Search results for: continuous care

Authors: A. P. Puvanasvaran, Suresh A. L. Vasu, N. Norazlin

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The Lean Environmental Management Integration System (LEMIS) framework development is integration between lean core element and ISO 14001. The curiosity on the relationship between continuous improvement and sustainability of lean implementation has influenced this study toward LEMIS. Characteristic of ISO 14001 standard clauses and core elements of lean principles are explored from past studies and literature reviews. Survey was carried out on ISO 14001 certified companies to examine continual improvement by implementing the ISO 14001 standard. The study found that there is a significant and positive relationship between Lean Principles: value, value stream, flow, pull and perfection with the ISO 14001 requirements. LEMIS is significant to support the continuous improvement and sustainability. The integration system can be implemented to any manufacturing company. It gives awareness on the importance on why organizations need to sustain its Environmental management system. At the meanwhile, the lean principle can be adapted in order to streamline daily activities of the company. Throughout the study, it had proven that there is no sacrifice or trade-off between lean principles with ISO 14001 requirements. The framework developed in the study can be further simplified in the future, especially the method of crossing each sub requirements of ISO 14001 standard with the core elements of Lean principles in this study.

Keywords: LEMIS, ISO 14001, integration, framework

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Authors: Chia-Yi Wu, Jung-Chen Chang, Wen-Yu Hu, Ming-Been Lee

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In nearly all physical health conditions, suicide risk is increased compared to healthy people even after adjustment for age, gender, mental health, and substance use diagnoses. In order to highlight the importance of suicide risk assessment for the inpatients and early identification and engagement for inpatients’ mental health problems, a study was designed aiming at developing a comprehensive psychosomatic nursing engagement (PSNE) model with standardized operation procedures informing how nurses communicate, assess, and engage with the inpatients with emotional distress. The purpose of the study was to promote the gatekeeping role of clinical nurses in performing brief assessment and interventions to detect depression and anxiety symptoms among the inpatients, particularly in non-psychiatric wards. The study will be carried out in a 2000-bed university hospital in Northern Taiwan in 2019. We will select a ward for trial and develop feasible procedures and in-job training course for the nurses to offer mental health care, which will also be validated through professional consensus meeting. The significance of the study includes the following three points: (1) The study targets at an important but less-researched area of PSNE model in the cultural background of Taiwan, where hospital service is highly accessible, but mental health and suicide risk assessment are hardly provided by non-psychiatric healthcare personnel. (2) The issue of PSNE could be efficient and cost-effective in the identification of suicide risks at an early stage to prevent inpatient suicide or to reduce future suicide risk by early treatment of mental illnesses among the high-risk group of hospitalized patients who are more than three-times lethal to suicide. (3) Utilizing a brief tool with its established APP ('The Five-item Brief Symptom Rating Scale, BSRS-5'), we will invent the standardized procedure of PSNE and referral steps in collaboration with the medical teams across the study hospital. New technological tools nested within nursing assessment/intervention will concurrently be invented to facilitate better care quality. The major outcome measurements will include tools for early identification of common mental distress and suicide risks, i.e., the BSRS-5, revised BSRS-5, and the 9-item Concise Mental Health Checklist (CMHC-9). The main purpose of using the CMHC-9 in clinical suicide risk assessment is mainly to provide care and build-up therapeutic relationship with the client, so it will also be used to nursing training highlighting the skills of supportive care. Through early identification of the inpatients’ depressive symptoms or other mental health care needs such as insomnia, anxiety, or suicide risk, the majority of the nursing clinicians would be able to engage in critical interventions that alleviate the inpatients’ suffering from mental health problems, given a feasible nursing input.

Keywords: mental health care, clinical outcome improvement, clinical nurses, suicide prevention, psychosomatic nursing

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Authors: Suresh Lokiah

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The emerging trend of integrating robots into elderly care, particularly for assisting patients with dementia, holds the potential to greatly transform the sector. Assisted living facilities, which house a significant number of elderly individuals and dementia patients, constantly strive to engage their residents in stimulating activities. However, due to staffing shortages, they often rely on volunteers to introduce new activities. Despite the availability of social interaction, these residents, frequently overlooked in society, are in desperate need of additional support. Robots designed for elder care are categorized based on their design and functionality. These categories include companion robots, telepresence robots, health monitoring robots, and rehab robots. However, the integration of such robots raises significant ethical concerns, notably regarding privacy, autonomy, and the risk of dehumanization. Privacy issues arise as these robots may need to continually monitor patient activities. There is also a risk of patients becoming overly dependent on these robots, potentially undermining their autonomy. Furthermore, the replacement of human touch with robotic interaction may lead to the dehumanization of care. This paper delves into the ethical considerations of incorporating robotic assistance in eldercare. It proposes a series of guidelines and strategies to ensure the ethical deployment of these robots. These guidelines suggest involving patients in the design and development process of the robots and emphasize the critical need for human oversight to respect the dignity and rights of the elderly and dementia patients. The paper also recommends implementing robust privacy measures, including secure data transmission and data anonymization. In conclusion, this paper offers a thorough examination of the ethical implications of using robotic assistance in elder care. It provides a strategic roadmap to ensure this technology is utilized ethically, thereby maximizing its potential benefits and minimizing any potential harm.

Keywords: human-robot interaction, robots for eldercare, ethics, health, dementia

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Authors: T. Mcgraw, F. N. Morin, N. Desai

