Search results for: international employee health
Commenced in January 2007
Frequency: Monthly
Edition: International
Paper Count: 12471

Search results for: international employee health

9471 A Critical Analysis of the Creation of Geoparks in Brazil: Challenges and Possibilities

Authors: Isabella Maria Beil

Abstract:

The International Geosciences and Geoparks Programme (IGGP) were officially created in 2015 by the United Nations Educational, Scientific and Cultural Organization (UNESCO) to enhance the protection of the geological heritage and fill the gaps on the World Heritage Convention. According to UNESCO, a Global Geopark is an unified area where sites and landscapes of international geological significance are managed based on a concept of sustainable development. Tourism is seen as a main activity to develop new sources of revenue. Currently (November 2022), UNESCO recognized 177 Global Geoparks, of which more than 50% are in Europe, 40% in Asia, 6% in Latin America, and the remaining 4% are distributed between Africa and Anglo-Saxon America. This picture shows the existence of a much uneven geographical distribution of these areas across the planet. Currently, there are three Geoparks in Brazil; however, the first of them was accepted by the Global Geoparks Network in 2006 and, just fifteen years later, two other Brazilian Geoparks also obtained the UNESCO title. Therefore, this paper aims to provide an overview of the current geopark situation in Brazil and to identify the main challenges faced by the implementation of these areas in the country. To this end, the Brazilian history and its main characteristics regarding the development of geoparks over the years will be briefly presented. Then, the results obtained from interviews with those responsible for each of the current 29 aspiring geoparks in Brazil will be presented. Finally, the main challenges related to the implementation of Geoparks in the country will be listed. Among these challenges, the answers obtained through the interviews revealed conflicts and problems that pose hindrances both to the start of the development of a Geopark project and to its continuity and implementation. It is clear that the task of getting multiple social actors, or stakeholders, to engage with the Geopark, one of UNESCO’s guidelines, is one of its most complex aspects. Therefore, among the main challenges, stand out the difficulty of establishing solid partnerships, what directly reflects divergences between the different social actors and their goals. This difficulty in establishing partnerships happens for a number of reasons. One of them is that the investment in a Geopark project can be high and investors often expect a short-term financial return. In addition, political support from the public sector is often costly as well, since the possible results and positive influences of a Geopark in a given area will only be experienced during future mandates. These results demonstrate that the research on Geoparks goes far beyond the geological perspective linked to its origins, and is deeply embedded in political and economic issues.

Keywords: Brazil, geoparks, tourism, UNESCO

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9470 Study of Biofouling Wastewater Treatment Technology

Authors: Sangho Park, Mansoo Kim, Kyujung Chae, Junhyuk Yang

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The International Maritime Organization (IMO) recognized the problem of invasive species invasion and adopted the "International Convention for the Control and Management of Ships' Ballast Water and Sediments" in 2004, which came into force on September 8, 2017. In 2011, the IMO approved the "Guidelines for the Control and Management of Ships' Biofouling to Minimize the Transfer of Invasive Aquatic Species" to minimize the movement of invasive species by hull-attached organisms and required ships to manage the organisms attached to their hulls. Invasive species enter new environments through ships' ballast water and hull attachment. However, several obstacles to implementing these guidelines have been identified, including a lack of underwater cleaning equipment, regulations on underwater cleaning activities in ports, and difficulty accessing crevices in underwater areas. The shipping industry, which is the party responsible for understanding these guidelines, wants to implement them for fuel cost savings resulting from the removal of organisms attached to the hull, but they anticipate significant difficulties in implementing the guidelines due to the obstacles mentioned above. Robots or people remove the organisms attached to the hull underwater, and the resulting wastewater includes various species of organisms and particles of paint and other pollutants. Currently, there is no technology available to sterilize the organisms in the wastewater or stabilize the heavy metals in the paint particles. In this study, we aim to analyze the characteristics of the wastewater generated from the removal of hull-attached organisms and select the optimal treatment technology. The organisms in the wastewater generated from the removal of the attached organisms meet the biological treatment standard (D-2) using the sterilization technology applied in the ships' ballast water treatment system. The heavy metals and other pollutants in the paint particles generated during removal are treated using stabilization technologies such as thermal decomposition. The wastewater generated is treated using a two-step process: 1) development of sterilization technology through pretreatment filtration equipment and electrolytic sterilization treatment and 2) development of technology for removing particle pollutants such as heavy metals and dissolved inorganic substances. Through this study, we will develop a biological removal technology and an environmentally friendly processing system for the waste generated after removal that meets the requirements of the government and the shipping industry and lays the groundwork for future treatment standards.

Keywords: biofouling, ballast water treatment system, filtration, sterilization, wastewater

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9469 The Relation between Vitamin C and Oral Health

Authors: Mai Ashraf Talaat

Abstract:

Background: Vitamin C (ascorbic acid) is an essential nutrient for the development and repair of all body tissues. It can be obtained from a healthy diet or through supplementation. Due to its importance, vitamin C has become a mainstay in the treatment and prevention of many diseases and in maintaining immune, skin, bone and overall health. This review article aims to discuss the studies and case reports conducted to evaluate the effect of Vitamin C on oral health and the recent advances in oral medicine that involve the use of vitamin C. Data/Sources: The review was conducted for clinical studies, case reports and published literature in the English language that addresses this topic. An extensive search in the electronic databases of PubMed, PubMed Central, Web of Science, National Library of Medicine and ResearchGate was performed. Conclusion: Vitamin C is thought to treat periodontal diseases and gingival enlargement. It also affects biofilm formation and therefore, it helps in reducing caries incidence. Recently, vitamin C mesotherapy has been used to treat inflamed gingiva, bleeding gums and gingival hyperpigmentation. More research and randomized controlled trials are needed on this specific topic for more accurate judgment. Clinical significance: A minimally invasive approach - the usage of vitamin C in dental care could drastically reduce the need for surgical intervention.

