Of the two surveillance studies, one examined a prospective maternal mortality surveillance system that used key informants, in contrast to retrospective systems used in most low-income settings and relying upon secondary data sources. The surveillance system, which covers three districts and a total population of , , was found to produce reliable data at a relatively low cost USD per month [ 41 ].
A second surveillance system used a Geographic Information System GIS to generate dynamic maps of hot spots for malaria in tribal areas at the district and village levels, with the purpose of developing rapid response for malaria control [ 36 ]. Using the GIS approach, map-generated figures can be easily and quickly updated and information can be done through electronic formats - computer facilities are located at the district level. Furthermore, once it is set up, the system can be easily converted to monitor other diseases, such as dengue.
No cost estimates of this intervention were provided. In order to increase the effectiveness of interventions suggestions were made for multi-pronged approaches. Two studies found that the widespread acceptance of long lasting insecticide treated mosquito nets LLINs was often not due to an understanding of the link between their use and malaria prevention but for other reasons, such as limiting the nuisance of mosquito bites [ 33 , 35 ] The authors suggest that the distribution of LLINs is insufficient without adequate transfer of knowledge of malaria and how it is spread, and recommend an educational component to coincide with the introduction of LLINs programs.
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Another study found that girls aged 14 to 18 years who participated in a program that combined iron-supplementation with a life-skills training program that included the importance of consuming iron for their health found a significant improvement in their haemoglobin levels [ 40 ]. This study, however, did not separately examine the effects of the iron-supplementation and the training program.
Therefore, it cannot be determined the effect, if any, of the training program on reducing haemoglobin levels of participants.
One study demonstrated the improvement in nutritional status of STs with TB following the beginning of their treatment [ 39 ]. Given that malnutrition predisposes individuals to TB, addressing both malnutrition and TB will be more effective that addressing either factor in isolation. Integrating ST participation into public health interventions was proposed in several studies.
One study trained literate ST youth volunteers in detecting cases of pulmonary TB in their communities [ 37 ]. Another study trained village volunteers in a tribal area although we could not determine if these volunteers had ST affiliations to distribute chloroquine to malaria patients and to fill out a 'fever treatment sheet' upon each deliver [ 34 ]. Volunteers were selected by the villages or heads of villages and were generally male and either small farmers or agricultural labourers. Over a period of 3 years, the volunteers treated 88, fever cases, and malaria mortality and morbidity was reduced significantly more in villages with the program compared to control villages.
These results need to be interpreted with caution, however due to potential selection bias; the authors controlled for prevalence of malaria in the villages, but other factors that may impact outcomes of their intervention e.
Community-involvement in an ITN program was also found to increase the likelihood of the retreatment of the nets therefore preserving their protective effect from malaria [ 32 ]. Despite the large disparities in health between ST and non ST populations in India, we identified only a small number of articles that examined interventions to improve the health of STs.
Furthermore, the studies in this review included only disease-specific interventions; we did not identify any article that assessed a comprehensive health intervention for STs. Finally, assessing public health interventions requires rigorous methods and the majority of studies were either descriptive or had a weak study design, even after rejecting those that were more seriously limited.
Implementing stronger quasi-experimental designs that address major biases, such as selection bias, would have provided stronger evidence [ 42 ]. However, experimental and quasi-experimental designs may not be feasible or appropriate to assess some interventions, notably complex interventions with multiple interacting components [ 43 ]. Researchers need to consider various 'trade-offs' that may arise in the pursuit of the best choice of design, given the type of intervention, the populations, the context, and the availability of resources [ 43 , 44 ].
But regardless of study design, there are steps researchers can take to ensure their approach is rigorous and the study is of good quality [ 45 ]. In our review, we found the evidence collected to be limited in its quantity, scope, and methodological rigour, and thus should be interpreted with caution. Reviews of the effectiveness of public health interventions in other contexts with indigenous populations have similarly found an 'underdeveloped' evidence base in terms of both the number of available studies and the rigour of the studies [ 46 — 48 ].
The evidence compiled in this review revealed three issues that promote effective public health interventions with STs. First, there is a need to develop and implement interventions that are low-cost, give rapid results and can be easily administered. This addresses the challenge of delivering effective interventions to ST communities who predominantly live in remote areas, where there is limited access to health care, few laboratory facilities, inadequate surveillance, poor vital registrations, and few skilled workers to implement highly technical tasks.
Innovative technologies, such as rapid diagnosis tests that do not require laboratories and GIS, offer new opportunities. But by moving one step further and connecting innovative technologies with ST culture and harnessing STs' capacity to use these technologies, could increase opportunities for STs to develop new skills and increase their control over interventions.
Second, even though the study included interventions that addressed a specific disease or a single health need, a multi-pronged approach was advanced by several authors based largely on limitations to the intervention design identified by their studies. ST populations face multiple risks of ill health and are exposed to a number of diseases.
