Secondary Health Care Level Research Articles

Cross-sectional study at the secondary health care level on Cardio-respiratory disease in three municipalities of Abidjan district hospitals with contrasted levels of air pollution

Background/Aim The human health effects for both particulate matter and gaseous contaminants are global public health concern. The objective of this study was to assess any variations of air pollution in contributions from waste burning, heavy motor vehicle traffic and biomass burning and the impact on health in Abidjan, with special attention to cardiorespiratory diseases, Methods A survey was conducted during two years in 5 hospitals, 3 months during the rainy and the dry season. We estimated air pollution levels simultaneously with health care assessment with a particular attention for cardio-respiratory diseases. PM2.5 concentration and cardiorespiratory diseases outcomes were recorded in a questionnaire sheet in the district hospitals. The relative Risks (RR) of the relationship between the observed cardiorespiratory outcomes and air pollution exposure were estimated using a Poisson regression model. Results The results showed that PM2.5 Concentrations from the waste burning and traffic sites were comparable with annual averages of 28.51 µg/m3 and 29.69 µg/m3 respectively. In Yopougon, where domestic fires are common, the annual average is drastically higher at 155.1 µg/m3. PM2.5 were elevated in both seasons with an average of 145µ/m3; more than the one recommended by WHO. Also, cardiorespiratory diseases occurred in 66% and the most affected were women (54%) and children under 18 years old. The highest PM2.5 concentrations were due to biomass burning, seen in Yopougon. Outpatient visits for cardiorespiratory symptoms showed a significant association with PM2.5 concentrations during the rainy season and respiratory outpatient visits were significant throughout the entire year. Overall, we estimate that 143 hospital visits could have been avoided during the rainy seasons of our study periodConclusion: Accessing to air pollution data has been difficult in developing countries. This survey was one the first conducted so far in Côte d’Ivoire addressing pollutant concentrations and cardiorespiratory outcomes.

Tuberculosis drug safety and pharmacovigilance in health system of Kosova: A cross-sectional analysis.

Tuberculosis (TB) remains a significant worldwide social and life-threatening epidemiological problem. Because this disease requires multiple drug treatment and prolonged therapy for several months, followed by a high probability of adverse effects (AEs), we assessed AE monitoring for anti-TB drugs in the Health Care System of Kosova. This survey was a cross-sectional analysis performed at the primary, secondary and tertiary health care levels in Kosova. We included 930 registered tuberculosis patients within three levels of this health system in our study. Furthermore, we interviewed 62 physicians and 71 nurses at TB health facilities. Data were collected from official TB registers and personal contact with patients for 12 months. The representative age group was 19 to 29 years (30.49%), followed by a group of patients aged >60 years (23.23%). Among 930 patients treated with TB drugs, the total incidence of adverse AEs was 29.03%. Female TB patients had a higher rate of AEs than did male patients (33.56% vs 28.84%, respectively). The highest incidence of registered AEs was recorded in the gastrointestinal system (270, 80.83%), followed by the central nervous system (CNS, 7.50%) and was lower in other organ systems. The reporting of anti-TB drug effects by medical staff (TB medical doctor and TB medical nurse) at different levels of TB medical settings occurred among 62.90% of medical doctors and 81.69% of nurses. Only 53.23% of medical doctors and 46.48% of nurses completed pharmacovigilance training. The pharmacovigilance approach in Health System of Kosova is not comprehensible and not systematic. The relatively low incidence of AEs among TB patients is due under reporting of these by medical staff. The knowledge, attitudes, and adherence of medical staff reveal low awareness for pharmacovigilance activities, and this concern should be addressed to reinforce this important issue for the safe treatment of TB patients.

Policies for Prevention and Control of Oral Cancer in the light of Giddens' Structuration Theory.