Keywords: oral health, periodontology, vitamin C, Gingivitis

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9468 Clique and Clan Analysis of Patient-Sharing Physician Collaborations

Authors: Shahadat Uddin, Md Ekramul Hossain, Arif Khan

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The collaboration among physicians during episodes of care for a hospitalised patient has a significant contribution towards effective health outcome. This research aims at improving this health outcome by analysing the attributes of patient-sharing physician collaboration network (PCN) on hospital data. To accomplish this goal, we present a research framework that explores the impact of several types of attributes (such as clique and clan) of PCN on hospitalisation cost and hospital length of stay. We use electronic health insurance claim dataset to construct and explore PCNs. Each PCN is categorised as ‘low’ and ‘high’ in terms of hospitalisation cost and length of stay. The results from the proposed model show that the clique and clan of PCNs affect the hospitalisation cost and length of stay. The clique and clan of PCNs show the difference between ‘low’ and ‘high’ PCNs in terms of hospitalisation cost and length of stay. The findings and insights from this research can potentially help the healthcare stakeholders to better formulate the policy in order to improve quality of care while reducing cost.

Keywords: clique, clan, electronic health records, physician collaboration

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9467 Constructing Optimized Criteria of Objective Assessment Indicators among Elderly Frailty

Authors: Shu-Ching Chiu, Shu-Fang Chang

Abstract:

The World Health Organization (WHO) has been actively developing intervention programs to deal with geriatric frailty. In its White Paper on Healthcare Policy 2020, the Department of Health, Bureau of Health Promotion proposed that active aging and the prevention of disability are essential for elderly people to maintain good health. The paper recommended five main policies relevant to this objective, one of which is the prevention of frailty and disability. Scholars have proposed a number of different criteria to diagnose and assess frailty; no consistent or normative standard of measurement is currently available. In addition, many methods of assessment are recursive, which can easily result in recall bias. Due to the relationship between frailty and physical fitness with regard to co-morbidity, it is important that academics optimize the criteria used to assess frailty by objectively evaluating the physical fitness of senior citizens. This study used a review of the literature to identify fitness indicators suitable for measuring frailty in the elderly. This study recommends that measurement criteria be integrated to produce an optimized predictive value for frailty score. Healthcare professionals could use this data to detect frailty at an early stage and provide appropriate care to prevent further debilitation and increase longevity.

Keywords: frailty, aging, physical fitness, optimized criteria, healthcare

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9466 Stigmatization of Individuals Who Receive Mental Health Treatment and the Role of Social Media: A Cross-Generational Cohort Design and Extension

Authors: Denise Ben-Porath, Tracy Masterson

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In the past, individuals who struggled with and sought treatment for mental health difficulties were stigmatized. However, the current generation holds more open attitudes around mental health issues. Indeed, public figures such as Demi Lovato, Naomi Osaka, and Simone Biles have taken to social media to break the silence around mental health, discussing their own struggles and the benefits of treatment. Thus, there is considerable reason to believe that this generation would hold fewer stigmatizing attitudes toward mental health difficulties and treatment compared to previous ones. In this study, we explored possible changes in stigma on mental health diagnosis and treatment seeking behavior between two generations: Gen Z, the current generation, and Gen X, those born between 1965-1980. It was hypothesized that Gen Z would hold less stigmatizing views on mental illness than Gen X. To examine possible changes in stigma attitudes between these two generations, we conducted a cross-generational cohort design by using the same methodology employed 20 years ago from the Ben-Porath (2002) study. Thus, participants were randomly assigned to read one of the following four case vignettes employed in the Ben-Porath (2002) study: (a) “Tom” who has received psychotherapy due to depression (b) “Tom” who has been depressed but received no psychological help, (c) “Tom” who has received medical treatment due to a back pain, or (d) “Tom” who had a back pain but did not receive medical attention. After reading the vignette, participants rated “Tom” on various personality dimensions using the IFQ Questionnaire and answered questions about their frequency of social media use and willingness to seek mental health treatment on a scale from 1-10. Identical to the results 20 years prior, a significant main effect was found for diagnosis with “Tom” being viewed in more negative terms when he was described as having depression vs. a medical condition (back pain) [F (1, 376) = 126.53, p < .001]. However, in the study conducted 20 years earlier, a significant interaction was found between diagnosis and help-seeking behavior [F (1, 376) = 8.28, p < .005]. Specifically, “Tom” was viewed in the most negative terms when described as depressed and seeking treatment. Alternatively, the current study failed to find a significant interaction between depression and help seeking behavior. These findings suggest that while individuals who hold a mental health diagnosis may still be stigmatized as they were 20 years prior, seeking treatment for mental health issues may be less so. Findings are discussed in the context of social media use and its impact on destigmatization.

Keywords: stigma, mental illness, help-seeking, social media

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9465 Activity-Based Costing in the Hospitality Industry: A Case Study in a Hotel

Authors: Bita Mashayekhi, Mohammad Ara

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The purpose of this study is to provide some empirical evidence about implementing Activity-Based Costing (ABC) in the hospitality industry in Iran. For this purpose, we consider the Tabriz International Hotel as our sample hotel and then gather the relevant data from its cost accounting system in 2012. Then, we use ABC as our costing method and compare the cost of each service unit with that cost which had been extracted for the traditional costing method. The results show a different cost per unit for two methods. Also, because of its more precise and detailed provided information, an ABC system facilitates the decision-making process for managers on decisions related to profitability analysis, budgeting, pricing, and so on.

Keywords: Activity-Based Costing (ABC), activity, cost driver, hospitality industry

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9464 Expectations of Unvaccinated Health Workers in Greece and the Question of Trust: A Qualitative Study of Vaccine Hesitancy

Authors: Sideri Katerina, Chanania Eleni

Abstract:

The reasons why people remain unvaccinated, especially health workers, are complex. In Greece, 2 percent of health workers (around 7,000) remain unvaccinated, despite the fact that for this group of people vaccination against COVID-19 is mandatory. In April 2022, the Greek health minister repeated that unvaccinated health care workers will remain suspended from their jobs ‘for as long as the pandemic lasts,’ explaining that the suspension of the workers in question was ‘entirely their choice’ and that health professionals who do not believe in vaccines ‘do not believe in their own science.’ Although policy circles around the world often link vaccine hesitancy to ignorance of science or misinformation, various recently published qualitative studies show that vaccine hesitancy is the result of a combination of factors, which include distrust towards elites and the system of innovation and distrust towards government. In a similar spirit, some commentators warn that labeling hesitancy as “anti-science” is bad politics. In this paper, we worked within the tradition of STS taking the view that people draw upon personal associations to enact and express civic concern with an issue, the enactment of public concern involves the articulation of threats to actors’ way of life, personal values, relationships, lived experiences, broader societal values and institutional structures. To this effect, we have conducted 27 in depth interviews with unvaccinated Greek health workers and we are in the process of conducting 20 more interviews. We have so far found that rather than a question of believing in ‘facts’ vaccine hesitancy reflects deep distrust towards those charged with the making of decisions and pharmaceutical companies and that emotions (rather than rational thinking) play a crucial role in the formation of attitudes and the making of decisions. We need to dig deeper so as to understand the causes of distrust towards technical government and the ways in which public(s) conceive of and want to be part in the politics of innovation. We particularly address the question of the effectiveness of mandatory vaccination of health workers and whether such top-down regulatory measures further polarize society, to finally discuss alternative regulatory approaches and governance structures.

