GC-MS fingerprinting, nutritional composition, in vitro pharmacological activities and molecular docking studies of Piper chaba from Uttarakhand region.

This study aimed to evaluate the potential therapeutic effects of Piper chaba (PC) growing in the northern region of India, having differences in the phytochemicals, nutritional content, antimicrobial and antioxidant properties by reducing power assay (RPA), 2,2-diphenyl-1-picrylhydrazyl (DPPH) assay, phosphomolybdate assay, and antidiabetic potential by α-amylase assay with change in the geographical location. Outcomes of the gas chromatography-mass spectrometry (GC-MS) analysis revealed that phytochemicals such as piperine (46.69%), kusunokinin (8.9%), and sitostenone (7.57%) are the prominent compounds found in PC. The plant has also shown a good nutritional value, i.e., iron (11.25 mg), calcium (147 mg), and vitamin C (9.30 mg) per 100 g. PC has a higher phenolic content than other species (⁓ 13.75 g/100 g plant powder). Among the four tested bacterial strains, the extract is best responsive toward Escherichia coli (35 ± 0.68 mm) which is more than the standard ciprofloxacin (24 ± 0.8 mm). Similarly, among two tested fungal strains, Saccharomyces cerevisiae shows the best zone of inhibition (ZOI) (27.5 ± 0.8 mm), which is greater than tat of standard amphotericin (20.25 ± 0.28 mm). The DDPH method demonstrated the highest antioxidant activity (⁓ 42.61 ± 1.82 µg/ml). IC50 for the antidiabetic potential of PC was found to be 23.09 ± 0.3 µg/ml against α-amylase assay. A molecular docking study revealed that three compounds, piperine, sitostenone and kusunokinin, showed strong binding affinity toward bacterial tyrosyl-tRNA synthetases, fungal dihydrofolate reductase, and α-amylase, respectively. Therefore, the findings of the current study indicate that PC can be considered as a source of food and medicines, either in the form of traditional preparations or as pure active constituents. Supplementary Information: The online version contains supplementary material available at 10.1007/s13205-024-03996-7.

Evaluation of Utility of Invasive Electroencephalography for Definitive Surgery in Patients with Drug-Resistant Epilepsy: A Systematic Review and Meta-Analysis.

When noninvasive tests are unable to define the epileptogenic zone in patients, intracranial electroencephalography (iEEG) is a method of localizing the epileptogenic zone. Compared with noninvasive evaluations, it offers more precise information about patterns of epileptiform activity, which results in useful diagnostic information that supports surgical decision-making. The primary aim of the present study was to assess the utility of iEEG for definitive surgery for patients with drug-resistant epilepsy. Online databases such as PubMed, Medline, Embase, Scopus, Cochrane Library, Web of Science, and IEEE Xplore were searched for MeSH terms and free-text keywords. The ROBINS I (risk of bias in non-randomized studies - of interventions) critical appraisal tool was used for quality assessment. The prevalence from different studies was pooled together using the inverse variance heterogeneity method. Egger's regression analysis and funnel plot were used to evaluate publication bias. The systematic review included 18 studies, and the meta-analysis included 10 studies to estimate the prevalence of seizure freedom (Engel class I) in patients undergoing surgery after iEEG. A total of 526 patients were included in the meta-analysis. The follow-up period ranged from 1 to 10 years. The overall pooled estimate of the prevalence of seizure freedom (Engel class I) for patients undergoing surgery after iEEG was 53% (95% confidence interval, 44%-62%). The results additionally demonstrated that 12 studies had a moderate risk of bias and 6 had a low risk. Future studies are crucial to enhance our understanding of iEEG to guide patient choices and unravel their implications.

Cost analysis of telemedicine use in paediatric nephrology-the LMIC perspective.