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Background: Antimicrobial resistance is a critical issue in global health care and a significant contributor to increased patient morbidity and mortality. Suspected urinary tract infection (UTI) is a key area of inappropriate antibiotic prescription in pediatrics. Management patterns of infectious diseases have been shown to vary by provider type within a single setting. The aim of this study was to assess compliance with national UTI management guidelines by nurse practitioners in a pediatric emergency department (ED). Methods: This was a post-hoc analysis of a retrospective cohort study to review and evaluate visits to a tertiary care freestanding pediatric emergency department. Patients were included if they were 60 days to 36 months old and discharged with a diagnosis of UTI or ‘rule-out UTI’ between July 2015 and July 2020. Primary outcome measure was proportion of visits seen by Nurse Practitioners (NP) which were associated with national guideline compliance in the diagnosis and treatment of suspected UTI. We performed descriptive statistics and comparative analyses to determine differences in practice patterns between NPs, and physicians. Results: A total of 636 charts were reviewed, of which 402 patients met inclusion criteria. 17 patients were treated by NPs, 385 were treated by either Pediatric Emergency Medicine physicians (PEM) or non-PEM physicians. Overall, the proportion of infants receiving guideline-compliant care was 25.9% (21.8-30.4%). Of those who were prescribed antibiotics, 79.6% (74.7-83.8%) received first line guideline recommended therapy and 58.9% (53.8-63.8%) received fully compliant therapy with respect to age, dose, duration, and frequency. In patients treated by NPs, 16/17 (94%(95% CI:73.0-99.0)) required antibiotics, 15/16 (93%(95% CI: 71.7-98.9)) were treated with first line agent (cephalexin), 8/16 (50%(95% CI:28-72)) were guideline compliant of dose and duration. 5/8 (63%(95% CI:30.6-86.3)) were noncompliant for dose being too high. There was no difference in receiving guideline compliant empiric antibiotic therapy between physicians and nurse practitioners (OR: 0.837 CI: 0.302-2.69). Conclusion: In this post-hoc analysis, guideline noncompliance by nurse practitioners is common in children tested and treated for UTIs in a pediatric emergency department. Care by a Nurse Practitioner was not associated with greater rate of noncompliance than care by a Pediatric Emergency Medicine physician. Future appropriately powered studies may focus on confirming these results.

Keywords: antibiotic stewardship, infectious disease, nurse practitioner, urinary tract infection

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Authors: Heikki Valmu, Eero Kupila, Raisa Vartia

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A major curricular reform was implemented in Metropolia UAS in 2014. The teaching was to be based on larger course entities and collaborative pedagogy. The most thorough reform was conducted in the department of electrical engineering and automation technology. It has been already shown that the reform has been extremely successful with respect to student progression and drop-out rate. The improvement of the results has been much more significant in this department compared to the other engineering departments making only minor pedagogical changes. In the beginning of the spring term of 2017, a thorough student feedback project was conducted in the department. The study consisted of thirty questions about the implementation of the curriculum, the student workload and other matters related to student satisfaction. The reply rate was more than 40%. The students were divided to four different categories: first year students [cat.1] and students of all the three different majors [categories 2-4]. These categories were found valid since all the students have the same course structure in the first two semesters after which they may freely select the major. All staff members are divided into four teams respectively. The curriculum consists of consecutive 15 credit (ECTS) courses each taught by a group of teachers (3-5). There are to be no end exams and continuous assessment is to be employed. In 2014 the different teacher groups were encouraged to employ innovatively different assessment methods within the given specs. One of these methods has been since used in categories 1 and 2. These students have to complete a number of compulsory tasks each week to pass the course and the actual grade is defined by a smaller number of tests throughout the course. The tasks vary from homework assignments, reports and laboratory exercises to larger projects and the actual smaller tests are usually organized during the regular lecture hours. The teachers of the other two majors have been pedagogically more conservative. The student progression has been better in categories 1 and 2 compared to categories 3 and 4. One of the main goals of this survey was to analyze the reasons for the difference and the assessment methods in detail besides the general student satisfaction. The results show that in the categories following more strictly the specified assessment model much more versatile assessment methods are used and the basic spirit of the new pedagogy is followed. Also, the student satisfaction is significantly better in categories 1 and 2. It may be clearly stated that continuous assessment and teacher cooperation improve the learning outcomes, student progression as well as student satisfaction. Too much academic freedom seems to lead to worse results [cat 3 and 4]. A standardized assessment model is launched for all students in autumn 2017. This model is different from the one used so far in categories 1 and 2 allowing more flexibility to teacher groups, but it will force all the teacher groups to follow the general rules in order to improve the results and the student satisfaction further.

Keywords: continuous assessment, course integration, curricular reform, student feedback

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Authors: Gehan Hussein, Hams Ahmad, Baher Matta, Yasmeen Mansi, Mohamad Fawzi

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Background: Congenital heart disease (CHD) is a common problem worldwide with variable incidence in different countries. The exact etiology is unknown, suggested to be multifactorial. We aimed to study the incidence of various CHD in a neonatal intensive care unit (NICU) in a tertiary care hospital in Egypt and the possible associations with variable risk factors. Methods: Prospective study was conducted over a period of one year (2013 /2014) at NICU KasrAlAini School of Medicine, Cairo University. Questionnaire about possible maternal and/or paternal risk factors for CHD, clinical examination, bedside echocardiography were done. Cases were classified into groups: group 1 without CHD and group 2 with CHD. Results: from 723 neonates admitted to NICU, 180 cases were proved to have CHD, 58 % of them were males. patent ductus arteriosus(PDA) was the most common CHD (70%), followed by an atrial septal defect (ASD8%), while Fallot tetralogy and single ventricle were the least common (0.45 %) for each. CHD was found in 30 % of consanguineous parents Maternal age ≥ 35 years at the time of conception was associated with increased incidence of PDA (p= 0.45 %). Maternal diabetes and insulin intake were significantly associated with cases of CHD (p=0.02 &0.001 respectively), maternal hypertension and hypothyroidism were both associated with VSD, but the difference did not reach statistical significance (P=0.36 &0.44respectively). Maternal passive smoking was significantly associated with PDA (p=0.03). Conclusion: The most frequent CHD in the studied population was PDA, followed by ASD. Maternal conditions as diabetes was associated with VSD occurrence.