Keywords: vaccine hesitancy, innovation, trust in vaccines, sociology of vaccines, attitude drivers towards scientific information, governance

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9463 Venezuela in the US Oil Geopolitics: An Analysis in the Light of the New Oil Landscape

Authors: William Clavijo, Edmar Almeida

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The article analyzes the importance of Venezuela in the US geopolitics of oil considering the new oil landscape. To this end, the importance of oil in the geopolitics of the United States is discussed from the perspective of energy security as well as considering a broader view of national security. Based on this discussion, the relevance of Venezuelan oil reserves on US geopolitical agenda is analyzed. Among the results, the article shows that the transformations in the supply structure of the international oil market during the last decade have allowed the United States to achieve greater levels of independence from oil imports from other producing countries. This new reality has profoundly changed the US interest in Venezuelan oil to a broader subject that involves sensitive issues of its national security agenda.

Keywords: oil geopolitics, Venezuela, United States, energy security, national security

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9462 Exploring Communities of Practice through Public Health Walks for Nurse Education

Authors: Jacqueline P. Davies

Abstract:

Introduction: Student nurses must develop skills in observation, communication and reflection as well as public health knowledge from their first year of training. This paper will explain a method developed for students to collect their own findings about public health in urban areas. These areas are both rich in the history of old public health that informs the content of many traditional public health walks, but are also locations where new public health concerns about chronic disease are concentrated. The learning method explained in this paper enables students to collect their own data and write original work as first year students. Examples of their findings will be given. Methodology: In small groups, health care students are instructed to walk in neighbourhoods near to the hospitals they will soon attend as apprentice nurses. On their walks, they wander slowly, engage in conversations, and enter places open to the public. As they drift, they observe with all five senses in the real three dimensional world to collect data for their reflective accounts of old and new public health. They are encouraged to stop for refreshments and taste, as well as look, hear, smell, and touch while on their walk. They reflect as a group and later develop an individual reflective account in which they write up their deep reflections about what they observed on their walk. In preparation for their walk, they are encouraged to look at studies of quality of Life and other neighbourhood statistics as well as undertaking a risk assessment for their walk. Findings: Reflecting on their walks, students apply theoretical concepts around social determinants of health and health inequalities to develop their understanding of communities in the neighbourhoods visited. They write about the treasured historical architecture made of stone, bronze and marble which have outlived those who built them; but also how the streets are used now. The students develop their observations into thematic analyses such as: what we drink as illustrated by the empty coke can tossed into a now disused drinking fountain; the shift in home-life balance illustrated by streets where families once lived over the shop which are now walked by commuters weaving around each other as they talk on their mobile phones; and security on the street, with CCTV cameras placed at regular intervals, signs warning trespasses and barbed wire; but little evidence of local people watching the street. Conclusion: In evaluations of their first year, students have reported the health walk as one of their best experiences. The innovative approach was commended by the UK governing body of nurse education and it received a quality award from the nurse education funding body. This approach to education allows students to develop skills in the real world and write original work.

Keywords: education, innovation, nursing, urban

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9461 Problem Solving: Process or Product? A Mathematics Approach to Problem Solving in Knowledge Management

Authors: A. Giannakopoulos, S. B. Buckley

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Problem solving in any field is recognised as a prerequisite for any advancement in knowledge. For example in South Africa it is one of the seven critical outcomes of education together with critical thinking. As a systematic way to problem solving was initiated in mathematics by the great mathematician George Polya (the father of problem solving), more detailed and comprehensive ways in problem solving have been developed. This paper is based on the findings by the author and subsequent recommendations for further research in problem solving and critical thinking. Although the study was done in mathematics, there is no doubt by now in almost anyone’s mind that mathematics is involved to a greater or a lesser extent in all fields, from symbols, to variables, to equations, to logic, to critical thinking. Therefore it stands to reason that mathematical principles and learning cannot be divorced from any field. In management of knowledge situations, the types of problems are similar to mathematics problems varying from simple to analogical to complex; from well-structured to ill-structured problems. While simple problems could be solved by employees by adhering to prescribed sequential steps (the process), analogical and complex problems cannot be proceduralised and that diminishes the capacity of the organisation of knowledge creation and innovation. The low efficiency in some organisations and the low pass rates in mathematics prompted the author to view problem solving as a product. The authors argue that using mathematical approaches to knowledge management problem solving and treating problem solving as a product will empower the employee through further training to tackle analogical and complex problems. The question the authors asked was: If it is true that problem solving and critical thinking are indeed basic skills necessary for advancement of knowledge why is there so little literature of knowledge management (KM) about them and how they are connected and advance KM?This paper concludes with a conceptual model which is based on general accepted principles of knowledge acquisition (developing a learning organisation), knowledge creation, sharing, disseminating and storing thereof, the five pillars of knowledge management (KM). This model, also expands on Gray’s framework on KM practices and problem solving and opens the doors to a new approach to training employees in general and domain specific areas problems which can be adapted in any type of organisation.

Keywords: critical thinking, knowledge management, mathematics, problem solving

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9460 Evaluation of a Higher Diploma in Mental Health Nursing Using Qualitative and Quantitative Methods: Effects on Student Behavior, Attitude and Perception

Authors: T. Frawley, G. O'Kelly

Abstract:

The UCD School of Nursing, Midwifery and Health Systems Higher Diploma in Mental Health (HDMH) nursing programme commenced in January 2017. Forty students successfully completed the programme. Programme evaluation was conducted from the outset. Research ethics approval was granted by the UCD Human Research Ethics Committee – Sciences in November 2016 (LS-E-16-163). Plan for Sustainability: Each iteration of the programme continues to be evaluated and adjusted accordingly. Aims: The ultimate purpose of the HDMH programme is to prepare registered nurses (registered children’s nurse (RCN), registered nurse in intellectual disability (RNID) and registered general nurse (RGN)) to function as effective registered psychiatric nurses in all settings which provide care and treatment for people experiencing mental health difficulties. Curriculum evaluation is essential to ensure that the programme achieves its purpose, that aims and expected outcomes are met and that required changes are highlighted for the programme’s continuing positive development. Methods: Both quantitative and qualitative methods were used in the evaluation. A series of questionnaires were used (the majority pre and post programme) to determine student perceptions of the programme, behaviour and attitudinal change from commencement to completion. These included the student assessment of learning gains (SALG); mental health knowledge schedule (MAKS); mental health clinician attitudes scale (MICA); reported and intended behaviour scale (RIBS); and community attitudes towards the mentally ill (CAMI). In addition, student and staff focus groups were conducted. Evaluation methods also incorporated module feedback. Outcome/Results: The evaluation highlighted a very positive response in relation to the achievement of programme outcomes and preparation for future work as registered psychiatric nursing. Some areas were highlighted for further development, which have been taken cognisance of in the 2019 iteration of the programme.