Combining two or more activities in a single intervention will likely improve health outcomes. This has been demonstrated among other indigenous groups and vulnerable populations in low-income countries [ 49 ]. Given the high levels of health need there is a need for a public health as opposed to a medical or disease approach to improve the health of STs and reduce the disparities in health that exist between STs and other social groups. For policy-makers considering new intervention designs, the challenge is to retain the 'quick-wins' of low-cost and easy administration, but always with an eye to adding more elements to a program to make it more comprehensive and capable of responding to health determinants residing in the contexts of STs' cultural, geographic and economic environments.
Third, the involvement of ST populations in the intervention was advocated to help address the isolation of many ST communities, the cultural specificities of STs, the limited resources available and to promote community control. Involving ST populations may improve current programs that have demonstrated poor performance. For example, an increase in the prevalence of TB between and was observed in Car Nicobar the administrative headquarters for the Nicobar district in the Andaman and Nicobar Islands , despite the implementation of a national TB program [ 38 ].
The authors argue that this increase may be attributed to the lack of a district level TB control program which contributed to insufficient TB control in the area. A district level program as part of the national one could allow for ST participation in its design, improving its community acceptance by, and cultural appropriateness for, the local population. The participation of indigenous populations in public health interventions has been found to be an effective strategy in other contexts [ 47 ].
The paucity of good quality evidence on population health interventions for ST populations suggests ways in which the present level of knowledge can be improved. Given the marginalisation and cultural oppression of many ST populations, however, there is also a need to undertake research that is culturally and ethically appropriate. We propose two avenues to pursue this goal. First, the highest ethical standards should be followed.
This includes ensuring that individuals and communities are truly informed and consent to the research being undertaken. One approach that has been used with ST populations is the development of an ethical code of research conduct, and collecting community consent prior to individual consent [ 50 ]. The development of ethical guidelines undertaking research with ST populations could help to promote national standards.
The development of ethical guidelines and tools at the local level could further help to address the needs of specific tribal communities and can be developed in partnership with these communities. Second, indigenous researchers have advocated for a need for new approaches to research that integrate indigenous views and perspectives and promote self-determination, mobilisation and transformation of these communities [ 28 ].
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One way to pursue these goals is through participatory research, which is rooted in the philosophy that those who are most affected by health and development issues should be active participants in the research process and subsequent policy action [ 50 — 53 ]. Participatory research combines local knowledge, expertise and experiences with scientific methods and theories, and can be used with a range of study designs and methods including randomized controlled trials [ 52 ].
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The benefits of participatory approaches for intervention research can extend beyond the research project by increasing the capacity of communities to address their own health needs and redress imbalances in power within the community, which may ultimately contribute to reducing social disparities in health [ 53 ]. Researchers can also pursue innovative approaches that include developing partnerships with NGOs who have established programs with ST populations in order to document their existent but largely undocumented knowledge and other collaborations e.
Another approach is to develop solid theoretical foundations for public health interventions and health outcomes for STs, which will help to refine hypothesis generating and improve the accuracy of the interpretation of findings [ 54 , 55 ]. These theoretical frameworks can be developed specifically for ST populations, integrating indigenous 'ways of knowing'. Finally, given the need for the implementation of 'low cost interventions', cost effectiveness studies can provide valuable information for decision-making in selecting the most appropriate intervention strategies. This suggests that future research priority be given to quality public health intervention studies that assess a broad range of interventions and outcomes.
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Key programs to evaluate include: 1 interventions specific for ST populations, both disease-specific interventions and comprehensive tribal health programs, such as the Tribal Health Initiative in South India,[ 56 ] 2 tribal development programs that fall outside of the health sector, but address key determinants of health,[ 57 ] and 3 population level interventions to identify how these interventions may better address the needs of STs. In the latter case, these interventions should include not only local or national level programs, but also those that address global factors that may impact ST communities, such as climate change, financialization of economic markets and global trade [ 58 , 59 ].
Research should account for heterogeneity that exists across tribal groups e. Finally, due to the great diversity across India, studies should be undertaken in different contexts e. As India's economy continues to grow and the health of the population improves, there is a need for greater attention and resources to be allotted to those populations who have not benefitted from the country's economic growth and who continue to face high levels of health needs. Despite pursuing affirmative action for more than fifty years, there are persistent gaps in health and well-being between STs and non STs.
This suggests the need to devise and implement new policies. Given the large gaps in knowledge on how to improve the health of STs, resources should be targeted to developing a critical mass of researchers in this domain, including training of researchers with ST affiliations. The findings of this review identified three effective strategies for improving health outcomes among ST populations in India: low-cost, rapid results, and easily administered programs, multi-pronged approaches, and including ST participation in the intervention.
The evidence base, however, is insufficient.
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There is a need for a better understanding of how to improve their health by pursuing public health intervention research appropriate for ST populations. Economic and Political Weekly. PLoS Medicine. Hawe P, Potvin L: What is population health intervention research?. Can J Public Health. Office of the Registrar General and Census Commissioner: Total population, population of scheduled castes and scheduled tribes and their proportions to the total population. Anthropological Science. Ghosh R, Bharati P: Haemoglobin status of adult women of two ethnic groups living in a peri-urban area of a Kolkata city, India: a micro-level study.