BACKGROUND: The overall cost of managing chronic diseases is a significant barrier to accessing complete and timely healthcare, especially in rural and geographically isolated areas. This cost disparity becomes more pronounced in the case of children and more so in under-resourced regions of the world. In the era of COVID-19, as the need for physical distancing increased, there was a transition in approach to healthcare provision to telemedicine consultations. This study evaluates the cost saving using teleconsultations in a paediatric nephrology clinic. METHODS: This prospective cohort study was conducted at AIIMS Jodhpur, a tertiary care centre in western Rajasthan from March 2021 to October 2022. All consecutive paediatric (29 days-18 years) patients attending telemedicine services for kidney-related illness were enrolled. Basic demographic details were collected. Cost analysis was done after 6 months, regarding perceived cost savings for the patient and family by using telehealth for follow-up during 6 months starting from enrolment. RESULTS: A total of 112 patients were enrolled; 266 teleconsultations attended; 109 patients who could be followed up saved INR 457,900 during 6 months of follow-up. The average cost saving was INR - 1577/patient/visit. Patients saved 4.99% of the family income (median 2.16% (IQR 0.66-5.5)). The highest expenditure per visit was incurred for food and transport. The median distance from the residence to the clinic was 122.5 km (IQR 30-250). Over the 6-month study period, patients saved a travel distance of 83,274 km (743 km/patient). CONCLUSIONS: The use of telemedicine as a follow-up method helps save significant costs and distances travelled by patients. A higher-resolution version of the Graphical abstract is available as Supplementary information.

The Health Impact of mHealth Interventions in India: Systematic Review and Meta-Analysis.

Background: Considerable use of mobile health (mHealth) interventions has been seen, and these interventions have beneficial effects on health and health service delivery processes, especially in resource-limited settings. Various functionalities of mobile phones offer a range of opportunities for mHealth interventions. Objective: This review aims to assess the health impact of mHealth interventions in India. Methods: This systematic review and meta-analysis was conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Studies conducted in India, and published between April 1, 2011, and March 31, 2021, were considered. A literature search was conducted using a combination of MeSH (Medical Subject Headings) terms in different databases to identify peer-reviewed publications. Thirteen out of 1350 articles were included for the final review. Risk of bias was assessed using the Risk of Bias 2 tool for RCTs and Risk Of Bias In Non-randomised Studies - of Interventions tool (for nonrandomized trials), and a meta-analysis was performed using RevMan for 3 comparable studies on maternal, neonatal, and child health. Results: The meta-analysis showed improved usage of maternal and child health services including iron-folic acid supplementation (odds ratio [OR] 14.30, 95% CI 6.65-30.75), administration of both doses of the tetanus toxoid (OR 2.47, 95% CI 0.22-27.37), and attending 4 or more antenatal check-ups (OR 1.82, 95% CI 0.65-5.09). Meta-analysis for studies concerning economic evaluation and chronic diseases could not be performed due to heterogeneity. However, a positive economic impact was observed from a societal perspective (ReMiND [reducing maternal and newborn deaths] and ImTeCHO [Innovative Mobile Technology for Community Health Operation] interventions), and chronic disease interventions showed a positive impact on clinical outcomes, patient and provider satisfaction, app usage, and improvement in health behaviors. Conclusions: This review provides a comprehensive overview of mHealth technology in all health sectors in India, analyzing both health and health care usage indicators for interventions focused on maternal and child health and chronic diseases. Trial Registration: PROSPERO 2021 CRD42021235315; https://tinyurl.com/yh4tp2j7.

Defeating diabetes in the desert: A community-based mHealth diabetes screening intervention in Jodhpur Rajasthan.

Background: There is a paucity of demonstrated models for mHealth-based diabetes screening and coordinated care in India, especially in western Rajasthan, which is the part of Thar desert. Materials and Methods: JSPH collaboratively developed and implemented an easy-to-use, noninvasive, mobile phone-based screening interview, to identify adults at high risk for diabetes. The high risk for diabetes was defined using multiple clinical and epidemiologic criteria, all based on the evidence for India and globally. Since participants above 35 years or older were only considered in the screening, the application was designed to categorize the participants as high and low risk. Results: Out of 4000 screened participants, the percentage of males and females were 51% and 50%, respectively. Participants found to be at high risk and low risk were n = 3600 (90%) and 400 (10%). The mean age of high- and low-risk participants was 52.2 (+12.8) and 36.2 (+4.2), respectively. Of the 3600 high-risk individuals who have been given a follow-up interview, 90.50% of high-risk individuals obtained diabetes testing, and of these, 65.67% had a written report showing they test positive for diabetes or prediabetes, requiring ongoing clinical care. Conclusions: JSPH mHealth application provided a novel noninvasive way to better identify those at high diabetes risk in the community and demonstrated how to optimize the use of mobile health methods in diabetes prevention and care services.

Identification of Bioactive Phytoconstituents, Nutritional Composition and Antioxidant Activity of Calyptocarpus vialis.