Keywords: learning gains, mental health, nursing, stigma

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9459 Assessment of Chromium Concentration and Human Health Risk in the Steelpoort River Sub-Catchment of the Olifants River Basin, South Africa

Authors: Abraham Addo-Bediako

Abstract:

Many freshwater ecosystems are facing immense pressure from anthropogenic activities, such as agricultural, industrial and mining. Trace metal pollution in freshwater ecosystems has become an issue of public health concern due to its toxicity and persistence in the environment. Trace elements pose a serious risk not only to the environment and aquatic biota but also humans. Chromium is one of such trace elements and its pollution in surface waters and groundwaters represents a serious environmental problem. In South Africa, agriculture, mining, industrial and domestic wastes are the main contributors to chromium discharge in rivers. The common forms of chromium are chromium (III) and chromium (VI). The latter is the most toxic because it can cause damage to human health. The aim of the study was to assess the contamination of chromium in the water and sediments of two rivers in the Steelpoort River sub-catchment of the Olifants River Basin, South Africa and human health risk. The concentration of Cr was analyzed using inductively coupled plasma–optical emission spectrometry (ICP-OES). The concentration of the metal was found to exceed the threshold limit, mainly in areas of high human activities. The hazard quotient through ingestion exposure did not exceed the threshold limit of 1 for adults and children and cancer risk for adults and children computed did not exceed the threshold limit of 10-4. Thus, there is no potential health risk from chromium through ingestion of drinking water for now. However, with increasing human activities, especially mining, the concentration could increase and become harmful to humans who depend on rivers for drinking water. It is recommended that proper management strategies should be taken to minimize the impact of chromium on the rivers and water from the rivers should properly be treated before domestic use.

Keywords: land use, health risk, metal pollution, water quality

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9458 The Debureaucratization Strategy for the Portuguese Health Service through Effective Communication

Authors: Fernando Araujo, Sandra Cardoso, Fátima Fonseca, Sandra Cavaca

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A debureaucratization strategy for the Portuguese Health Service was assumed by the Executive Board of the SNS, in deep articulation with the Shared Services of the Ministry of Health. Two of the main dimensions were focused on sick leaves (SL), that transform primary health care (PHC) in administrative institutions, limiting access to patients. The self-declaration of illness (SDI) project, through the National Health Service Contact Centre (SNS24), began on May 1, 2023, and has already resulted in the issuance of more than 300,000 SDI without the need to allocate resources from the National Health Service (NHS). This political decision allows each citizen, in a maximum 2 times/year, and 3 days each time, if ill, through their own responsibility, report their health condition in a dematerialized way, and by this way justified the absence to work, although by Portuguese law in these first three days, there is no payment of salary. Using a digital approach, it is now feasible without the need to go to the PHC and occupy the time of the PHC only to obtain an SL. Through this measure, bureaucracy has been reduced, and the system has been focused on users, improving the lives of citizens and reducing the administrative burden on PHC, which now has more consultation times for users who need it. The second initiative, which began on March 1, 2024, allows the SL to be issued in emergency departments (ED) of public hospitals and in the health institutions of the social and private sectors. This project is intended to allow the user who has suffered a situation of acute urgent illness and who has been observed in an ED of a public hospital or in a private or social entity no longer need to go to PHC only to apply for the respective SL. Since March 1, 54,453 SLs have been issued, 242 in private or social sector institutions and 6,918 in public hospitals, of which 134 were in ED and 47,292 in PHC. This approach has proven to be technically robust, allows immediate resolution of problems and differentiates the performance of doctors. However, it is important to continue to qualify the proper functioning of the ED, preventing non-urgent users from going there only to obtain SL. Thus, in order to make better use of existing resources, it was operationalizing this extension of its issuance in a balanced way, allowing SL to be issued in the ED of hospitals only to critically ill patients or patients referred by INEM, SNS24, or PHC. In both cases, an intense public campaign was implemented to explain the way it works and the benefits for patients. In satisfaction surveys, more than 95% of patients and doctors were satisfied with the solutions, asking for extensions to other areas. The administrative simplification agenda of the NHS continues its effective development. For the success of this debureaucratization agenda, the key factors are effective communication and the ability to reach patients and health professionals in order to increase health literacy and the correct use of NHS.

Keywords: debureaucratization strategy, self-declaration of illness, sick leaves, SNS24

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9457 Fair Value Accounting and Evolution of the Ohlson Model

Authors: Mohamed Zaher Bouaziz

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Our study examines the Ohlson Model, which links a company's market value to its equity and net earnings, in the context of the evolution of the Canadian accounting model, characterized by more extensive use of fair value and a broader measure of performance after IFRS adoption. Our hypothesis is that if equity is reported at its fair value, this valuation is closely linked to market capitalization, so the weight of earnings weakens or even disappears in the Ohlson Model. Drawing on Canada's adoption of the International Financial Reporting Standards (IFRS), our results support our hypothesis that equity appears to include most of the relevant information for investors, while earnings have become less important. However, the predictive power of earnings does not disappear.

