Consolidated Framework for Implementation Research is composed of five major domains. Intervention characteristics, outer setting, inner setting, characteristics of the individuals involved and the process of implementation.46 Another popular example is the plan–do–study–act model.47 48 Specific to crisis checklists and EMs, Goldhaber-Fiebert and Howard proposed four vital elements for widespread and successful implementation.

Create, familiarise, use and integrate.11 12 Agarwala et al reported an institutional case study of perioperative EM implementation that centred around three goals. (1) place EMs in every anaesthetising location, (2) create interprofessional engagement and (3) demonstrate that a majority of anaesthesia clinicians would use the EMs in some way within the first year.49 Factors such as leadership support and dedicated time to train staff can be essential.45 50 51 More successful implementation of crisis checklists and EMs has been reported when institutions used these tools to assist both during the management of the critical events and in debriefing after critical events.45 An association between the quality of implementation and improved outcomes has similarly been seen with routine surgical safety checklists.52 53 There is also value in research that considers not only whether the tool is used, but also how implementation and training strategies can be leveraged to improve thoughtful adherence to the items on the checklist and avoid issues from going unnoticed.54–56 For critical event debriefing, there is potentially a wide gap between principle and practice. Studies across different medical disciplines have reported that debriefing after critical events takes place only a fraction of the time.34 57 58 Barriers mentioned in studies and other publications include competing clinical priorities, lack of debriefing training, interpersonal dynamics and leadership buy-in.33 34 37 58–61 Several of these barriers potentially overlap with the goals of implementing crisis checklists, and there may be synergy in viewing prevention, crisis events and their aftermath within a continuum.At a fundamental level, many of the cognitive aids discussed in this editorial are designed to both improve cognition and foster interdisciplinary communication about essential best practices at key moments in time. There should not be an illusion that this communication is already taking place or an assumption that it is not necessary. There also should not be a fallacy that these critical event cognitive aids are simply ‘memory aids’.

Growing evidence of EMs during real-time use has described providers reporting the use of these tools associated with decreased stress, improved teamwork, a calmer atmosphere and better care.14 16 There is active work, including collaboration with expertise from the Human Systems Integration Division from the National Aeronautics and Space Administration, exploring how to optimise critical event cognitive aid design relative to the high cognitive load and other factors intrinsic to a crisis.62–66 Emerging research has explored whether it is beneficial to have a crisis checklist reader role, separate from the crisis event leader, when resources allow.13 67Future work on cognitive aids for medical crises should not only address whether they are present, but also how they are designed, used, simulated and implemented towards the most successful outcomes, and its effect on communication. As the scope of patient safety efforts surrounding crisis management continues to expand, there is value in thinking both spatially and temporally via both medical simulation and real events.Ethics statementsPatient consent for publicationNot required.The haemoglobin A1c (HbA1c) level has become the standard of care for monitoring type 2 diabetes as it reflects a person’s average blood glucose level over the previous 2–3 months, is correlated with risk of long-term complications and can be measured cheaply and easily. International guidelines recommend testing HbA1c every 6–12 months for those with stable type 2 diabetes, and every 3–6 months in adults with unstable type 2 diabetes until HbA1c is controlled on unchanging therapy.1–3 However, these guidelines are based on expert consensus rather than robust evidence on whether the frequency of HbA1c measurement impacts patient outcomes. To date, most studies have focused on the association between testing frequency and glycaemic control.4–6In this issue of BMJ Quality &. Safety Imai and colleagues go further, demonstrating an association between adherence to guideline-recommended testing frequency and health outcomes.7 Using data from electronic health records (EHRs), they examined adherence to guideline-recommended HbA1c testing frequency over a 5-year period in 6424 people with type 2 diabetes across 250 general practices in Australia.

An adherence rate was calculated for each person with type 2 diabetes, dividing the number of tests performed within the recommended intervals by the total number of conducted tests (minus 1). Patients were categorised into low-adherence (<33%), moderate-adherence (34%–66%) and high-adherence groups (>66%). Where there was high adherence to guideline-recommended testing frequency, HbA1c values remained stable or improved over time. In contrast, with low adherence, HbA1c values remained unstable or deteriorated over the 5-year period. The risk of developing chronic kidney disease was lower among those with high adherence compared to those with low adherence (OR 0.42, 95% CI 0.18 to 0.99).

There was no evidence of an association between the rate of adherence and the development of ischaemic heart disease. This study provides support for the importance of frequent HbA1c testing as recommended in current clinical guidelines for prevention of complications of diabetes.The study exploits an abundance of observational data on processes and outcomes of care readily available in EHRs in a real-life setting and among a general population with type two diabetes over a 5 year period. However, the authors highlight methodological challenges. Using EHRs to explore the association between adherence to testing frequency and HbA1c is susceptible to selection bias, given that patients need to have HbA1c measurements recorded to be included in the study. Imai and colleagues include ‘active patients’ defined as individuals who attended the practices three or more times in the past 2 years at the time of the visit and had two or more HbA1c tests over the study period.7 While this restriction was necessary to avoid duplication of patients across primary care practices and to study the development of complications over time, it may introduce selection bias and also reduce the generalisability of the findings.