This study is focused to highlight the phytochemical, nutrient content and in vitro antioxidant capacity of the wildly growing plant Calyptocarpus vialis (CV) of the Asteraceae family collected from the Garhwal region of India. Phytochemical and nutritional analysis of CV is done by qualitative and quantitative methods. Fourier-transform infrared spectroscopy (FT-IR) analysis confirmed the presence of phenols, alkanes, aliphatic primary amines, carboxylic acids, nitrile, aromatics and alcohols. Gas chromatography and mass spectroscopy (GC-MS) revealed the presence of terpenoids, plant sterols and phenols such as phytol (14.9%), stigmasterol (10.02%), viridiflorol (4.19%), squalene (2.54%) and various other phytochemicals. The plant's study reveals the existence of numerous nutritious elements, including proteins, vitamins, carbohydrates and amino acids. It also revealed the presence of the huge amount of phenolic content ⁓13.49 g in a 100-g dried CV plant sample. The antioxidant potential of methanolic extract of CV was estimated using DPPH (2, 2-diphenyl-1-picrylhydrazyl) free radical scavenging assay, phosphomolybdate assay and reducing power assay. The highest percentage of antioxidant activity determined from three assays is 74 to 87% for 1 mg of dry extract. It is observed that the CV extract act as a good antioxidant when compared to other plants of the Asteraceae family even at very low concentration of the sample. Hence, CV found in the foothills of Himalayas can be further explored as a source of potent bioactive compounds and natural and economical antioxidant for biomedical and immunity-boosting applications.

Competence-Based Assessment of Biomedical Equipment Management and Maintenance System (e-Upkaran) Using Benefit Evaluation Framework.

Introduction To establish a centralized inventory management system for the efficient functioning of all healthcare facilities, e-Upkaran (equipment management and maintenance system) was launched in 2015 in the state of Rajasthan. This study is conducted to assess the functioning of e-Upkaran in Rajasthan. Methods The assessment of the e-Upkaran system for primary and secondary healthcare centers was carried out using a systematic review of the literature and a multi-indicator stakeholder questionnaire. The benefits evaluation framework focused on the system quality, information and service quality, use and user satisfaction, and net benefits utilized for the assessment. A review of the literature was done to highlight the importance of computerized medical equipment management and maintenance systems and appraise the challenges and benefits associated with such systems as compared to the traditional pen-paper register. Information was gathered based on available documents, field observation, and data obtained from specific hospital staff, including the bioengineers and other users of e-Upkaran. Results The finding of this study suggests that e-Upkaran efficiently improves documentation, reporting, maintenance, and management of medical equipment. It is more efficient than the traditional paper-pen system. It is designed to minimize downtime and maintain equipment in good operating condition and has potential benefits in terms of improving information quality, use, and net benefit. The cost of service ratio is within the benchmark value. This system has also considerably reduced out-of-pocket expenditure. Computer proficiency and the workload of other e-health programs pose a challenge in the implementation of this program. Conclusion The e-Upkaran system is competent in terms of improving information quality, use, and net benefit. Other Indian states could also adopt this system to improve their biomedical equipment management and maintenance system.

Assessment of e-aushadhi program (drug inventory e-health initiative in Rajasthan) using benefit evaluation framework.

Background: E-aushadhi is a drug supply chain management initiative of the Rajasthan government. This study is conducted to assess this e-health program as evidence is lacking in this context. Methods: A mix-method study was conducted. Primary data were recorded from key stakeholders using qualitative interviews. Secondary data were collected from internet-based searches, reports, documents, and available literature. Findings were contextualized into the Benefit-Evaluation framework using six dimensions. Results: E-aushadhi provides a systematic approach for sourcing, storing, and re-distribution of essential medicine through its three-tier structure. Its user-friendly dashboard entails accurate entries, customizable reports, and easy tracking. It has reduced workload and improved information management with timely drug supply while allowing monitoring with key performance indicators. Conclusions: E-aushadhi has been successful in improving beneficiary access at public health facilities and may act as a backbone architecture for various digital interventions in the National Digital Health Mission that supports the universal health coverage.

Economic analysis of ASHA-soft programme (online payment and monitoring system) in Jodhpur, Rajasthan.