Keywords: fair value accounting, Ohlson model, IFRS adoption, value-relevance of equity and earnings

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9456 Reproductive Health of Women After Taking Chemotherapy for Gestational Trophoblastic Disease

Authors: Ezeh Chukwunonso Peter Excel, Akruti Vg

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Aim/Background: To show that even after undergoing 1-5 courses of chemotherapy for Gestational Trophoblastic Disease (GTD) reproductive health of women is intact and they conceive successfully after it. Method: Retrospective cohort analysis using data from the Lugansk regional maternity hospital database of years 1993-2013, which shows n=18 females had GTD and underwent 1-5 courses of chemotherapy. Results and Discussion: Frequency of GTD was rare. All 18 patients (pts) belong to age group of 17-39 years, covering wide range of reproductive age. Out of 18 pts, 15 had hydatidiform mole (HM) while other 3 had choriocarcinoma (CC). In anamnesis, among CC pts, 1 had early pre-eclampsia at 24 weeks and 1 had 4th week of late postpartum (PP) bleeding, while all HM pts had genital inflammatory diseases, 1 pt of HM during follow-up had High hCG and 3 times curettage in 5 months. 18 women became pregnant for 25 times after chemotherapy. Chemotherapy was given under indication of either high level of HCG, luteal cyst >6cm or path-morphological results of curettage. CC 3 pts had (2 spontaneous abortions (SA), 2 term cesarean section (CS), 1 preterm CS). HM 15 pts had (3 artificial abortion, 2 SA, 7CS (5 term and 2 preterm), 8 vaginal deliveries (7 term and 1 preterm)). Conclusion: During our research we got 22.2% preterm deliveries and 55.6% CS which is higher than the normal cases, but still all the 18 women were able to have kids successfully after chemotherapy. So we can conclude that chemotherapy for GTD was successful in keeping the reproductive health of women intact.

Keywords: reproductive health, chemotherapy, gestational trophoblastic disease, women

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9455 A Qualitative Study of COVID-19's Impact on Mental Health and Corresponding Alcohol and Other Substance Use among Indigenous Women in Toronto Canada

Authors: Kristen Emory, Jerry Flores

Abstract:

Purpose: We explore the unique and underrepresented experiences of Indigenous women living in Toronto, Canada, during the first year of the COVID-19 pandemic. The purpose of this study is to better document the impacts of COVID-19 on the mental health and well-being of Indigenous women in Toronto, Canada, in order to better understand unmet needs, as well as lay the groundwork for more targeted research and potential interventions based on these needs. Background: It has been fairly well documented that the COVID-19 pandemic has increased mental health concerns among various populations globally. There have also been numerous studies indicating increases in substance use and abuse in response to the stress of the pandemic. There is also evidence that the COVID-19 pandemic has disproportionately impacted a variety of historically marginalized populations in Canada, the US, and globally, including Indigenous populations. While these studies provide some insight into how the COVID-19 pandemic is impacting the global population, much less is known about the lived experiences of Indigenous populations during the time of COVID-19. Better understanding these experiences will allow public health professionals, governments, and non-governmental organizations better combat health inequities related to the pandemic. Methods: In-depth qualitative semi-structured virtual (due to COVID-19) interviews with 13 Indigenous women were conducted during the first year of the COVID-19 pandemic (2020). Interviews were recorded, transcribed, and analyzed by team members using Dedoose qualitative analysis software. Findings: COVID-19 negatively affected Indigenous females identifying participants’ mental health and corresponding reported increases in substance use. In addition to the daily stress of the unpredictability of life in the time of the COVID-19 pandemic, participants cited job loss, economic concerns, homeschooling, and lack of access to medical resources as primary factors in increasing their stress and decreasing mental health and wellbeing. In response to these stressors, a majority of participants cited coping mechanisms such as increased substance use to help deal with the uncertainty. In particular, alcohol and tobacco emerged as coping mechanisms to help participants cope with stress related to the pandemic (as well as its social and economic toll on respondents' lives). We will present qualitative data to be presented, including participant direct quotes, explaining their experiences with COVID-19, mental health, and increased substance use, as well as analysis and synthesis with the existing scientific evidence base. Conclusion: This research is among the good studies to our knowledge that scientifically explore the impact of COVID-19 on mental health and well-being and corresponding increases in reported substance use.

Keywords: mental health, covid-19, indigenous, inequity, anxiety, depression, stress

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9454 Determination of the Element Contents in Turkish Coffee and Effect of Sugar Addition

Authors: M. M. Fercan, A. S. Kipcak, O. Dere Ozdemir, M. B. Piskin, E. Moroydor Derun

Abstract:

Coffee is a widely consumed beverage with many components such as caffeine, flavonoids, phenolic compounds, and minerals. Coffee consumption continues to increase due to its physiological effects, its pleasant taste, and aroma. Robusta and Arabica are two basic types of coffee beans. The coffee bean used for Turkish coffee is Arabica. There are many elements in the structure of coffee and have various effect on human health such as Sodium (Na), Boron (B), Magnesium (Mg) and Iron (Fe). In this study, the amounts of Mg, Na, Fe, and B contents in Turkish coffee are determined and effect of sugar addition is investigated for conscious consumption. The analysis of the contents of coffees was determined by using inductively coupled plasma optical emission spectrometry (ICP-OES). From the results of the experiments the Mg, Na, Fe and B contents of Turkish coffee after sugar addition were found as 19.83, 1.04, 0.02, 0.21 ppm, while without using sugar these concentrations were found 21.46, 0.81, 0.008 and 0.16 ppm. In addition, element contents were calculated for 1, 3 and 5 cups of coffee in order to investigate the health effects.

Keywords: health effect, ICP-OES, sugar, Turkish coffee

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9453 The Roles of ECOWAS Parliament on Regional Integration of the West African Sub-Region

Authors: Sani Shehu, Mohd Afandi Salleh

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Parliament is a law making body which provided at national, state, province and territorial level playing a parliamentary role of representing people, law making, peace, and conflict resolution, ratifying and incorporating international convention into municipal law. Parliaments are created globally to give solid legitimacy to good governance under democratic system of government, and the representatives must be elected by the people, so the ECOWAS parliament is entitled to have this legitimacy, where members must be elected by adult people among the citizens of ECOWAS member states. This paper will discuss on the roles that ECOWAS parliament plays for the achievement of regional integration and economic goals of development and cooperation in the sub-region.

Keywords: ECOWAS parliament, composition, competence, power

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9452 Examining the Potential of Linear Parks as Sustainable Development Components

Authors: Andreas Savvides, Chloe Kadi

Abstract:

The objective of this study is to investigate how the planning and design of open parks within neighborhoods and communities can promote physical activity in order to enhance the health of the local population. An extensive literature review was conducted for studies regarding the relationship between health and physical activity and the park characteristics that can promote physical activity among people. The findings of the literature review were then compared and analysed, in order to identify the main characteristics of urban parks that can promote physical activity and enhance public health. In order to find out how the characteristics identified in the literature were applied in real life, an analysis of three existing parks in three different countries was conducted. The parks, apart from their geographical location, also vary in size and layout. The parks were chosen because they are urban open parks and they include facilities for physical activity.