The authors suggest their findings are conservative estimates of the association between adherence to guideline-recommended testing frequency and outcomes, given the positive association between practice visits and glycaemic control. However, those who do not attend general practice regularly differ in many other ways, which may also affect the association between adherence to guideline-recommended testing frequency and health outcomes. A recent systematic review of non-attendance at outpatient diabetes appointments, including those with a general practitioner or nurse, found that younger adults, smokers and those with financial pressures were less likely to attend.8 In addition, even among those who attend general practice regularly, differences in other aspects of care such as self-management behaviour are likely to exist between those with high-adherence versus low-adherence rates.9 In the study by Imai and colleagues, data were not available on potentially important factors, such as patients’ body mass index, smoking status and adherence to medication,7 making it difficult to attribute unstable or deteriorating HbA1c to low-adherence rates. Furthermore, the adherence rate was estimated based on average test numbers over 5 years, so adherence may vary over time. Future research could build on the work of Imai and colleagues to examine the causal relationships between a range of care processes (including testing frequency), HbA1c and health outcomes by assessing the temporality of relationships, accounting for selection bias and confounding, and exploring potential causal mechanisms such as treatment intensification.9Imai and colleagues also found that the median testing frequency in people with type 2 diabetes was less than the recommended two tests per year in Australia (median 1.6 tests per year).7 Poor adherence to recommended testing frequency is documented in several countries with similar guidelines, including countries in Europe10 11 and Asia12 as well as in the USA,13 thus raising questions about how best to improve this process of care.

Diabetes care is the subject of extensive quality improvement and implementation research,14 and a variety of interventions have been shown to improve processes and outcomes of care for people with diabetes.15 How and why these interventions work is unclear because of the range of intervention components operating at the patient, professional and system levels. Most interventions focus on a range of guideline-recommended behaviours in both health professionals and patients and are often described more broadly than changing or targeting one specific behaviour.16 For instance, adherence to HbA1c testing frequency itself is not one specific behaviour. It includes a series of behaviours by the person with diabetes, and potentially their support network, as well as behaviours by health professionals. The person with diabetes must initiate an appointment. The health professional may prompt the person to attend for regular testing.

On deciding and making the effort to attend, the person with diabetes must agree to the blood test. And the health professional must carry out the blood test and send it to a lab for analysis. To improve adherence to HbA1c testing frequency, we may have to intervene in multiple places, but first we need to identify where the process breaks down.There also needs to be a clearer understanding of why the process breaks down. To date, there has been no systematic review of the factors associated with adherence to the frequency of HbA1c testing recommended in guidelines. Individual studies, conducted in different health systems, have identified a range of patient-level factors including age, rurality, disease duration, receipt of specialist care, glycaemic control, cardiovascular risk factors and diabetes-related complications.10–13 Few studies have examined the professional, organisational and system-level determinants of adherence.

Yet we have reason to believe that factors at these levels are also important. In a qualitative synthesis of barriers to optimal diabetes management in primary care, perceived professional barriers included limited time and resources, changing professional boundaries leading to uncertainty about clinical responsibility, and a lack of confidence in knowledge of guidelines and skills.17 A meta-analysis of professional and practice-level factors associated with the quality of diabetes management in primary care identified doctor gender and age, doctor-level diabetes volume, practice deprivation and use of EHRs as significant determinants of quality, typically measured by a collection of individual indicators or a composite measure.18 Furthermore, evidence from a systematic review and meta-analysis of quality improvement interventions for diabetes suggests that strategies that intervene on the entire system of chronic disease management are associated with the largest effects irrespective of baseline HbA1c.15 Thus, to improve adherence to the frequency of HbA1c testing frequency, the problem needs to be understood in context, and solutions should incorporate professional and system-facing interventions as well as patient-facing interventions.Based on their analysis of the content of implementation interventions to support diabetes care, Presseau and colleagues call for better reporting of who needs to do what differently at all levels, including the system level, which is often underspecified.16 This, they propose, would contribute to the development of an underlying programme theory for improvement interventions linking activities to intended outcomes.19 Such an approach is relevant to many chronic conditions where disease management involves multiple actors, actions and settings. The development of testable theories and integration of causal reasoning are increasingly advocated in improvement and implementation science as a way to enhance the generalisability of interventions.20 21 Causal diagram modelling,20 the action–effect method19 and the implementation research logic model,22 facilitate the development and communication of intervention programme theory. The action effect method in particular is intended as a facilitated collaborative process to enhance the practicality of programme theory and to provide an actionable guide for quality improvement teams.19The current study by Imai and colleagues underscores the importance of the link between regular HbA1c testing, better glycaemic control and reduced risk of complications.7 While the causal mechanisms require further investigation, this study provides an important piece of the puzzle. Few interventions target Hba1c testing frequency alone, and this is unlikely to be the sole priority for people with diabetes or their health professionals, given the multiple processes recommended for optimal clinical and self-management.