Context: The Government of India under a performance-based payment scheme is providing remuneration as per the activities completed by the Accredited Social Health Activists (ASHA) health workers. Each state in India has a differentperformance-based payment system for ASHAs. The state of Rajasthan developed the ASHA-Soft system in 2014 for providing incentives to ASHAs. Aims: This study is planned to analyze the performance of ASHA-Soft considering the economic aspects as there is a paucity of studies in this context. Settings and Design: This study was conducted in Jodhpur, Rajasthan. Methods and Material: Economic analysis of ASHA-Soft program was performed based on Incentive paid to ASHA workers; Number of beneficiaries; Overall contribution of ASHAs in the health services; and unit cost per health service under ASHA-Soft program. Data of five financial years, that is, from the inception of ASHA-Soft was analyzed. Results: Consolidated incentive for maternal health, child health, and Immunization services provided to ASHAs through ASHA-Soft in the year 2015--16 was $96794.22, $35348.32, and $49016.83 which increased to $200285.00, $116320.52, and $101686.48 in the year 2019-20, respectively. Family planning and national program services were provided to 6,259 and 4,061 beneficiaries, respectively, in the year 2015--16 which markedly increased to 16,360 and 9,552 in the year 2019--20. Unit-cost of service provided by ASHAs in the National Programme ($1.13) was the lowest and for Family Planning Services ($5.71) were the highest. Conclusions: ASHA-Soft program seems a potential program to attract ASHA workers for delivering health care services. The findings of this study could assist policymakers in guiding further decision-making.

Tobacco Use Pattern, Dependence, Oral Cancer Awareness and Health Education needs Among Urban Slum Dwellers of Jodhpur City.

Background: The rapid migration from rural to urban region results in mushrooming of slums in India. Urban-slums are comparatively poor vulnerable groups which are mostly affected with oral cancer due to higher exposure to risk factors like tobacco use. Aims: To assess pattern of tobacco consumption, awareness about oral cancer and related health education needs in urban slums of Jodhpur city. Methods: Study was conducted during July 2018Nov 2018 in slum of Jodhpur city. On the basis of cluster sampling strategy data were collected from 1200 participants regarding tobacco use and perception regarding oral cancer to identify health education needs in urban slums. Descriptive statistics, Chi-square test, multivariate logistics analysis were used and P < 0.05 was considered statistically significant. Results: A total of 1200 participants were surveyed, out of which 48.5% were males. Among the study population, 58.5% (n = 462/789) males and 41.45% (n = 327/789) females were consuming tobacco in one or more forms. The statistical association between: age and bidi, gutka, zarda consumption; gender and bidi, cigarette, gutka consumption was found to be significant (P < 0.001). The younger population (1530 years) has more willingness to quit tobacco than the older population. (OR = 1.52, 95% CI = 1.092.11). Almost 56% were aware of oral cancer. Conclusions: An effective information, education and communication (IEC) strategy for tobacco cessation should be designed with focus on different education needs according to age, gender, and education status of slum population.

Approaches to Assess E-Health Programs: A Scoping Review.

CONTEXT: With the increasing trend of adopting e-Health technologies, the need for evidence for assessing e-Health technologies has become crucial. The appraisal of the e-Health program is important as this could provide guidance on further e-Health investment and adoption. AIMS: The aim of the study was to provide an articulated body of literature on the current state of knowledge about the assessment of e-Health interventions. SETTINGS AND DESIGN: Scoping review was conducted based on the framework provided by Arksey and O'Malley (2005) and considering enhancements proposed by Peters et al. (2015). SUBJECTS AND METHODS: We searched the electronic databases and available gray literature from inception until the last week of October 2019. PRISMA flowchart for the study selection process was used to guide reporting. Data extraction included information on study design, authors, year of study, country, and key findings in terms of approaches used for assessment of e-Health programs. Data were compiled and summarized narratively. RESULTS: Searches were performed between October and December 2019. Seventy-one relevant papers published between the years until the last week of October 2019 were reviewed and analyzed. After considering all the eligibility criteria, 15 papers were included. We identified 15 approaches for assessing e-Health programs, which were summarized and tabulated. CONCLUSIONS: This review showed that available literature on the assessment of e-Health programs is heterogeneous in terms of the methodology used. e-Health interventions are highly contextual; therefore; the phase of maturity and objective of the assessment should be considered while carrying out the assessment of e-Health programs.

Developing a health-promoting school using Knowledge to Action framework.