Keywords: urban planning, active living behaviour, open parks, sustainable mobility

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9451 Policy and Strategy to Combatting Terrorism in Indonesia: Analysis Socio Juridical Counter and Contra Terrorism

Authors: Dini Dewi Heniarti

Abstract:

In the past decades, Indonesia has suffered severe terrorist attacks, faced major terrorism challenges and has made impressive progress in countering it. The trend of terrorist groups operating in Indonesia is to focus on ‘soft’ targets. Indonesia has made notable progress in strengthening the legal regime against terrorism, in conformity with the international treaties against terrorism. Further measures are however needed to complete the legal regime building processes. This paper will demonstrate analyze socio yuridical contra and counter terrorism by Indonesia Government.

Keywords: policy, strategy, combatting terrorism, socio juridical, counter and contra terrorism

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9450 A Global Business Network Built on Hive: Two Use Cases: Buying and Selling of Products and Services and Carrying Out of Social Impact Projects

Authors: Gheyzer Villegas, Edgardo Cedeño, Veruska Mata, Edmundo Chauran

Abstract:

One of the most significant changes that occurred in global commerce was the emergence of cryptocurrencies and blockchain technology. There is still much debate about the adoption of the economic model based on crypto assets, and myriad international projects and initiatives are being carried out to try and explore the potential that this new field offers. The Hive blockchain is a prime example of this, featuring two use cases: of how trade based on its native currencies can give successful results in the exchange of goods and services and in the financing of social impact projects. Its decentralized management model and visionary administration of its development fund have become a key part of its success.

Keywords: Hive, business, network, blockchain

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9449 Transforming Healthcare with Immersive Visualization: An Analysis of Virtual and Holographic Health Information Platforms

Authors: Hossein Miri, Zhou YongQi, Chan Bormei-Suy

Abstract:

The development of advanced technologies and innovative solutions has opened up exciting new possibilities for revolutionizing healthcare systems. One such emerging concept is the use of virtual and holographic health information platforms that aim to provide interactive and personalized medical information to users. This paper provides a review of notable virtual and holographic health information platforms. It begins by highlighting the need for information visualization and 3D representation in healthcare. It then proceeds to provide background knowledge on information visualization and historical developments in 3D visualization technology. Additional domain knowledge concerning holography, holographic computing, and mixed reality is then introduced, followed by highlighting some of their common applications and use cases. After setting the scene and defining the context, the need and importance of virtual and holographic visualization in medicine are discussed. Subsequently, some of the current research areas and applications of digital holography and holographic technology are explored, alongside the importance and role of virtual and holographic visualization in genetics and genomics. An analysis of the key principles and concepts underlying virtual and holographic health information systems is presented, as well as their potential implications for healthcare are pointed out. The paper concludes by examining the most notable existing mixed-reality applications and systems that help doctors visualize diagnostic and genetic data and assist in patient education and communication. This paper is intended to be a valuable resource for researchers, developers, and healthcare professionals who are interested in the use of virtual and holographic technologies to improve healthcare.

Keywords: virtual, holographic, health information platform, personalized interactive medical information

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9448 Air Quality Health Index in Windsor, Canada, and the Impact of Regional Scale Transport

Authors: Xiaohong Xu, Tianchu Zhang, Yangfan Chen, Rongtai Tan

Abstract:

In Canada, Air Quality Health Index (AQHI) is a scale designed to help residences understand the impact of air quality on human health. In Ontario, Canada, AQHI was implemented in June 2015. This study investigated temporal variability of daily AQHI and impact of regional transport on AQHI in Windsor, Ontario, Canada from 2016 to 2019. During 2016–2019, 1428 daily AQHIs were recorded in Windsor Downtown Station. Among those, the AQHIs were at the low health risk level (AQHI = 1, 2 or 3) in 82% of days, only a few days at high risk level (AQHI = 7), the rest were at moderate health risk level (AQHI = 4, 5, 6), indicating air quality in Windsor was fairly good with relatively low health risk. The annual mean AQHI value decreased from 2.95 in 2016 to 2.81 in 2019, demonstrating the improvement of air quality. Half of the days, AQHI were 3 regardless of season. AQHI was higher in the warm season (3.1) than in the cold season (2.6) due to more frequent moderate risk days (27%, AQHI = 4) in warm season and more frequent low risk days (42%, AQHI = 2) in the cold season. Among the three pollutants considered in AQHI calculation, O3 was the most frequently reported dominant contributor to daily AQHI (88% of days), followed by NO2 (12%), especially in the cold season, with small contribution from PM2.5 (<1%). In the past two decades, NO2 concentrations had decreased significantly and O3 concentrations had increased, resulting in daily AQHI being less reliance on NO2 (from 51% of days being the primary contributor during 2003–2010 to 12% during 2016–2019) and more on O3 concentrations (49% to 88%). Trajectory analysis found that AQHI ≤ 3 days were closely associated with air masses from the north and northwest, whereas AQHI > 3 days were closely associated with air masses from the west and southwest. This is because northerly flows brought in clear air mass owing to less industrial facilities, while polluted air masses were transported from the south of Windsor, where several industrial states of the US were located. Overall, O3 concentrations dictate the daily AQHI values, the seasonal variability of AQHI, and the impact of regional transport on AQHI in Windsor. This makes further reductions of AQHI challenging because O3 concentrations are likely to continue increasing due to weakened consumption of O3 by NO owing to decreasing NO emissions and more hot days because of climate change. The predominant and increasing contribution of O3 to AQHI calls for more effective control measures to mitigate O3 pollution and its impact on human health and the environment.