However, given its centrality and profile in diabetes management, targeting HbA1c could be a lever for wider improvement. The foundation for such an intervention should be a better understanding and more precise articulation of who needs to do what differently, as well as how and why this intervention is expected to change specific processes of care and ultimately improve patient outcomes.Ethics statementsPatient consent for publicationNot required..

A saying often buy kamagra online australia attributed to George Bernard Shaw is ‘The single biggest problem in communication is the illusion that it has taken place.’ While it has been debated who originally made this statement, this expression has been used across several industries in different ways.1–4 Communication is an essential aspect of patient safety. One could argue for expanding this proverb to emphasise the importance of recognising buy kamagra online australia that communication at key moments is intrinsically valuable. The biggest problems in communication are the illusion that it has taken place and the assumption that it is not necessary.Over the past 100 years, cognitive aids for crisis events during patient care have been called for, developed, refined and examined.5–12 While much of this literature comes from high-risk industries and medical simulation, there is increasing supporting evidence from healthcare on how these tools can act as cognitive aids in clinical settings. Regarding terminology, we cite a review article buy kamagra online australia on emergency manuals (EMs). €˜EMs are context-relevant sets of cognitive aids, such as crisis buy kamagra online australia checklists, that are intended to provide professionals with key information for managing rare emergency events.

Synonyms and related terms include crisis checklists. Emergency checklists and cognitive aids, a much broader term, although often also used to describe tools for use during emergency events specifically.’13 Published accounts from healthcare professionals who experienced real-life events have described the power of these tools to prevent errors of omission, commission and lapses in communication.14–18 These events can be both common in large health systems and rare at the level of the individual clinician.10 It is also hard buy kamagra online australia to predict when they will occur. These attributes create a meaningful role to study crisis checklists, EMs and other cognitive aids using medical simulation, particularly in healthcare settings (such as the emergency department (ED)) where they have been understudied.In this issue of BMJ Quality and Safety, Dryver et al make a major contribution to the expanding scope of these evidence-based tools into the realm of emergency medicine.19 In a simulation-based multi-institutional, multidisciplinary randomised controlled trial on the use of medical crisis checklists in the ED, the authors evaluated resuscitation teams in performing indicated emergency interventions during simulated medical crisis events (eg, anaphylactic shock, status epilepticus), with or without access to a crisis checklist for that scenario. Emergency medicine resuscitation teams, comprised of physicians (mainly residents), nurses, nursing assistants and medical secretaries, participated in buy kamagra online australia these simulations. They took place during the teams’ clinical shift in the ED setting, buy kamagra online australia with access to their usual equipment, medications and cognitive aids.

The checklist for each scenario was displayed on large wall-mounted or television screens and outlined possible interventions to consider during the management of that particular crisis, including for instance medications with their indication, contraindication and risks as well as dose and route of administration. The authors found, buy kamagra online australia among other findings, a notable and significant difference in the median percentage of indicated emergency interventions when the checklists were available. 38.8% without checklist access and 85.7% with checklist access (p<0.001). They also found that the vast majority of participants (94%) agreed that they would use the checklists if faced with a similar case buy kamagra online australia during actual patient care. Consistent with findings from prior studies in the New England Journal of Medicine (studying operating room teams) and the Journal of Critical Care (studying intensive care unit teams), Dryver et al have demonstrated yet another setting (the ED) where buy kamagra online australia crisis checklists, EMs and other critical event cognitive aids may be beneficial.10 20The study should be interpreted in the context of its study design, strengths and limitations.

The study was conducted using in situ simulation, that is, the performance of medical simulation in a clinical care area pertaining to the events being studied. When done safely, this method provides opportunities for participants to practise the management of critical events in the actual location where they may encounter them during actual patient care situations.21–23 It is also a multi-institutional study buy kamagra online australia that involved two EDs from an academic centre. One from a rural community hospital, and one from a large community hospital. The checklists were tailored to the medications available at each institution’s ED location as opposed to a buy kamagra online australia generic pocket-card cognitive aid. The value of such local customisation has been noted across several publications on crisis checklists and EMs, also highlighting the broader factors to consider (in addition to medication details) such as the medium used (eg, paper vs digital, tablet vs computer), device models and settings (eg, transcutaneous pacemakers settings, defibrillator settings), and methods to call for help (eg, local emergency phone numbers).10 12 24This study focused on the presence or absence of a readily displayed checklist with a medical crisis made readily apparent from the simulated buy kamagra online australia scenario’s introduction.