BACKGROUND: There is a lack of organized effort in the arena of school health promotion, which has been recognized as an effective approach to combat the growing incidence of communicable and noncommunicable diseases. With this view, a study was conducted to develop comprehensive and replicable model for health promotion in schools. MATERIALS AND METHODS: The Knowledge to Action (KTA) framework recognized by the World Health Organization as an implementational framework was used in an implementation study in a school of urban Jodhpur to assess the challenges and gaps associated with health promotion interventions in the school. Baseline regarding knowledge application and practices was gathered using interviews with school staff, parents, and group interaction with students. Knowledge synthesis was done by a thorough search of available literature and the gathered baseline. Resource mapping was carried out using checklists developed from knowledge synthesis. Tailor-made tools were constructed for knowledge implementation for each component of the action cycle. Knowledge of facts related to health behaviors among students was evaluated using pre- and postquestionnaires and practical application of knowledge was assessed using a checklist of 28 indicators on a 5-point Likert scale. Values of tests were gathered and compared with test values 3 and 6 months after the implementation of tailored interventions using descriptive and inferential statistics. RESULTS: Increase in correct answers by students (42% to 96%) and average response for indicators on the Likert scale (3.23-4.86) was seen on repeated interventions over 6 months. Tobacco consumption by school staff reduced by 20% and an increase in willingness among teachers was observed on follow-up interviews. CONCLUSION: The study thus developed a model for health promotion in a school with the help of the KTA framework using tailored interventions that could further be evolved in other setups based on local needs and available resources.

Overview of e-Health initiatives in Rajasthan: An exploratory study.

BACKGROUND: Government of Rajasthan has undertaken a series of e-Health initiatives, especially under various programs of National Health Mission in the past few years. There is a paucity of studies which document and provide appraisal of these initiatives in Rajasthan. AIM: To document ongoing e-Health Initiatives based on technologies and approaches used, coverage by the region and population, services provided and scope. MATERIALS AND METHODS: Primary data collection in form of key-informant interviews while secondary data collection in form of internet-based search of peer and non-peer reviewed literature was conducted to achieve the study objectives. Appropriate documents, records, and reports were reviewed to ensure that all necessary information was obtained. RESULTS: A total of 13 e-Health initiatives were included in the study. The e-Health programs were classified with the use of WHO's classification of Digital Health Interventions v1.0. Most of the initiatives perceived in the study were found to be beneficial to the community, covering the entire population targeted. Supporting agencies, technologies used, and challenges faced during the implementation were identified and documented. Lack of trained manpower, technical and software glitches and deficiency of awareness activities were few obstacles that were found consistent across all user groups. CONCLUSIONS: The overview from this study augmented the knowledge about further scopes and sustainability of these initiatives. Deploying dedicated professionals may improve the functioning of these initiatives. Since e-Health interventions significantly influence healthcare systems, further scale-up of such studies with appropriate evaluation should be planned to guide policy decisions.

Study of feasibility and effectiveness of ASHA-Soft (Online Payment and Performance Monitoring System) in Rajasthan.

OBJECTIVE: ASHA-Soft is the pioneer e-Health program which was launched to manage online payment and for monitoring performance of ASHA workers in Rajasthan. There is a paucity of studies which documents the feasibility and effectiveness of this program with aim to assess the feasibility and effectiveness of ASHA-Soft program. METHODS: Study was conducted in Jodhpur using quantitative and qualitative method. Primary and secondary data approach was used to assess feasibility and effectiveness of ASHA-Soft. Purposive sampling was done to recruit 150 ASHA workers having experience of more than 5 years to capture the perception before and after implementation of ASHA-Soft. Qualitative data was also obtained from ASHA workers and key stakeholders. To assess the effectiveness secondary data was obtained from various sources was analyzed. RESULTS: Mean age of participants were 35.51+ 6.7 years. Most of ASHAs agreed that ASHA-Soft mediated timely payment (68%) and payment according to their performance (81%). It also increased their motivational level (96%).There were no significant difference in different work experience of ASHAs and perception towards ASHA-Soft regarding timely payment (p=0.99), improving quality of life (p=0.66) and motivation level (p=0.40). This program has provided standard online procedure of online payment and monitoring for ASHAs. Incentives received by ASHAs increased to 77%, performance increased by 7% and 9% for maternal health and child health respectively within one year of its initial implementation. CONCLUSIONS: Study finding demonstrate that ASHA-Soft program is acceptable to the users and is effective in terms of meeting organizational requirement.