Keywords: NICU, risk factors, congenital heart disease, echocardiography

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Authors: Peninah Agaba, Monica Magadi, Bev Orton

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Uganda is one of the countries with high maternal mortality (336/100,000) where adolescents account for 24 percent of the total maternal deaths. Research shows that use of maternal health services may prevent some of these deaths and good provider attitudes attract adolescents to use the services. However, poor health provider’s attitudes discourage adolescents from seeking the services during the maternity period. This study explores the experiences of unmarried female adolescents at the health facilities during the maternity period. The study population is unmarried adolescent girls aged 10-19 years who were pregnant or had given birth within three years before the interview. This is a special interest group that requires attention throughout this period. Most of the pregnancies among unmarried adolescents are unwanted; as a result, many of them have been abused and neglected by parents and close family members including partners who deny fatherhood of the pregnancy/child. These adolescents hope to find comfort from health providers like being listened to during counseling, not abused and judged; unfortunately this is not the case always. The research was approved by the University of Hull, School of Education and Social Sciences ethics review committee, Mildmay Uganda Research Ethics Committee and Uganda National Council of Science and Technology. The study was carried out in Bushenyi and Kibale districts in Western Uganda. Fourteen in-depth interviews and seven focus group discussions were completed in the local languages and later transcribed to English language. Thematic analysis to identify the themes was done. Adolescents were aged 16-19 years, two had become pregnant before 15 years. Most had not completed secondary education; none had tertiary education and three of the 14 IDI adolescent participants wanted to get pregnant. Analysis shows varied experiences; most adolescents were abused verbally and physically by the health providers due to their young age of pregnancy, lack of essential items during this period (maternity dresses, children clothes, delivery kit) and fear of labour pains. Another cause for abuse was these adolescents coming for antenatal care with no partners yet the implementation of a policy on increasing male involvement in reproductive health in Uganda requires them to attend antenatal care with their partners and most of these unmarried adolescents have no partners to accompany them. Despite the above challenges, the study also identified the care some of these unmarried adolescents received during the maternity visits for example they were not abused, were provided with appropriate information and supported with child care. The study identified abuse and support the unmarried adolescents received during the maternity period. Efforts to provide adolescents with adequate information including what to expect during labour by providers and provision of basic needs are essential. Health providers should have trainings on client care especially how to embrace unmarried adolescents when they come to access maternity services. More so, the policy on improving male involvement in RH issues need to be considerate of unmarried adolescents who in most cases do not have the partners to go with to access maternity care.

Keywords: abuse, maternity care, Uganda, unmarried, adolescents

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Authors: J. M. Muñoz, Y. Vasquez, P. Oyola, M. Rubio

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All emissions of contaminants inside of homes, offices, school and another enclosure closer that affect the health of those who inhabit or use them are cataloged how indoor pollution. The importance of this study is because individuals spend most of their time in indoors ambient. The main indoor pollutants are oxides of nitrogen (NOₓ), sulfur dioxide (SO₂), carbon monoxide (CO) and particulate matter (PM). Combustion heaters are an important source of pollution indoors. It will be measured: NOₓ, SO₂, CO, PM₂,₅ y PM₁₀ continuous and discreet form at indoor and outdoor of two households with different heating energy; kerosene and electricity (control home) respectively, in addition to environmental parameters such as temperature. With the values obtained in the 'control home' it will be possible estimate the contaminants transport from outside to inside of the household and later the contribution generated by kerosene heating. Transporting the emissions from burning kerosene to a photochemical chamber coupled to a continuous and discreet measuring system of contaminants it will be evaluated the oxidation of the emissions and formation of secondary particulate matter. It will be expected watch a contaminants transport from outside to inside of the household and the kerosene emissions present a high potential of formation secondary particulate matter.

Keywords: heating, indoor pollution, kerosene, secondary particulate matter

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Authors: Pablo González Álvarez, Anna Vinaixa Vergés, Paula Sol Ventura, Paula Fernández, Mercè Redorta, Gemma Ginovart Galiana, Maria Méndez Hernández

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Context: The use of music therapy is gaining popularity worldwide, and it has shown positive effects in neonatology. Hospital Germans Trias i Pujol has recently established a music therapy unit and initiated a project in their neonatal intensive care unit (NICU). Research Aim: The aim of this study is to measure the effect of a music therapy intervention in the NICU of Hospital Germans Trias i Pujol in Spain. Methodology: The study will be an observational analytical case-control study. All newborns admitted to the neonatology unit, both term and preterm, and their parents will be offered a session of music therapy. Data will be collected from families who receive at least two music therapy sessions. Maternal and paternal anxiety levels will be measured through a pre- and post-intervention test. Findings: The study aims to demonstrate the benefits and acceptance of music therapy by patients, parents, and healthcare workers in the neonatal unit. The findings are expected to show a reduction in maternal and paternal anxiety levels following the music therapy sessions. Theoretical Importance: This study contributes to the growing body of literature on the effectiveness of music therapy in neonatal care. It will provide evidence of the acceptance and potential benefits of music therapy in reducing anxiety levels in both parents and babies in the NICU setting. Data Collection: Data will be collected from families who receive at least two music therapy sessions. This will include pre- and post-intervention test results to measure anxiety levels. Analysis Procedures: The collected data will be analyzed using appropriate statistical methods to determine the impact of music therapy on reducing anxiety levels in parents. Questions Addressed: - What is the effect of music therapy on maternal anxiety levels? - What is the effect of music therapy on paternal anxiety levels? - What is the acceptability and perceived benefits of music therapy among patients and healthcare workers in the NICU? Conclusion: The study aims to provide evidence supporting the value of music therapy in the neonatal intensive care unit. It seeks to demonstrate the positive effect of music therapy on reducing anxiety levels among parents.

Keywords: neonatology, music therapy, neonatal intensive care unit, babies, parents

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Authors: Nam-Phuong T. Hoang, Divna Haslam, Matthew Sanders

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Parenting psychological control (PPC) is a parenting manner of which intrusive tactics such as guilt induction, shaming or love withdrawal is adopted to manipulate the child's behavior, emotion and beliefs. PPC has been widely reported to be associated with both psychological dysfunction and low self-esteem in adolescents. Highly demanding and restrictive parenting was also found to related to high rate of risk behaviors, depression, anxiety and anti-social behaviors in adults who co-live with their parents. In many cultures like that of Asia, adults keep on co-live with their parents even after having their own families, and this is not an uncommon practice. Due to the culture obligation of family relationship and the filial piety, children are expected to stay with their parents to taking care of them when they get older, and the parents are also expected to co-live with their children in order to support them with grandchild care. As one become a grandparent, however, it does not means one stop being the parent to their own child. The effect of PPC if exist thus might continue to interfere one’s relationship with their adult children and also their adult child’s parenting. This study was designed to examine that effect of PPC on adults’ life as parents. Data was collected from 501 Vietnamese parents whose children between the age of 2 to 12 and having their parent living with them or taking care of the grandchild on daily basic. Findings show that grandparent psychological control (GPPC) is significantly associated with parent’s harsh parenting, parent’s well-being, and parent-grandparent coparenting relationship. Significantly, GPPC is the strongest predictor for the coparenting conflict between parent and grandparent.