It was not aimed to evaluate the ability of teams to correctly diagnose the critical event of interest. While the authors note that this allowed the simulations to focus on treatment, other studies on crisis checklists/EMs have intentionally included scenarios where the diagnosis was unclear or not within the EM available.10 25 One simulation-based study that included scenarios not within the EM available showed variable usage of the EMs (‘with some teams not using the [emergency manual] at all’) and variable impact on buy kamagra online australia team performance.25 Future studies on the use of ED crisis checklists by resuscitation teams may want to factor in the complexity of an undifferentiated medical scenario, where a patient may present with an unknown diagnosis, or where a clinical presentation may be confounded by comorbidities.Not only the range of care settings expands where cognitive aids are considered beneficial when dealing with crisis situations, ongoing work also extends the use of such tools temporally. (1) preventing the crisis and/or its manifestations from occurring in the first buy kamagra online australia place, and (2) dealing with the aftermath of the crisis event. The WHO Safe Surgery Saves Lives Surgical Safety Checklist is a well-known example of the first category, containing a set of evidence-based processes of care meant to be carried out at key pause points during surgery. This tool includes a pause-point to allow anticipated buy kamagra online australia critical events to be reviewed, as well as processes that could lead to a critical event if missed (eg, reviewing allergies, confirming counts are correct towards the end of a procedure).26 A systematic review of articles describing the actual use of surgical safety checklists found that they were associated with increased detection of potential safety hazards, decreased surgical complications and improved staff communication.27 Regarding the second category, dealing with the aftermath of a crisis, critical event debriefing is a long-standing practice that has been noted for its potential benefits to healthcare professionals at the individual, team and systems level.28–33 It can help mitigate the negative impact of crisis events on healthcare providers, offer opportunities for education and learning, and serve as a vehicle to identify systems gaps in overall quality and safety.33 34 Something as simple as a well-timed drop of WATER (Welfare check, Acute/short-term corrections, Team reactions and reflection, Education, and Resource awareness/longer term needs), the beginnings of a cognitive aid in itself, can have a meaningful ripple effect if used when indicated (figure 1).

Several cognitive aids for various forms of debriefing have been described. The Promoting Excellence buy kamagra online australia And Reflective Learning in Simulation (PEARLS) debriefing tool was developed based on experiences in medical simulation.35 Versions of PEARLS have been adapted for healthcare debriefing and systems-focused debriefing.32 36 The Debriefing In-Situ Conversation after Emergent Resuscitation Now tool was developed in the study of resuscitations at a paediatric ED.37 An adapted version was created during the erectile dysfunction treatment kamagra for end-of-shift debriefing in EDs (Debriefing In Situ erectile dysfunction treatment to Encourage Reflection and Plus-Delta in Healthcare After Shifts End).38 There is a large body of literature from medical simulation and other disciplines supporting critical event debriefing.33 34 Considerations to avoid psychological iatrogenic effects from debriefing (such as customisation to local culture and available resources/debriefing training) have been noted.33 34 39 Future research, both via simulation and after real events, can help inform ways to improve the quality and frequency of debriefing after the very events that have been studied with crisis checklists and EMs.40Elements to consider for debriefing just after a perioperative critical event. These elements are buy kamagra online australia not meant to be comprehensive. Customisation to local culture and available resources is essential.33 34 The responsibility for interpretation/application lies with the reader. Image.

Restivo D. Water Drop impact on water surface. Available at https://commons.wikimedia.org/wiki/File:Water_drop_impact_on_a_water-surface_-_(5).jpg. Accessed 13 Feb 2021. With permission via Creative Commons CC BY-SA 2.0 License (https://creativecommons.org/licenses/by-sa/2.0/legalcode).

QI, quality improvement." data-icon-position data-hide-link-title="0">When translating these interventions from medical simulation to the point of care, there are many lessons to be learnt from the implementation sciences. Editorials and perspective pieces have called for checklists to be viewed within a broader sociocultural or sociotechnical context, including factors such as team training and thoughtful implementation.41 42 Original research on team training initiatives that include surgical safety checklists has been associated with improved patient outcomes.43 Crisis checklists and EMs are substantially less effective if they are sitting in a drawer collecting dust during an emergency. To minimise the likelihood of this happening, it is important that their implementation is approached with the same rigour as all good quality improvement work. Including conducting a needs assessment, customising the cognitive aids, obtaining key stakeholder buy-in, establishing implementation champions, developing training programmes, evaluation and ongoing measurement and iterative improvement, which all have been well described.11 44 45 As another example of an implementation framework, the Consolidated Framework for Implementation Research is composed of five major domains. Intervention characteristics, outer setting, inner setting, characteristics of the individuals involved and the process of implementation.46 Another popular example is the plan–do–study–act model.47 48 Specific to crisis checklists and EMs, Goldhaber-Fiebert and Howard proposed four vital elements for widespread and successful implementation.