Challenges remain to ensure access to diagnosis and treatment ten years into continuous cancer prevention, control, and oral health policies. This study aims to analyze the oncology and oral health policies in force regarding the process of implanting oral cancer-related care components. Ten policies were analyzed under the lenses of the Structuration Theory, besides data on the supply of services between 2002 and 2017. Low coverage and inadequate regional distribution were highlighted in primary and secondary health care levels, despite increased funding and number of services. Unequal distribution of performed surgeries was identified in tertiary care. The limitation of home care services has hindered users' access to palliative care. A convergence was identified between the analyzed policies and concern with the regulation of authoritative resources and the increase of allocative resources, which stirred the expansion of services. Investments should be made in the expansion, regionalization, and universalization of services. A possible setback in these policies could aggravate the situation and contribute to the increase in health inequalities.

Demanding of Lassa Fever: Reducing Its Risk as an Infectious Disease

In recent years, Lassa fever has been announced as an infectious disease in the world, a few imported cases have been accounted for in various pieces of the world and there are developing worries of the possibilities of Lassa fever Virus as an organic weapon. Regardless of its assaulting impact, no substantial arrangement has been created to reduce the hazard of the ailment, about a large portion of 10 years after identifying it. A Review based on the documents from the literature search on PubMed, Scopus, Goggle Scholar and Science direct. Out of these, the final 16 articles that met the criteria were selected. Relevant information on epidemiology, the burden of management and control were obtained. Timely and effective containment of the Lassa fever disease in Lassa village four decades ago could have minimized the devastating effect and threats posed by this illness in the West African sub-region and indeed the entire globe. That was a hard lesson calling for much more proactive measures towards the eradication of the illness at primary, secondary, and tertiary levels of health care. Hence, the paper is aimed at appraising the threats associated with Lassa fever disease; its demands on curtailing the menace of the epidemic, and recommendations on important focal points.

Cervical Cancer Screening Program in Bangladesh

Background: Cervical cancer (CC) is the fourth most common cancer in women worldwidewith an estimated 569,847 new cases and 311,365 deaths in the year 2018. In Bangladesh,the incidence of CC was 8068 and 5214 women died from CC in the year 2018.1CC constitutesabout 12% of the female cancer in this country.1
 Methods: The present situation of cervical cancer screening program is reviewed.
 Results: The Government of Bangladesh (GOB) adopted visual inspection of cervix withacetic acid (VIA) method for cervical cancer screening. The major strengths of VIA is itssimplicity, low cost, potential for immediate linkage with investigations/treatment, feasible inlow resource settings and the possibility of rapid training to the providers. The GOB hasextended the program to all districts and selected upazilas.The screening programme hasbeen implemented through capacity building of service providers of Medical College Hospitals(MCHs), District Hospitals (DHs), Mother and Child care Welfare Centers (MCWCs) andselected Upazila Health Compleses(UHCs) and several institutes.Serviceprovidersareperforming VIA for the women of 30 years and above at about 417 VIA centres at primary,secondary and tertiary level health care facilities of 64 districts of Bangladesh. Screen positivecases are being referred to the colposcopy clinics of 14 government MCHs and BSMMU,where evaluation and management are carried out. From January 2005 to June 2017,1647380VIA tests were performed at different facilities with 4.6%positivity.Among the VIA+ve women attending women at the colposcopy clinic of Bangabandhu Sheikh Mujib MedicalUniversity (BSMMU), 51% had precancerous or cancerous condition of the cervix, 3312(14.10%) were treated by local excision, 2428 (10.30%)by local ablative method and1413(6%) women with cervical cancer were referred to oncology. In Bangladesh, LEEPand thermalablation has acquired acceptability as a commonly used treatment method for selected CINand ‘see-and-treat’ approach for high grade diseases combining colposcopy and LEEP/thermal ablation has been adopted since the year 2010 to improve compliance to treatment.
 Conclusion: Bangladesh has established VIA as screening test for prevention of cervicalcancer in quiet a good number of facilities with wide coverage. But the program has to beexpanded readily to prevent cancer and reduce sufferings & untimely death of women dueto this devastating disease.
 Bangladesh J Obstet Gynaecol, 2018; Vol. 33(1) : 63-73

Measures of geographic accessibility to health care in the Ashanti Region of Ghana