Keywords: parenting psychological control, grandparent, coparenting, well-being

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Authors: E. Njuguna, S. Ilovi, P. Muiruri, K. Mutai, J. Kinuthia, P. Njoroge

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Introduction: Cervical cancer is the commonest cause of cancer-related morbidity and mortality among women in developing countries in Sub Saharan Africa. Screening for cervical cancer in all women regardless of HIV status is crucial for the early detection of cancer of the cervix when treatment is most effective in curing the disease. It is particularly more important to screen HIV infected women as they are more at risk of developing the disease and progressing faster once infected with HPV (Human Papilloma Virus). We aimed to determine the factors affecting the utilization of cervical cancer screenings among HIV infected women above 18 years of age at Kenyatta National Hospital (KNH) Comprehensive Care Center (CCC). Materials and Methods: A cross-sectional mixed quantitative and qualitative study involving randomly and purposefully selected HIV positive female respectively was conducted. Qualitative data collection involved 4 focus group discussions of eligible female participants while quantitative data were acquired by one to one interviewer administered structured questionnaires. The outcome variable was the utilization of cervical cancer screening. Data were entered into Access data base and analyzed using Stata version 11.1. Qualitative data were analyzed after coding for significant clauses and transcribing to determine themes arising. Results: We enrolled a total of 387 patients, mean age (IQ range) 40 years (36-44). Cervical cancer screening utilization was 46% despite a health care provider recommendation of 85%. The screening results were reported as normal in 72 of 81 (88.9%) and abnormal 7 of 81(8.6%) of the cases. Those who did not know their result were 2 of 81(2.5%). Patients were less likely to utilize the service with increasing number of years attending the clinic (OR 0.9, 95% CI 0.86-0.99, p-value 0.02), but more likely to utilize the service if recommendation by a staff was made (OR 10, 95% CI 4.2-23.9, p<0.001), and if cervical screening had been done before joining KNH CCC (OR 2.9, 95% CI 1.7-4.9, p < 0.001). Similarly, they were more likely to rate the services on cervical cancer screening as good (OR 5.0, 95% CI 1.7-3.4, p <0.001) and very good (OR 8.1, 95% CI 2.5-6.1, p<0.001) if they had utilized the service. The main barrier themes emerging from qualitative data included fear of screening due to excessive pain or bleeding, lack of proper communication on screening procedures and increased waiting time. Conclusions: Utilization of cervical cancer screening services was low despite health care recommendation. Patient socio-demographic characteristics did not influence whether or not they utilized the services, indicating the important role of the health care provider in the referral and provision of the service.

Keywords: cervical, cancer, HIV, women, comprehensive care center

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Authors: Sweta Das

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This case report highlights the atypical clinical manifestation of ipsilateral head, neck, shoulder, and eye pain with erythema and edema of right eyelid and conjunctiva, along with typical presentation of right sided Horner’s syndrome in a 37-year-old female, who was correctly diagnosed with Wallenberg syndrome due to collaborative effort from optometry, primary care, emergency, and neurology specialties in medicine. Horner’s syndrome is present in 75% of patients with Wallenberg syndrome. Given that patients with Wallenberg syndrome often first present to the Emergency Department with a vast variety of non-specific symptoms, and a normal MRI, a delayed diagnosis is common. Therefore, a collaborative effort between emergency department, optometry, primary care, and neurology is essential in correctly diagnosing Wallenberg’s syndrome in a timely manner.

Keywords: horner's syndrome, stroke, wallenberg syndrome, lateropulsion of eyes

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Authors: J. M. Cruz, X. Vecıno, L. Rodrıguez-López, J. M. Dominguez, A. B. Moldes

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The cosmetic and personal care industry are the fields where biosurfactants could have more possibilities of success because in this kind of products the replacement of synthetic detergents by natural surfactants will provide an additional added value to the product, at the same time that the harmful effects produced by some synthetic surfactants could be avoided or reduced. Therefore, nowadays, consumers are disposed to pay and additional cost if they obtain more natural products. In this work we provide data about the potential of biosurfactants in the cosmetic and personal care industry. Biosurfactants from corn steep liquor, that is a fermented and condensed stream, have showed good surface-active properties, reducing substantially the surface tension of water. The bacteria that usually growth in corn steep liquor comprises Lactobacillus species, generally recognize as safe. The biosurfactant extracted from CSL consists of a lipopeptide, composed by fatty acids, which can reduce the surface tension of water in more than 30 units. It is a yellow and viscous liquid with a density of 1.053 mg/mL and pH=4. By these properties, they could be introduced in the formulation of cosmetic creams, hair conditioners or shampoos. Moreover this biosurfactant extracted from corn steep liquor, have showed a potent antimicrobial effect on different strains of Streptococcus. Some species of Streptococcus are commonly found weakly living in the human respiratory and genitourinary systems, producing several diseases in humans, including skin diseases. For instance, Streptococcus pyogenes produces many toxins and enzymes that help to stabilize skin infections; probably biosurfactants from corn steep liquor can inhibit the mechanisms of the S. pyogenes enzymes. S. pyogenes is an important cause of pharyngitis, impetigo, cellulitis and necrotizing fasciitis. In this work it was observed that 50 mg/L of biosurfactant extract obtained from corn steep liquor is able to inhibit more than 50% the growth of S. pyogenes. Thus, cosmetic and personal care products, formulated with biosurfactants from corn steep liquor, could have prebiotic properties. The natural biosurfactant presented in this work and obtained from corn milling industry streams, have showed a high potential to provide an interesting and sustainable alternative to those, antibacterial and surfactant ingredients used in cosmetic and personal care manufacture, obtained by chemical synthesis, which can cause irritation, and often only show short time effects.