Create, familiarise, use and integrate.11 12 Agarwala et al reported an institutional case study of perioperative EM implementation that centred around three goals. (1) place EMs in every anaesthetising location, (2) create interprofessional engagement and (3) demonstrate that a majority of anaesthesia clinicians would use the EMs in some way within the first year.49 Factors such as leadership support and dedicated time to train staff can be essential.45 50 51 More successful implementation of crisis checklists and EMs has been reported when institutions used these tools to assist both during the management of the critical events and in debriefing after critical events.45 An association between the quality of implementation and improved outcomes has similarly been seen with routine surgical safety checklists.52 53 There is also value in research that considers not only whether the tool is used, but also how implementation and training strategies can be leveraged to improve thoughtful adherence to the items on the checklist and avoid issues from going unnoticed.54–56 For critical event debriefing, there is potentially a wide gap between principle and practice. Studies across different medical disciplines have reported that debriefing after critical events takes place only a fraction of the time.34 57 58 Barriers mentioned in studies and other publications include competing clinical priorities, lack of debriefing training, interpersonal dynamics and leadership buy-in.33 34 37 58–61 Several of these barriers potentially overlap with the goals of implementing crisis checklists, and there may be synergy in viewing prevention, crisis events and their aftermath within a continuum.At a fundamental level, many of the cognitive aids discussed in this editorial are designed to both improve cognition and foster interdisciplinary communication about essential best practices at key moments in time. There should not be an illusion that this communication is already taking place or an assumption that it is not necessary. There also should not be a fallacy that these critical event cognitive aids are simply ‘memory aids’.

Growing evidence of EMs during real-time use has described providers reporting the use of these tools associated with decreased stress, improved teamwork, a calmer atmosphere and better care.14 16 There is active work, including collaboration with expertise from the Human Systems Integration Division from the National Aeronautics and Space Administration, exploring how to optimise critical event cognitive aid design relative to the high cognitive load and other factors intrinsic to a crisis.62–66 Emerging research has explored whether it is beneficial to have a crisis checklist reader role, separate from the crisis event leader, when resources allow.13 67Future work on cognitive aids for medical crises should not only address whether they are present, but also how they are designed, used, simulated and implemented towards the most successful outcomes, and its effect on communication. As the scope of patient safety efforts surrounding crisis management continues to expand, there is value in thinking both spatially and temporally via both medical simulation and real events.Ethics statementsPatient consent for publicationNot required.The haemoglobin A1c (HbA1c) level has become the standard of care for monitoring type 2 diabetes as it reflects a person’s average blood glucose level over the previous 2–3 months, is correlated with risk of long-term complications and can be measured cheaply and easily. International guidelines recommend testing HbA1c every 6–12 months for those with stable type 2 diabetes, and every 3–6 months in adults with unstable type 2 diabetes until HbA1c is controlled on unchanging therapy.1–3 However, these guidelines are based on expert consensus rather than robust evidence on whether the frequency of HbA1c measurement impacts patient outcomes. To date, most studies have focused on the association between testing frequency and glycaemic control.4–6In this issue of BMJ Quality &. Safety Imai and colleagues go further, demonstrating an association between adherence to guideline-recommended testing frequency and health outcomes.7 Using data from electronic health records (EHRs), they examined adherence to guideline-recommended HbA1c testing frequency over a 5-year period in 6424 people with type 2 diabetes across 250 general practices in Australia.

An adherence rate was calculated for each person with type 2 diabetes, dividing the number of tests performed within the recommended intervals by the total number of conducted tests (minus 1). Patients were categorised into low-adherence (<33%), moderate-adherence (34%–66%) and high-adherence groups (>66%). Where there was high adherence to guideline-recommended testing frequency, HbA1c values remained stable or improved over time. In contrast, with low adherence, HbA1c values remained unstable or deteriorated over the 5-year period. The risk of developing chronic kidney disease was lower among those with high adherence compared to those with low adherence (OR 0.42, 95% CI 0.18 to 0.99).

There was no evidence of an association between the rate of adherence and the development of ischaemic heart disease. This study provides support for the importance of frequent HbA1c testing as recommended in current clinical guidelines for prevention of complications of diabetes.The study exploits an abundance of observational data on processes and outcomes of care readily available in EHRs in a real-life setting and among a general population with type two diabetes over a 5 year period. However, the authors highlight methodological challenges. Using EHRs to explore the association between adherence to testing frequency and HbA1c is susceptible to selection bias, given that patients need to have HbA1c measurements recorded to be included in the study. Imai and colleagues include ‘active patients’ defined as individuals who attended the practices three or more times in the past 2 years at the time of the visit and had two or more HbA1c tests over the study period.7 While this restriction was necessary to avoid duplication of patients across primary care practices and to study the development of complications over time, it may introduce selection bias and also reduce the generalisability of the findings.