Quantitative data on geographical accessibility to healthcare remain generally limited in sub-Saharan Africa. This study sought to generate quantitative evidence regarding health care access in the Ashanti region of Ghana. Dasymetric mapping technique and GIS tools were used to estimate the total population living within the World Health Organization (WHO)'s recommended 5 km distance to the nearest health facility. An estimated 81.4% of the population had access to general primary health care, 61.4% to secondary-level health care and, only 14.3% to tertiary health care. Despite the high levels of accessibility to general primary health care, accessibility remains poor in some selected districts, especially rural districts in the region. About 30% of the population are more likely to have to travel long distances to access healthcare, particularly specialist services which are available only at secondary and tertiary centres. There is the need for intensified efforts to address inequities in geographic accessibility to healthcare so as to minimise inequalities in health outcomes as well as achieve the desired improvements in population health.

Work-related musculoskeletal disorders among Slovenian physiotherapists

Introduction: Work-related musculoskeletal disorders (WMSDs) represent a major problem for society, employers, and employees. These kinds of problems can cause discomfort, pain, and poor work performance. Among physiotherapists, the 1-year prevalence of WMSD ranges from 28 to 96%. Most problems occur in the lower back, with a 1-year prevalence of up to 83%. This study aimed to determine the prevalence of WMSD on a sample of physiotherapists from Slovenia and to identify associations between demographic/anthropometric variables, job satisfaction, and physical activity with WRMD aiming to contribute to the development of effective prevention and control strategies. Methods: The extended Nordic musculoskeletal questionnaire was used to obtain data from a sample of 102 physiotherapists. Data were presented with descriptive statistics and processing was performed with the Spearman’s rank correlation coefficient for non-parametric variables. The level of statistical significance was set as p ≤ 0.05. Results: The 1-year prevalence of WMSD was 92.2%. One-year prevalence of WMSD was highest for the neck (64%) and lower back (63%). Higher age and more years of practice were correlated with WMSD for shoulders and ankles/feet areas. Several patients treated by a physiotherapist were a risk factor for difficulties in the neck and multiple body areas. The level of physical activity was not correlated with WMSD in different body areas. Conclusion: The prevalence of WMSD found in our study sample was among the highest compared to other countries, despite probably having similar working conditions as elsewhere in Europe. The first WMSD of Slovenian physiotherapists mostly did not occur in the first 5 years of practice as other studies reported, which could be explained as a result of a good educational training of young physiotherapists. Possible reasons for the high prevalence of WMSD could be that our study sample represented only secondary and tertiary levels of health care; another reason could also be non-ergonomic and hard working conditions during their careers. Physiotherapists are mostly adequately physically active, however, that did not turn out to be effective WMSD prevention in our sample. The relatively high prevalence is indicating the need for better interventions and prevention of WMSD in Slovenian physiotherapists.

Etiology of Childhood Bilateral Sensorineural Hearing Loss in Shandong Province, China.

Objectives The purpose of this study is to ascertain the etiology of bilateral sensorineural hearing loss (SNHL) in children aged ≤ 18 years living in Shandong province. Method Data were taken from a cross-sectional study, which was conducted between 2015 and 2017. The study included children aged ≤ 18 years, recruited from special schools for children with hearing loss and from hearing rehabilitation centers in Shandong province of China. Children were screened for bilateral SNHL through audiological testing. Clinical examination, genetic testing, and structured interviews were conducted for those children who were identified as having hearing loss to identify the potential cause. Results The etiology of bilateral SNHL in our sample was genetic in 874 (39.3%), acquired in 650 (29.3%), and unknown in 697 (31.4%) children. Among children with acquired SNHL, the cause was maternal viral infection in 75 (11.5%); perinatal factors in 238 (36.6%); meningitis, measles, and mumps in 146 (22.5%); and ototoxic exposure in 117 (18%) children. Among the children with genetic SNHL, only 44 (4.9%) were identified as having syndromic hearing loss, and the remainder (95.1%) were classified as nonsyndromic hearing loss. Conclusion The findings indicated that nearly 30% of bilateral SNHL in Shandong province could be preventable through immunization, early prenatal diagnosis, proper treatment of infections, and avoidance of prescription of ototoxic drugs. This finding emphasizes the need for programs aimed at improving the health services at primary and secondary levels of health care, which will in turn prevent childhood hearing loss.