Keywords: antimicrobial activity, biosurfactants, cosmetic, personal care

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Authors: Oluwaseun Adeleke, Samuel O. Ikani, Fidelis Edet, Anthony Nwala, Mopelola Raji, Simeon Christian Chukwu

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Introduction: Digital innovations have been useful in supporting a client’s contraceptive user journey from awareness to method initiation. The concept of contraceptive self-care is being promoted globally as a means for achieving universal access to quality contraceptive care; however, information about this approach is limited. An important determinant of the scale of awareness is the message construct, choice of information channel, and an understanding of the socio-epidemiological dynamics within the target audience. Significant gains have been made recently in expanding the awareness base of DMPA-SC -a relatively new entrant into the family planning method mix. The cornerstone of this success is a multichannel promotion campaign themed Discover your Power (DYP). The DYP campaign combines content marketing across select social media platforms, chatbots, Cyber-IPC, Interactive Voice Response (IVR), and radio campaigns. Methodology: During implementation, the project monitored predefined metrics of awareness and intent, such as the number of persons reached with the messages, the number of impressions, and meaningful engagement (link-clicks). Metrics/indicators are extracted through native insight/analytics tools across the various platforms. The project also enlists community mobilizers (CMs) who go door-to-door and engage WRA to advertise DISC’s online presence and support them to engage with IVR, digital companion (chatbot), Facebook page, and DiscoverYourPower website. Results: The result showed that the digital platforms recorded 242 million impressions and reached 82 million users with key DMPA-SC self-injection messaging in the three countries. As many as 3.4 million persons engaged (liked, clicked, shared, or reposted) digital posts -an indication of intention. Conclusion: Digital solutions and innovations are gradually becoming the archetype for the advancement of the self-care agenda. Digital innovations can also be used to increase awareness and normalize contraceptive self-care behavior amongst women of reproductive age if they are made an integral part of reproductive health programming.

Keywords: digital transformation, health systems, DMPA-SC, family planning, self-care

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Authors: Cinzia Valente

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Over the last few years, national legislators have been forced to deal with social changes that have had important repercussions in family law and children’s law. This growing focus on minors has provoked important reforms, specifically on issues relating to the welfare and protection of children. My presentation focuses on the issue of migrant children in particular I refer to unaccompanied children, or ‘children on the move’, or separate children or any other term defining migrant minors who cross national borders seeking protection or better opportunities. They arrive often illegally, on the European territory without a responsible adult who take care of them. There is a common assumption that migrants are running away from conflicts, poverty and human rights abuse and they arrive in a foreign country hoping a better life; children without persons who takes care of them encounter some difficulties in their integration in the host country. The migration flows recorded in recent decades towards EU countries, and Italy in particular, have imposed an intense pressure to modernize institutions, services and specific legal frameworks, with the aim of responding adequately to the needs of foreign individuals, as well as ensuring a good level of living standards and facilitating integration, especially for migrant children. The object of my paper is the analysis of the Italian rules, practices and services existing in favor of unaccompanied children (foster care, reunification, acquisition of citizenship and other) in comparison with other European legal systems on the same thematic with a comparative method. Highlighting European standards to find common principles for the best solution to children's problems is the conclusive aim of my presentation.

Keywords: Children , Family Law, Migration , Uniform Law

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Authors: Sathvika Reddy, Devi Revathi

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Background: In India, deliberate self-harm (DSH) with poisoning agents carries a significant impact on morbidity and mortality. Changes in the patterns of poisoning vary across various geographical locations. It is important to know the patterns in a given region in order to facilitate rapid clinical diagnosis, appropriate treatment to reduce associated morbidity and mortality. Aim and Objective: To study the patterns, treatment outcomes of acute poisoning in patients admitted to emergency wards in a tertiary care hospital and to provide poison information services. Materials and Methods: This study was conducted at M.S Ramaiah Memorial and Teaching Hospital from November 2016 to March 2017. The patient’s data was obtained from patient case sheet, interaction with health care professionals, interviewing patients and their caretakers (if possible), and were documented in a suitably designed form. Results: The study involved 131 patients with a mean age of 27.76 ± 15.5 years. Majority of the patients were in the age group 21-30 years, literates (n=53) dwelling in urban (n=113) areas belonging to upper middle class (n=50). Analgesics and antipyretics were commonly utilized in intentional drug overdosage (n=49). Envenomation constituted n=21(16.03%). Furthermore, a significant relationship was observed between marital status and self-poisoning (n=64) (P < 0.001) which commonly occurred through oral ingestion. The outcomes were correlated with the GCS and PSS system and n=85 recovered, n=17 were discharged against medical advice, and n=4 died, and n=4 were lost to follow up respectively. The poison information queries include drug overdose (n=29) and management related queries (n=22) provided majorly by residents (n=45) to update knowledge (n=11) and for better patient care (n=40). Conclusion: The trend in poisoning is dynamic. Medications were identified as the main cause of poisoning in urban areas of India. Educational programs with more emphasis on preventive measures are necessary to create awareness among the general public.

Keywords: poisoning, suicides, clinical pharmacist, envenomation, poison information services

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Authors: Nouf Al Harthi

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Venous thromboembolism (VTE) is one of the most common causes of hospital-related deaths in critically ill patients. Guidelines recommended VTE prophylaxis with standardized, fixed doses for most patients. The underweight population has limited data to guide the appropriate drug and dosing regimen. The aim of this study was to describe the pattern of VTE prophylaxis dose regimens for underweighted critically ill adult patients and the prevalence of associated VTE and bleeding. This study is a retrospective cohort study, conducted in King Abdulaziz Medical City, Saudi Arabia. It included all critical patients admitted to the intensive care units and were above 14 years old with weight less than 50 kg or BMI of 18.5 kg/m2 or less and were on heparin as VTE prophylaxis for more than 72 hours from January 2016 until January 2020. After screening 270 patients, only 40 patients were included in this study according to our inclusion and exclusion criteria. Only 6 patients (15%) received VTE prophylaxis as an adjusted dose of heparin 2500 U Q12, while the rest of the patients were taking standard dosing of heparin, 5000 U Q12 was given to 21 (52.50%) patients and 5000 U Q8 was given to 13 (32.50%) patients. None of the adjusted doses developed any complications such as VTE or bleeding. There was no significant difference compared with the standard dose group. This study focused on describing the pattern of heparin doses as VTE prophylaxis in underweight patients. We also compared the standard dosing and adjusted dosage of VTE prophylaxis on underweight patients and any complications. There was no significant difference in the complication’s outcome or benefits between the two groups.