The authors suggest their findings are conservative estimates of the association between adherence to guideline-recommended testing frequency and outcomes, given the positive association between practice visits and glycaemic control. However, those who do not attend general practice regularly differ in many other ways, which may also affect the association between adherence to guideline-recommended testing frequency and health outcomes. A recent systematic review of non-attendance at outpatient diabetes appointments, including those with a general practitioner or nurse, found that younger adults, smokers and those with financial pressures were less likely to attend.8 In addition, even among those who attend general practice regularly, differences in other aspects of care such as self-management behaviour are likely to exist between those with high-adherence versus low-adherence rates.9 In the study by Imai and colleagues, data were not available on potentially important factors, such as patients’ body mass index, smoking status and adherence to medication,7 making it difficult to attribute unstable or deteriorating HbA1c to low-adherence rates. Furthermore, the adherence rate was estimated based on average test numbers over 5 years, so adherence may vary over time. Future research could build on the work of Imai and colleagues to examine the causal relationships between a range of care processes (including testing frequency), HbA1c and health outcomes by assessing the temporality of relationships, accounting for selection bias and confounding, and exploring potential causal mechanisms such as treatment intensification.9Imai and colleagues also found that the median testing frequency in people with type 2 diabetes was less than the recommended two tests per year in Australia (median 1.6 tests per year).7 Poor adherence to recommended testing frequency is documented in several countries with similar guidelines, including countries in Europe10 11 and Asia12 as well as in the USA,13 thus raising questions about how best to improve this process of care.

Diabetes care is the subject of extensive quality improvement and implementation research,14 and a variety of interventions have been shown to improve processes and outcomes of care for people with diabetes.15 How and why these interventions work is unclear because of the range of intervention components operating at the patient, professional and system levels. Most interventions focus on a range of guideline-recommended behaviours in both health professionals and patients and are often described more broadly than changing or targeting one specific behaviour.16 For instance, adherence to HbA1c testing frequency itself is not one specific behaviour. It includes a series of behaviours by the person with diabetes, and potentially their support network, as well as behaviours by health professionals. The person with diabetes must initiate an appointment. The health professional may prompt the person to attend for regular testing.

On deciding and making the effort to attend, the person with diabetes must agree to the blood test. And the health professional must carry out the blood test and send it to a lab for analysis. To improve adherence to HbA1c testing frequency, we may have to intervene in multiple places, but first we need to identify where the process breaks down.There also needs to be a clearer understanding of why the process breaks down. To date, there has been no systematic review of the factors associated with adherence to the frequency of HbA1c testing recommended in guidelines. Individual studies, conducted in different health systems, have identified a range of patient-level factors including age, rurality, disease duration, receipt of specialist care, glycaemic control, cardiovascular risk factors and diabetes-related complications.10–13 Few studies have examined the professional, organisational and system-level determinants of adherence.

Yet we have reason to believe that factors at these levels are also important. In a qualitative synthesis of barriers to optimal diabetes management in primary care, perceived professional barriers included limited time and resources, changing professional boundaries leading to uncertainty about clinical responsibility, and a lack of confidence in knowledge of guidelines and skills.17 A meta-analysis of professional and practice-level factors associated with the quality of diabetes management in primary care identified doctor gender and age, doctor-level diabetes volume, practice deprivation and use of EHRs as significant determinants of quality, typically measured by a collection of individual indicators or a composite measure.18 Furthermore, evidence from a systematic review and meta-analysis of quality improvement interventions for diabetes suggests that strategies that intervene on the entire system of chronic disease management are associated with the largest effects irrespective of baseline HbA1c.15 Thus, to improve adherence to the frequency of HbA1c testing frequency, the problem needs to be understood in context, and solutions should incorporate professional and system-facing interventions as well as patient-facing interventions.Based on their analysis of the content of implementation interventions to support diabetes care, Presseau and colleagues call for better reporting of who needs to do what differently at all levels, including the system level, which is often underspecified.16 This, they propose, would contribute to the development of an underlying programme theory for improvement interventions linking activities to intended outcomes.19 Such an approach is relevant to many chronic conditions where disease management involves multiple actors, actions and settings. The development of testable theories and integration of causal reasoning are increasingly advocated in improvement and implementation science as a way to enhance the generalisability of interventions.20 21 Causal diagram modelling,20 the action–effect method19 and the implementation research logic model,22 facilitate the development and communication of intervention programme theory. The action effect method in particular is intended as a facilitated collaborative process to enhance the practicality of programme theory and to provide an actionable guide for quality improvement teams.19The current study by Imai and colleagues underscores the importance of the link between regular HbA1c testing, better glycaemic control and reduced risk of complications.7 While the causal mechanisms require further investigation, this study provides an important piece of the puzzle. Few interventions target Hba1c testing frequency alone, and this is unlikely to be the sole priority for people with diabetes or their health professionals, given the multiple processes recommended for optimal clinical and self-management.