Keywords: air quality, Air Quality Health Index (AQHI), hysplit, regional transport, windsor

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9447 A Phenomenographic Examination of Work Motivation to Perform at the Municipal Corporation of Bangladesh

Authors: Md. Rifad Chowdhury

Abstract:

This research study investigates employees' conception of work motivation to perform at the municipal corporation in Bangladesh. The municipal corporation is one of the key administrative bodies of Bangladesh’s local government. Municipal corporation employees provide essential public services in the country’s semi-urban areas. Work motivation has been defined as a result of interaction between the individual and the environment. Local government studies indicate the work environment of the municipal corporation is unique because of its key colonial and political history, several reform attempts, non-western social perspectives, job functions, and traditional governance. The explorative purpose of this study is to find and analyse the conceptions of employees’ work motivation within this environment to expand a better understanding of work motivation. According to the purpose of this study, a qualitative method has been adopted, which has remained a very unpopular method among work motivational researchers in Bangladesh. Twenty-two semi-structured online interviews were conducted in this study. Phenomenographic research methodology has been adopted to describe the limited number of qualitatively different ways of experiencing work motivation. During the analysis of the semi-structured interview transcripts, the focus was on the employees' perspectives as employees experience work motivation or the second-order perspective to explore and analyse the conceptions. Based on the participants' collective experiences and dimensions of variation across the different ways of experiencing, six conceptions of employee work motivation to perform at the municipal corporation were identified in this study. The relationships between conceptions were further elaborated in terms of critical variations across the conceptions. Six dimensions of critical variations have emerged within and between the conceptions. In the outcome space, the relationships between conceptions and dimensions of critical variations are presented in a logical structure. The findings of this research study show significance to expand the understanding of work motivation and the research context of phenomenography. The findings of this research will contribute to the ongoing attention of contextual work motivational understanding from a Bangladeshi perspective and phenomenographic research conceptions in organisational behaviour studies.

Keywords: work motivation, qualitative, phenomenography, local government

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9446 Consequences of Adolescent Childbearing Among Teen Mothers In Gatsibo District, Rwanda

Authors: Joselyne Rugema, Innocent Twagirayezu, Aimable Nkurunziza, Alice Nyirazigama, Vedaste Bagweneza, Belancilla Nikuze

Abstract:

Introduction: Burn injuries among children are associated with major complications. Early health care seeking and appropriate management are crucial in saving lives and preventing complications. Objective: To assess home-based management practices and health seeking behaviors among caregivers of children admitted with burn injuries at selected hospitals in Rwanda. Methods: A cross-sectional descriptive study was conducted among caregivers of children admitted with burn injuries at three hospitals in Kigali. A semi-structured questionnaire was used to collect the data that were analyzed using SPSS version 25. Statistical software Results: Most of the children with burn injuries had median age of 36 months, and 89.9% had second-degree burns. 92.4% of burns happened at home and 63.3% were scalds. Only 18% of the caregivers seek care immediately after children’s burn injuries. About 2.5% reported not seeking any care after burn injuries and 3.8% sought care from traditional healers. 65.9% of the participants used wrong practices before seeking care such as applying honey, cooking oil and urine to the burn injuries. Transportation difficulties before consulting health facilities were the main reported faced barriers to success health care (86.1%). Conclusion: Immediate health seeking behavior was low. Wrong practices including application of harmful products to burn injuries are common in the community. There is a need for community based interventions to prevent burn injuries at home and to empower the community with appropriate actions to take after injuries.

Keywords: adolescent pregnancy, qualitative design, childbearing, teenage mothers

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9445 Barbie in India: A Study of Effects of Barbie in Psychological and Social Health

Authors: Suhrita Saha

Abstract:

Barbie is a fashion doll manufactured by the American toy company Mattel Inc and it made debut at the American International Toy Fair in New York in 9 March 1959. From being a fashion doll to a symbol of fetishistic commodification, Barbie has come a long way. A Barbie doll is sold every three seconds across the world, which makes the billion dollar brand the world’s most popular doll for the girls. The 11.5 inch moulded plastic doll has a height of 5 feet 9 inches at 1/6 scale. Her vital statistics have been estimated at 36 inches (chest), 18 inches (waist) and 33 inches (hips). Her weight is permanently set at 110 pounds which would be 35 pounds underweight. Ruth Handler, the creator of Barbie wanted a doll that represented adulthood and allowed children to imagine themselves as teenagers or adults. While Barbie might have been intended to be independent, imaginative and innovative, the physical uniqueness does not confine the doll to the status of a play thing. It is a cultural icon but with far reaching critical implications. The doll is a commodity bearing more social value than practical use value. The way Barbie is produced represents industrialization and commodification of the process of symbolic production. And this symbolic production and consumption is a standardized planned one that produce stereotypical ‘pseudo-individuality’ and suppresses cultural alternatives. Children are being subject to and also arise as subjects in this consumer context. A very gendered, physiologically dissected sexually charged symbolism is imposed upon children (both male and female), childhood, their social worlds, identity, and relationship formation. Barbie is also very popular among Indian children. While the doll is essentially an imaginative representation of the West, it is internalized by the Indian sensibilities. Through observation and questionnaire-based interview within a sample population of adolescent children (primarily female, a few male) and parents (primarily mothers) in Kolkata, an Indian metropolis, the paper puts forth findings of sociological relevance. 1. Barbie creates, recreates, and accentuates already existing divides between the binaries like male- female, fat- thin, sexy- nonsexy, beauty- brain and more. 2. The Indian girl child in her associative process with Barbie wants to be like her and commodifies her own self. The male child also readily accepts this standardized commodification. Definition of beauty is thus based on prejudice and stereotype. 3. Not being able to become Barbie creates health issues both psychological and physiological varying from anorexia to obesity as well as personality disorder. 4. From being a plaything Barbie becomes the game maker. Barbie along with many other forms of simulation further creates a consumer culture and market for all kind of fitness related hyper enchantment and subsequent disillusionment. The construct becomes the reality and the real gets lost in the play world. The paper would thus argue that Barbie from being an innocuous doll transports itself into becoming social construct with long term and irreversible adverse impact.