Keywords: venous thromboembolism prophylaxis, heparin, underweight patients, adult, critical care units

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Authors: M. Kamimukai, M. Bhattarai, B. B. Rana, K. Maeda, H. B. Kc, T. Kawano, M. Murai

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Most of the aged people older than 70 have difficulty in chewing and swallowing more or less. According to magnitude of this difficulty, gruel, “nanhan” (semi-soft rice) and ordinary cooked rice are served in general, particularly in sanatoriums and homes for old people in Japan. Nanhan is the name of a cooked rice used in Japan, having softness intermediate between gruel and ordinary cooked rice, which is boiled with intermediate amount of water between those of the latter two kinds of cooked rice. In the present study, nanhan was made in the rate of 240g of water to 100g of milled rice with an electric rice cooker. Murai developed a high amylose-content and high-yielding elite line ‘Murai 79’. Sensory eating-quality test was performed for nanhan and ordinary cooked rice of Murai 79 and the standard variety ‘Hinohikari’ which is a high eating-quality variety representative in southern Japan. Panelists (6 to 14 persons) scored each cooked rice in six items viz. taste, stickiness, hardness, flavor, external appearance and overall evaluation. Grading (-3 ~ +3) in each trait was performed, regarding the value of the standard variety Hinohikari as 0. Paddy rice produced in a farmer’s field in 2013 and 2014 and in an experimental field of Kochi University in 2015 and 2016 were used for the sensory test. According to results of the sensory eating-quality test for nanhan, Murai 79 is higher in overall evaluation than Hinohikari in the four years. The former was less sticky than the latter in the four years, but the former was statistically significantly harder than the latter throughout the four years. In external appearance, the former was significantly higher than the latter in the four years. In the taste, the former was significantly higher than the latter in 2014, but significant difference was not noticed between them in the other three years. There were no significant differences throughout the four years in flavor. Regarding amylose content, Murai 79 is higher by 3.7 and 5.7% than Hinohikari in 2015 and 2016, respectively. As for protein content, Murai 79 was higher than Hinohikari in 2015, but the former was lower than the latter in 2016. Consequently, the nanhan of Murai 79 was harder and less sticky, keeping the shape of grains as compared with that of Hinohikari, which may be due to its higher amylose content. Hence, the nanhan of Murai 79 may be recognized as grains more easily in a human mouth, which could make easier the continuous performance of mastication and deglutition particularly in aged persons. Regarding ordinary cooked rice, Murai 79 was similar to or higher in both overall evaluation and external appearance as compared with Hinohikari, despite its higher hardness and lower stickiness. Additionally, Murai 79 had brown-rice yield of 1.55 times as compared with Hinohikari, suggesting that it would enable to supply inexpensive rice for making nanhan with high quality particularly for aged people in Japan.

Keywords: high-amylose content, high-yielding rice line, nanhan, nursing care food, sensory eating quality test

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Authors: N. Varsamis, M. Gerasimou, P. Christodoulou, S. Mantzoukis, G. Kolliopoulou, N. Zotos

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Purpose: Body fluids (pleural, peritoneal, synovial, pericardial, cerebrospinal) are an important element in the detection of microorganisms. For this reason, it is important to examine them in the Intensive Care Unit (ICU) patients. Material and Method: Body fluids are transported through sterile containers and enriched as soon as possible with Tryptic Soy Broth (TSB). After one day of incubation, the broth is poured into selective media: Blood, Mac Conkey No. 2, Chocolate, Mueller Hinton, Chapman and Saboureaud agar. The above selective media are incubated directly for 2 days. After this period, if any number of microbial colonies are detected, gram staining is performed. After that, the isolated organisms are identified by biochemical techniques in the automated Microscan system (Siemens) and followed by a sensitivity test on the same system using the minimum inhibitory concentration MIC technique. The sensitivity test is verified by Kirby Bauer-based plate test. Results: In 2017 the Laboratory of Microbiology received 60 samples of body fluids from the ICU. More specifically the Microbiology Department received 6 peritoneal fluid specimens, 18 pleural fluid specimens and 36 cerebrospinal fluid specimens. 36 positive cultures were tested. S. epidermidis was identified in 18 specimens, S. haemolyticus in 6, and E. faecium in 12. Conclusions: The results show low detection of microorganisms in body fluid cultures.

Keywords: body fluids, culture, intensive care unit, microorganisms

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Authors: Franklin Chu Buh, Irene Ule Ngole Sumbele, Andrew I. R. Maas, Mathieu Motah, Jogi V. Pattisapu, Eric Youm, Basil Kum Meh, Firas H. Kobeissy, Kevin W. Wang, Peter J. A. Hutchinson, Germain Sotoing Taiwe

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Introduction: Studying TBI characteristics and their relation to outcomes can identify initiatives to improve TBI prevention and care. The objective of this study was to define the features and outcomes of TBI patients seen over a 1-year period in a level-I trauma center in Cameroon. Methods: Data on demographics, causes, injury mechanisms, clinical aspects, and discharge status were prospectively collected over a period of 12 months. The Glasgow Outcome Scale-Extended (GOSE) and the Quality of Life Questionnaire after Brain Injury (QoLIBRI) were used to evaluate outcomes 6-months after TBI. Categorical variables were described as frequencies and percentages. Comparisons between 2 categorical variables were done using Pearson's Chi-square test or Fisher's exact test. Results: A total of 160 TBI patients participated in the study. The age group 15-45 years (78%; 125) was most represented. Males were more affected (90%; 144). Low educational level was recorded in 122 (76%) cases. Road traffic incidents (RTI) were the main cause of TBI (85%), with professional bike riders being frequently involved (27%, 43/160). Assaults (7.5%) and falls (2.5%) represent the second and third most common causes of TBI in Cameroon, respectively. Only 15 patients were transported to the hospital by ambulance, and 14 of these were from a referring hospital. CT-imaging was performed in 78% (125/160) of cases intracranial traumatic abnormality was identified in 77/125 (64%) cases. Financial constraints were the main reason for not performing a CT scan on 35 patients. A total of 46 (33%) patients were discharged against medical advice (DAMA) due to financial constraints. Mortality was 14% (22/160) but disproportionately high in patients with severe TBI (46%). DAMA had poor outcomes with QoLIBRI. Only 4 patients received post-injury physiotherapy services. Conclusion: TBI in Cameroon mainly results from RTIs and commonly affects young adult males, and low educational or socioeconomic status and commercial bike riding appear to be predisposing factors. Lack of pre-hospital care, financial constraints limiting both CT-scanning and medical care, and lack of acute physiotherapy services likely influenced care and outcomes adversely.