However, given its centrality and profile in diabetes management, targeting HbA1c could be a lever for wider improvement. The foundation for such an intervention should be a better understanding and more precise articulation of who needs to do what differently, as well as how and why this intervention is expected to change specific processes of care and ultimately improve patient outcomes.Ethics statementsPatient consent for publicationNot required..

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Latest Prevention cheap kamagra online uk &. Wellness News FRIDAY, Aug. 28, 2020 (HealthDay News) -- A warning about cheap kamagra online uk alcohol-based hand sanitizers in packaging that looks like food or drink has been issued by the U.S.

Food and Drug Administration."The agency has discovered that some hand sanitizers are being packaged in beer cans, children's food pouches, water bottles, juice bottles and vodka bottles," according to an FDA a news release. "Additionally, the FDA has found hand sanitizers that contain food flavors, such as chocolate or raspberry."Reports received by the FDA include a person who bought what they believed was drinking water but was actually hand sanitizer, and a hand sanitizer using children's cartoons in marketing and sold in a pouch that resembled a snack, CNN reported."I am increasingly concerned about hand sanitizer being packaged to appear to be consumable products, such as baby food or beverages. These products could confuse consumers into accidentally ingesting cheap kamagra online uk a potentially deadly product.

It's dangerous to add scents with food flavors to hand sanitizers which children could think smells like food, eat and get alcohol poisoning," FDA Commissioner Dr. Stephen Hahn said in the release.Copyright © 2019 HealthDay. All rights cheap kamagra online uk reserved.

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Latest Prevention buy kamagra online australia &. Wellness News FRIDAY, Aug. 28, 2020 (HealthDay News) -- A warning about alcohol-based hand sanitizers in packaging that looks like food buy kamagra online australia or drink has been issued by the U.S. Food and Drug Administration."The agency has discovered that some hand sanitizers are being packaged in beer cans, children's food pouches, water bottles, juice bottles and vodka bottles," according to an FDA a news release. "Additionally, the FDA has found hand sanitizers that contain food flavors, such as chocolate or raspberry."Reports received by the FDA include a person who bought what they believed was drinking water but was actually hand sanitizer, and a hand sanitizer using children's cartoons in marketing and sold in a pouch that resembled a snack, CNN reported."I am increasingly concerned about hand sanitizer being packaged to appear to be consumable products, such as baby food or beverages.

These products could confuse consumers into accidentally ingesting buy kamagra online australia a potentially deadly product. It's dangerous to add scents with food flavors to hand sanitizers which children could think smells like food, eat and get alcohol poisoning," FDA Commissioner Dr. Stephen Hahn said in the release.Copyright © 2019 HealthDay. All rights reserved buy kamagra online australia. SLIDESHOW Diet-Wrecking Foods.

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Twenty years ago, Greene County Health Care in buy cheap kamagra oral jelly Snow Hill, North Carolina, was interested in installing an electronic health record system, data warehouse and practice management system. So Greene County became one of the first health center control networks to fully jump into the digital space.Telehealth and remote patient monitoring was a logical additional step, said Doug Smith, CEO of Greene County Health Care. Ten years ago, Greene County piloted a telehealth program and kept buy cheap kamagra oral jelly at it. That's the background behind the organization's more recent interest in virtual care."Virtual visits were the thing of the future that now are coming on strong, so we started to do it, but obviously erectile dysfunction treatment and the risks of and people being afraid to go into a doctor's office stepped up our interest," Smith said.Last year, Greene County Health Care was awarded $948,576 for remote monitoring and diagnostic equipment and a telehealth platform subscription to provide erectile dysfunction treatment screenings using interactive voice recognition, as well as to monitor patients remotely using connected devices and to evaluate the monitoring data for abnormal readings and follow-up care."A problem we faced was that at least around here, many people are not familiar with this kind of technology, so although they were scared to go up to the office, they weren't thrilled with a virtual visit either," he explained.

"We continue to work our way through these issues."Also on the afraid-to-come-into-the-office front, buy cheap kamagra oral jelly there are the patients with chronic conditions. The FCC was particularly interested in erectile dysfunction treatment because it received dollars for that purpose, so Greene County wrote the grant request in a way that focused on monitoring a number of chronic conditions through a number of RPM devices such as pulse oximeter, weight and blood pressure, providing early warning signs for erectile dysfunction treatment."Virtual visits were the thing of the future that now are coming on strong."Doug Smith, Greene County Health Care"This allowed us to provide better management of chronic care of certain individuals," Smith said. "Because they weren't coming into the buy cheap kamagra oral jelly office. Also, we have a patient population that largely is uninsured.