Keywords: barbie, commodification, personality disorder, sterotype

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9444 Rapid Sexual and Reproductive Health Pathways for Women Accessing Drug and Alcohol Treatment

Authors: Molly Parker

Abstract:

Unintended pregnancy rates in Australia are amongst the highest in the developed world. Women with Substance Use Disorder often have riskier sexual behavior with nil contraceptive use and face disproportionately higher unintended pregnancies and Sexually Transmitted Infections, alongside Substance Use in Pregnancy (SUP) climbing at an alarming rate. In an inner-city Drug and Alcohol (D&A) service, significant barriers to sexual and reproductive health services have been identified, aligning with research. Rapid pathways were created for women seeking D&A treatment to be referred to Sexual and Reproductive Health services for the administration of Long-acting reversible contraception (LARC) and sexual health screening. For clients attending a D&A service, this is an opportunistic time to offer sexual and reproductive health services. Collaboration and multidisciplinary team input between D&A and sexual health and reproductive services are paramount, with rapid referral pathways being identified as the main strategy to improve access to sexual and reproductive health support for this population. With this evidence, a rapid referral pathway was created for women using the D&A service to access LARC, particularly in view of fertility often returning once stable on D&A treatment. A closed-ended survey was used for D&A staff to identify gaps in reproductive health knowledge and views of referral accessibility. Results demonstrated a lack of knowledge of contraception and appropriate referral processes. A closed-ended survey for clients was created to establish the need and access to services and to quantify data. A follow-up data collection will be reviewed to access uptake and satisfaction of the intervention from clients. Sexual health screening access was also identified as a deficit, particularly concerning due to the higher rates of STIs in this cohort. A rapid referral pathway will be undergoing implementation, reducing risks of untreated STIS both pre and post-conception. Similarly, pre and post-intervention structured surveys will be used to identify client satisfaction from the pathway. Although currently in progress, the research and pathway aim to be completed by December 2023. This research and implementation of sexual and reproductive health pathways from the D&A service have significant health and well-being benefits to clients and the wider community, including possible fetal/infancy outcomes. Women now have rapid access to sexual and reproductive health services, with the aim of reducing unplanned pregnancies, poor outcomes associated with SUP, client/staff trauma from termination of pregnancy, and client/staff trauma following the assumption of care of the child due to substance use, the financial cost for out of home care as required, the poor outcomes of untreated STIs to the fetus in pregnancy and the spread of STIs in the wider community. As evidence suggests, the implementation of a streamlined referral process is required between D&A and sexual and reproductive health services and has positive feedback from both clinicians and clients in improving care.

Keywords: substance use in pregnancy, drug and alcohol, substance use disorder, sexual health, reproductive health, contraception, long-acting reversible contraception, neonatal abstinence syndrome, FASD, sexually transmitted infections, sexually transmitted infections pregnancy

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9443 Indonesian Marriage Law Reform: A Doctrinal Research to Find the Way to Strengthen Children's Rights against Child Marriage

Authors: Erni Agustin, Zendy Prameswari

Abstract:

The Law Number 1 Year 1974 on Marriage was issued by Indonesian Government to replace the old marriage law stipulated in Burgerlijk Wetboek inherited from the Dutch colonial. The Law defines marriage as both physical and mental bond between a man and a woman as husband and wife with the purpose to form a harmonious family based on deity. Marriage shall be conducted when determined requirements are met based on the Law. Article 7 of the Law Number 1 Year 1974 stipulates the minimum age requirement to enter into marriage, which is 19 years for men and 16 years for women. This stipulation is made to make the marriage achieve the true goal to form a happy, eternal and prosperous family. It is expected at that age, each party has a mature soul and physic. However, it is possible for those who have not reached the age to enter into marriage if there is a dispensation granted by the courts or other official designated by the parents of each party in the marriage. As many other countries in the world, Indonesia has serious problems linked with the child or underage marriage. Indonesia is one of the countries with the highest absolute numbers of child marriage. In 2012, a judicial review was filed to the Constitutional Court against the provisions of the minimum age limit in the Law Number 1 Year 1974 on Marriage. The appeal was filed in order to raise the limit of minimum age for women from 16 years to be 18 years. However, the Constitutional Court considered that the provisions on the minimum age in the Law Number 1 Year 1974 on Marriage is constitutional. At the international level, Indonesia has participated in the formulation of variety of international human rights instrument which have an impact on children, and is a party to a number of them. Indonesia ratified the CRC through Presidential Decree of the Republic of Indonesia Number 36 Year 1990 on 5 September 1990. This paper attempts to analyze three main issues. Firstly, it will scrutinize the ratio legis of the stipulation on minimum age requirement to enter into marriage in the Law Number 1 Year 1974 on Marriage. Secondly, it will discuss the conformity of Indonesian marriage law to the principles and provisions on the CRC. Last, this paper will elaborate the legal measures shall be taken to strengthen the legal protection for children against child marriage. This paper is a doctrinal research using statute, conceptual and historical approaches. This study argues that The Law-making of Indonesian marriage law influenced by religious values that live in Indonesia. With regard to the conformity of Indonesian marriage law with the CRC, Indonesia is facing the issue of the compatibility of its respective national law with the CRC. Therefore, the legal measures that have to be taken are to review and amend the Indonesian Marriage Law to provide better protection for the children against underage marriage.

Keywords: child marriage, children’s rights, indonesian marriage law, underage marriage

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9442 Impacts of Public Insurance on Health Access and Outcomes: Evidence from India

Authors: Titir Bhattacharya, Tanika Chakraborty, Prabal K. De

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Maternal and child health continue to be a significant policy focus in developing countries, including India. An emerging model in health care is the creation of public and private partnerships. Since the construction of physical infrastructure is costly, governments at various levels have tried to implement social health insurance schemes where a trust calculates insurance premiums and medical payments. Typically, qualifying families get full subsidization of the premium and get access to private hospitals, in addition to low cost public hospitals, for their tertiary care needs. We analyze one such pioneering social insurance scheme in the Indian state of Andhra Pradesh (AP). The Rajiv Aarogyasri program (RA) was introduced by the Government of AP on a pilot basis in 2007 and implemented in 2008. In this paper, we first examine the extent to which access to reproductive health care changed. For example, the RA scheme reimburses hospital deliveries leading us to expect an increase in institutional deliveries, particularly in private hospitals. Second, we expect an increase in institutional deliveries to also improve child health outcomes. Hence, we estimate if the program improved infant and child mortality. We use District Level Health Survey data to create annual birth cohorts from 2000-2015. Since AP was the only state in which such a state insurance program was implemented, the neighboring states constituted a plausible control group. Combined with the policy timing, and the year of birth, we employ a difference-indifference strategy to identify the effects of RA on the residents of AP. We perform several checks against threats to identification, including testing for pre-treatment trends between the treatment and control states. We find that the policy significantly lowered infant and child mortality in AP. We also find that deliveries in private hospitals increased, and government hospitals decreased, showing a substitution effect of the relative price change. Finally, as expected, out-of-pocket costs declined for the treatment group. However, we do not find any significant effects for usual preventive care such as vaccination, showing that benefits of insurance schemes targeted at the tertiary level may not trickle down to the primary care level.

Keywords: public health insurance, maternal and child health, public-private choice

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