Keywords: characteristics, traumatic brain injury, outcome, disparities in care, prospective study

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Authors: Marta Fernández Batalla, José María Santamaría García, Maria Lourdes Jiménez Rodríguez, Roberto Barchino Plata, Adriana Cercas Duque, Enrique Monsalvo San Macario

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Background: Primary Care Nursing is taking more autonomy in clinical decisions. One of the most frequent therapies to solve is related to the problems of maintaining a sufficient supply of food. Nursing diagnoses related to food are addressed by the nurse-family and community as the first responsible. Objectives and interventions are set according to each patient. To improve the goal setting and the treatment of these care problems, a technological tool is developed to help nurses. Objective: To evaluate the computational tool developed to support the clinical decision in feeding problems. Material and methods: A cross-sectional descriptive study was carried out at the Meco Health Center, Madrid, Spain. The study population consisted of four specialist nurses in primary care. These nurses tested the tool on 30 people with ‘need for nutritional therapy’. Subsequently, the usability of the tool and the satisfaction of the professional were sought. Results: A simple and convenient computational tool is designed for use. It has 3 main entrance fields: age, size, sex. The tool returns the following information: BMI (Body Mass Index) and caloric consumed by the person. The next step is the caloric calculation depending on the activity. It is possible to propose a goal of BMI or weight to achieve. With this, the amount of calories to be consumed is proposed. After using the tool, it was determined that the tool calculated the BMI and calories correctly (in 100% of clinical cases). satisfaction on nutritional assessment was ‘satisfactory’ or ‘very satisfactory’, linked to the speed of operations. As a point of improvement, the options of ‘stress factor’ linked to weekly physical activity. Conclusion: Based on the results, it is clear that the computational tools of decision support are useful in the clinic. Nurses are not only consumers of computational tools, but can develop their own tools. These technological solutions improve the effectiveness of nutrition assessment and intervention. We are currently working on improvements such as the calculation of protein percentages as a function of protein percentages as a function of stress parameters.

Keywords: feeding behavior health, nutrition therapy, primary care nursing, technology assessment

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Authors: Mourad Makhlouf Sabrina Bouriche, Zoubir Benmaamar, Didier Villemin

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Background: The increasing presence of electromagnetic interference (EMI) requires the development of effective protection solutions. Intelligent textiles offer a promising approach due to their wear ability and the possibility of integration into everyday clothing. In this study, the use of graphene and polyaniline for EMI shielding on cotton fabrics was examined. Methods: In this study, the continuous dyeing of recycled graphite-derived graphene and polyaniline was examined. Bottom-reforming technology was adopted to improve adhesion and achieve uniform distribution of conductive material on the fiber surface. The effect of material weight ratio on fabric performance and X-band EMI shielding effectiveness (SE) was evaluated. Significant Findings: The dyed cotton fabrics incorporating graphene, polyaniline, and their combination exhibited improved conductivity. Notably, these fabrics achieved EMI SE values ranging from 9 to 16 dB within the X-band frequency range (8-9 GHz). These findings demonstrate the potential of this approach for developing intelligent textiles with effective EMI shielding capabilities. Additionally, the utilization of recycled materials contributes to a more sustainable shielding solution.

Keywords: Intelligent textiles, graphene, polyaniline, electromagnetic shielding, conductivity, recycling

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Authors: Jefrey Pilusa, Tumisang Seodigeng

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This research discusses a South African case study for the potential of utilizing refuse-derived fuel (RDF) obtained from non-burn treatment of health care risk waste (HCRW) as potential feedstock for green energy production. This specific waste stream can be destroyed via non-burn treatment technology involving high-speed mechanical shredding followed by steam or chemical injection to disinfect the final product. The RDF obtained from this process is characterised by a low moisture, low ash, and high calorific value which means it can be potentially used as high-value solid fuel. Due to the raw feed of this RDF being classified as hazardous, the final RDF has been reported to be non-infectious and can blend with other combustible wastes such as rubber and plastic for waste to energy applications. This study evaluated non-burn treatment technology as a possible solution for on-site destruction of HCRW in South African private and public health care centres. Waste generation quantities were estimated based on the number of registered patient beds, theoretical bed occupancy. Time and motion study was conducted to evaluate the logistics viability of on-site treatment. Non-burn treatment technology for HCRW is a promising option for South Africa, and successful implementation of this method depends upon the initial capital investment, operational cost and environmental permitting of such technology; there are other influencing factors such as the size of the waste stream, product off-take price as well as product demand.

Keywords: autoclave, disposal, fuel, incineration, medical waste

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Authors: Kaous Samira

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The lack of hand hygiene can contribute to nosocomial infections, including Central-venous-catheter-related bloodstream infections (CRBSI). An investigation from severally hospitals examined the frequency of hand hygiene in an OR among perioperative staff members who did not perform a surgical scrub. Among 50 operations (120 hours) that were observed, only 2% of staff members performed hand hygiene practices upon entering the OR, and 8.4% of staff performed hand hygiene upon leaving the OR. In addition, when performing radial arterial catheter placement, 0% of staff members wore gloves. Another study (A1170) surveyed healthcare providers regarding hand hygiene compliance. All of the 107 providers surveyed agreed that they should maintain hand hygiene, and most respondents believed that their own compliance was high. The author suggests that the low compliance problem associated with hand hygiene worldwide is a behavioral one among healthcare providers that requires acknowledgment and change.

Keywords: aneshesia, investigation, IOP, SBP

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Authors: Sina Keyhanian, Abbas Ahmadi, Behrooz Karimi

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We present a multi-objective binary programming model which considers surgical cases are scheduling among operating rooms and the configuration of surgical instruments in limited capacity hospital trays, simultaneously. Many mathematical models have been developed previously in the literature addressing different challenges in health-care logistics such as assigning operating rooms, leveling beds, etc. But what happens inside the operating rooms along with the inventory management of required instruments for various operations, and also their integration with surgical scheduling have been poorly discussed. Our model considers the minimization of movements between trays during a surgery which recalls the famous cell formation problem in group technology. This assumption can also provide a major potential contribution to robotic surgeries. The tray configuration problem which consumes surgical instruments requirement plan (SIRP) and sequence of surgical procedures based on required instruments (SIRO) is nested inside the bin packing problem. This modeling approach helps us understand that most of the same-output solutions will not be necessarily identical when it comes to the rearrangement of surgeries among rooms. A numerical example has been dealt with via a proposed nested simulated annealing (SA) optimization approach which provides insights about how various configurations inside a solution can alter the optimal condition.