It's around 80% buy cheap kamagra oral jelly uninsured. So they get a sliding-fee scale and we can generally get them into the office. But during erectile dysfunction treatment, it has been very hard to get a number of these people into the office for their regular check-up visits."So having them on remote patient monitoring with remote care managers monitoring all of the readings was very helpful," he continued. "We get buy cheap kamagra oral jelly alerts that contact providers when there is something significant for the provider to look into.

That way the provider has the option of having the patient scheduled for a visit. Administrative staff try to get the patient to come in for a visit or buy cheap kamagra oral jelly set up a telehealth visit."At Greene County, medical and behavioral health providers use the telemedicine technology. Vendor Connect America installed the remote patient monitoring technology. Greene County hired buy cheap kamagra oral jelly a care manager through Connect America who has more than 20 years of experience with this kind of care management.

The FCC funds sparked the RPM surge.Through other funding, Greene County was able to start a three-year program for RPM with hypertensive patients. It involves a connected health blood pressure cuff and about 1,000 patients."The technology has been buy cheap kamagra oral jelly shown to reduce blood pressure, to get more people compliant with treatment," Smith noted. "We have $157,000 in outside funding for this, and we have provided another $300,000 or so over the course of the three years. We should buy cheap kamagra oral jelly have 1,400 people with some remote patient monitoring going."Twitter.

@SiwickiHealthITEmail the writer. [email protected] IT News is a HIMSS Media publication..

Twenty years ago, Greene County Health Care http://mchtranslations.com/buy-amoxil-with-free-samples/ in Snow Hill, North Carolina, was interested in installing an electronic health buy kamagra online australia record system, data warehouse and practice management system. So Greene County became one of the first health center control networks to fully jump into the digital space.Telehealth and remote patient monitoring was a logical additional step, said Doug Smith, CEO of Greene County Health Care. Ten years buy kamagra online australia ago, Greene County piloted a telehealth program and kept at it.

That's the background behind the organization's more recent interest in virtual care."Virtual visits were the thing of the future that now are coming on strong, so we started to do it, but obviously erectile dysfunction treatment and the risks of and people being afraid to go into a doctor's office stepped up our interest," Smith said.Last year, Greene County Health Care was awarded $948,576 for remote monitoring and diagnostic equipment and a telehealth platform subscription to provide erectile dysfunction treatment screenings using interactive voice recognition, as well as to monitor patients remotely using connected devices and to evaluate the monitoring data for abnormal readings and follow-up care."A problem we faced was that at least around here, many people are not familiar with this kind of technology, so although they were scared to go up to the office, they weren't thrilled with a virtual visit either," he explained. "We continue to work our way through these issues."Also on the afraid-to-come-into-the-office buy kamagra online australia front, there are the patients with chronic conditions. The FCC was particularly interested in erectile dysfunction treatment because it received dollars for that purpose, so Greene County wrote the grant request in a way that focused on monitoring a number of chronic conditions through a number of RPM devices such as pulse oximeter, weight and blood pressure, providing early warning signs for erectile dysfunction treatment."Virtual visits were the thing of the future that now are coming on strong."Doug Smith, Greene County Health Care"This allowed us to provide better management of chronic care of certain individuals," Smith said.

"Because they weren't coming into buy kamagra online australia the office. Also, we have a patient population that largely is uninsured. It's around buy kamagra online australia 80% uninsured.

So they get a sliding-fee scale and we can generally get them into the office. But during erectile dysfunction treatment, it has been very hard to get a number of these people into the office for their regular check-up visits."So having them on remote patient monitoring with remote care managers monitoring all of the readings was very helpful," he continued. "We get alerts that contact providers when there is something significant for the provider to buy kamagra online australia look into.

That way the provider has the option of having the patient scheduled for a visit. Administrative staff try to get the patient buy kamagra online australia to come in for a visit or set up a telehealth visit."At Greene County, medical and behavioral health providers use the telemedicine technology. Vendor Connect America installed the remote patient monitoring technology.

Greene County hired a care manager through Connect America who has buy kamagra online australia more than 20 years of experience with this kind of care management. The FCC funds sparked the RPM surge.Through other funding, Greene County was able to start a three-year program for RPM with hypertensive patients. It involves a connected health blood pressure cuff and about 1,000 patients."The technology has been shown to reduce blood pressure, to get more people compliant with buy kamagra online australia treatment," Smith noted.

"We have $157,000 in outside funding for this, and we have provided another $300,000 or so over the course of the three years. We should have 1,400 people with some remote patient monitoring buy kamagra online australia going."Twitter. @SiwickiHealthITEmail the writer.

[email protected] IT News is a HIMSS Media publication..

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