Assessment of monitoring and online payment system (Asha Soft) in Rajasthan using benefit evaluation (BE) framework.

CONTEXT: e-Health programs are implemented assuming that e-health/digital health can prove beneficial but pieces of evidence for assessing the actual benefits of e-health programs are lacking. AIMS: To utilize the benefit evaluation (BE) framework to assess Asha Soft, which is an online payment and performance monitoring system initiative taken by Rajasthan. SETTINGS AND DESIGN: BE of Asha Soft in Rajasthan. METHODS AND MATERIALS: BE of ASHA Soft was done using scoping review with consultation exercise. The rationale behind using this methodological framework is to contextualize knowledge of the current state of understanding within BE framework practice contexts. The themes used for data compilation and analysis were based on three broad dimensions of BE framework namely, health information technology quality, use, and net benefits. RESULTS: The state of Rajasthan has been the first in the country to start an online system of payment and monitoring of ASHA workers, through Asha Soft. It has administrative and supportive functions. Its simple and easy to use graphical user interference helps users to make accurate data entries and obtain desired monitoring and analytical reports. It has attributed to the availability of data on various parameters which help decision-maker to decide about the performance of ASHA worker and has brought a positive impact on the work performance of ASHAs. This online payment and monitoring mechanism has argumented motivational level and intention of use. The program has optimally utilized available human resources and no apparent monetary cost was involved in developing this software. CONCLUSIONS: This scoping study using the BE framework has provided evidence on the potential benefits of Asha Soft adoption in Rajasthan. It is recommended that future in-depth assessment of other e-health initiatives could be undertaken to guide the decision making.

Study on the perception of Swachh Bharat Abhiyan and attitude towards cleanliness among the residents of urban Jodhpur.

CONTEXT: Swachh Bharat Abhiyan (SBA) is an ambitious project and has been successful in bringing a difference at the facility and infrastructure level, and the objectives of this programme can be achieved if people are aware of this mission and basic sanitation and waste management practices. AIMS: To assess awareness and perception of SBA and attitude towards cleanliness among the residents of urban Jodhpur. SETTINGS AND DESIGN: A cross-sectional survey was done in the largest mixed-income housing society of Jodhpur. METHODS AND MATERIALS: A semi-structured questionnaire was designed for data collection. Sample size was 400. Participants aged above 18 years were included in the study. STATISTICAL ANALYSIS USED: Descriptive and inferential statistical analysis was done using Epi Info Version 7.1. The data were evaluated using Chi-square test and P < 0.05 was considered statistically significant. RESULTS: Mean age of female participants were 30.02 ± 11.34 years and male participants were 34.92 ± 13.10 years. Mean perception about SBA for being able to communicate the importance of cleanliness was 4.8, i.e. lying between strongly agree and agree. No significant association was observed between educational status and attitude towards cleanliness (P < 0.005). A significant association was seen between gender and knowledge about SBA in terms of correctly mentioning the duration of the SBA programme (P > 0.005). CONCLUSIONS: Existing knowledge about SBA and perception towards cleanliness among participants were positive but still there is need of programmes and strategies that help in bringing positive behaviour among group of people who are reluctant towards adopting proper cleanliness, sanitation and hygiene practices.

Human and spiritual agency in Angami healing.

Despite the thought-provoking theological and philosophical implications of the adage urging the healer to heal him/herself, medical anthropology has, with some notable exceptions, given relatively little attention to the problems of well-being experienced by healers themselves, as distinct from those of their patients. This paper focuses on the conflicts experienced by men and women who become healers and how they try to resolve them. The case taken is of the Angami people of Nagaland, northeastern India. There are broadly two kinds of healer, each of whom is subject to contrasting pressures and conflicts. Shamans depend on tutelary spirits who may at various points control the shaman him or herself, who may have been initially reluctant to become a shaman. Other healers such as herbalists and masseurs may sometimes use but do not rely on tutelary spirits and draw instead on their own non-divinational skills. An increasing number of such healers have become Christian and are obliged to adapt their practices accordingly, including the divinity of a new God, sometimes denying a previous personal or family connection with shamanism. At issue in both cases is a struggle between human and divine agency, which, writ large, is a struggle between human self-determination and external forces of control, this being possibly reflected in the fact that Nagaland has for many years been the scene of an armed struggle against the Indian government for political autonomy.