Keywords: health-care logistics, hospital tray configuration, off-line bin packing, simulated annealing optimization, surgical case scheduling

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Authors: Genevieve R. Kan, Jolyon Ford

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Background: Caesarean section has become the routine route of delivery for breech fetuses, but breech cesarean deliveries are hypothesized to have poorer immediate neonatal outcomes when compared to cephalic deliveries. In accordance with this, in many Australian hospitals, the pediatric team is routinely required to attend every elective breech cesarean section in case urgent resuscitation is required. Our study aimed to determine whether term elective breech deliveries indeed had worse immediate neonatal outcomes at delivery, which will justify the necessity of pediatric staff presence at every elective breech cesarean delivery and influence the workload for the pediatric team. Objective: Elective breech cesarean deliveries were compared to elective cephalic cesarean deliveries at 37 weeks gestation or above to evaluate the immediate neonatal outcomes (Apgar scores <7 at 5 minutes, and Special Care Nursery admissions on Day 1 of life) of each group. Design: A retrospective cohort study Method: This study examined 2035 elective breech and cephalic singleton cesarean deliveries at term over 5 years from July 2017 to July 2022 at Frankston Hospital, a metropolitan hospital in Melbourne, Australia. There were 260 breech deliveries and 1775 cephalic deliveries. De-identified patient data were collected retrospectively from the hospital’s electronically integrated pregnancy and birth records to assess demographics and neonatal outcomes. Results: Apgar scores <7 at 5 minutes of life were worse in the breech group compared to the cephalic group (3.4% vs 1.6%). Special Care Nursery admissions on Day 1 of life were also higher for the breech cohort compared to the cephalic cohort (9.6% vs 8.7%). Conclusions: Our results support the expected findings that breech deliveries are associated with worse immediate neonatal outcomes. It, therefore, suggests that routine attendance at elective breech cesarean deliveries by the pediatric team is indeed required to assist with potentially higher needs for neonatal resuscitation and special care nursery admission.

Keywords: breech, cesarean section, Apgar scores, special care nursery admission

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Authors: Anthony Townsend, Robyn Fasser

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While complete objectivity is a desirable scientific position from which to conduct a care and contact evaluation (CCE), it is precisely the recognition that we are inherently incapable of operating objectively that is the foundation of ethical practice and skilled assessment. Drawing upon recent research from Daniel Kahneman (2021) on the differences between noise and bias, as well as different inherent biases collectively termed “The Elephant in the Brain” by Kevin Simler and Robin Hanson (2019) from Oxford University, this presentation addresses both the various ways in which our judgments, perceptions and even procedures can be distorted and contaminated while conducting a CCE, but also considers the value of second order cybernetics and the psychodynamic concept of ‘ambivalence’ as a conceptual basis to inform our assessment methodologies to limit such errors or at least better identify them. Both a conceptual framework for ambivalence, our higher-order capacity to allow for the convergence and consideration of multiple emotional experiences and cognitive perceptions to inform our reasoning, and a practical methodology for assessment relying on data triangulation, Bayesian inference and hypothesis testing is presented as a means of promoting ethical practice for health care professionals conducting CCEs. An emphasis on widening awareness and perspective, limiting ‘splitting’, is demonstrated both in how this form of emotional processing plays out in alienating dynamics in families as well as the assessment thereof. In addressing this concept, this presentation aims to illuminate the value of ambivalence as foundational to ethical practice for assessors.

Keywords: ambivalence, forensic, psychology, noise, bias, ethics

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Authors: Saira Mehnaz, Ali Jafar Abedi, Shazia Farooq Fazli, Sakeena Mushfiq, Zulfia Khan, M. Athar Ansari

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Introduction: Public health spending is a necessity in an underdeveloped country like India. The people are already suffering from poverty and that clubbed with out of pocket expenditure leads them to a very catastrophic situation, reducing the overall access to healthcare. Objectives: This study was designed to determine the usual source of medical care opted, the illness pattern, the expenditure incurred on illness and its source of procurement by the study population. It also intended to assess this expenditure as a determinant of access to health care. Methodology: Cities like Aligarh, which are classified as B grade cities in India are thought to be ripe sites for getting livelihood and hence are almost half filled with migrants living in urban slums. A cross sectional study was done to study the newer slum pockets. 3409 households with a population of 16,978 were studied with the help of pretested questionnaire; SPSS 20 was used for statistical analysis. Results and Conclusions: In our study, we found that almost all the households suffered from catastrophic health expenditure. The study population, which was already vulnerable owing to their low socio-economic and migrant status was further being forced with into poverty and indebtedness on account of expenditure on illness. This lead to a significant decrease in access to health. National health financing systems should be designed to protect households from financial catastrophe, by reducing out-of-pocket spending.

Keywords: access to healthcare, catastrophic health expenditure, new urban slums, out of pocket expenditure

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Authors: Yuthapoom Thanakijborisut

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This paper studies consumption insurance against the chronic illness in Thailand. The study estimates the impact of household consumption in the chronic illness on consumption growth. Chronic illness is the health care costs of a person or a household’s decision in treatment for the long term; the causes and effects of the household’s ability for smooth consumption. The chronic illnesses are measured in health status when at least one member within the household faces the chronic illness. The data used is from the Household Social Economic Panel Survey conducted during 2007 and 2012. The survey collected data from approximately 6,000 households from every province, both inside and outside municipal areas in Thailand. The study estimates the change in household consumption by using an ordinary least squares (OLS) regression model. The result shows that the members within the household facing the chronic illness would reduce the consumption by around 4%. This case indicates that consumption insurance in Thailand is quite sufficient against chronic illness.

Keywords: consumption insurance, chronic illness, health care, Thailand

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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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