The Role of Telecardiology in Dealing with Patients with Cardiac Rhythm Disorders in Family Medicine - Systematic Review.

PurposeHeart rhythm disorders (HRD) are often present in patients visiting their family physician (FP). Dealing with their problems is not always simple, efficient and cost effective. The aim of this paper is to review the existing literature about the use and experience of telecardiology in patients experiencing HRD.MethodsWe conducted a review of literature in PubMed biographical databases (MeSH thesaurus), Web of Science and Cochrane, between 1995 and 2019. We included original articles in English that describe the use of telecardiology at primary and secondary healthcare levels. Exclusion criteria are those publications that discuss heart failure or observation of the activity of pacemakers or defibrillators and the age of patients under 18 years. A total of 19 papers met the inclusion criteria, thirteen of them were original scientific articles and we included them in the analysis.ResultsUse of telemedicine can shorten the time from diagnosis to the necessary treatment (2/13), telemedicine can reduce mortality in patients with acute myocardial infarction (4/13), it can shorten the time to diagnose atrial fibrillations (4/13), it can help determine the diagnosis for patients complaining about heart rhythm disorders which were not detected on the standard ECG recording (2/13) and can also help identify cardiac causes for syncope or collapse (2/13). All studies have confirmed that the use of telecardiology significantly reduces the number of unnecessary referrals to a cardiologist or hospitalization, and shortens the time needed to treat patients with life-threatening conditions.ConclusionThe use of telecardiological techniques increases the quality and safety of work in managing patients with cardiovascular disease in FP practice. Usage of telecardiologic devices can also save money and bridge the gap between the primary and secondary healthcare levels.

Implementing an mhGAP-based training and supervision package to improve healthcare workers\u2019 competencies and access to mental health care in Malawi

BackgroundIt is now well established that the integration of mental health care into primary care is one of the most effective ways of reducing the substantial treatment gap for mental disorders which exists in most low- and middle-income countries. This study set out to determine whether a Mental Health Gap Action Programme (mhGAP) training and supervision package could be contextualised and implemented within the existing health care system in five districts in Southern Malawi. In addition, the study assessed the feasibility of holding community awareness events and establishing peer support groups in each district to further improve the access of the population to evidence-based mental health care.MethodsA lead training team of experienced Malawian mental health professionals was appointed and mhGAP training materials were contextualised for use in Malawi. The lead team delivered a 4-day training package to district mental health teams in five districts covering three core conditions: psychosis, moderate-severe depression, and alcohol and substance use disorders. District mental health teams then delivered a 2-day training package and provided monthly supervision for 3 months to 500 non-specialist healthcare workers. Paired sample t-tests were used to compare knowledge, confidence and attitude scores before and immediately after training, and after 6 months in two districts. Case detection rates measured pre- and post-training in the pilot district were compared using Wilcoxon Rank Sum Test. Community awareness events were held and peer support groups were established in each of the five districts. The acceptability of the package was assessed through focus group discussions involving specialist and non-specialist healthcare workers, users and carers.ResultsNon-specialist healthcare workers’ knowledge and confidence scores significantly increased immediately after training in comparison to pre-training. These scores were maintained at 6 months. However, no statistically significant change in attitude scores was detected. Case detection rates increased immediately after the training in comparison to pre-training. Responses from focus group discussion participants illustrated the programme’s acceptability.ConclusionsThis study demonstrated that, with minimal additional funding and working within existing structures, an mhGAP based training at primary and secondary health care levels is feasible in Southern Malawi.

Till death do us part: the effect of marital status on health care utilization and costs at end-of-life. A register study on all colorectal cancer decedents in Norway between 2009 and 2013

BackgroundEconomic analyses of end-of-life care often focus on single aspects of care in selected cohorts leading to limited knowledge on the total level of care required to patients at their end-of-life. We aim at describing the living situation and full range of health care provided to patients at their end-of-life, including how informal care affects formal health care provision, using the case of colorectal cancer.MethodsAll colorectal cancer decedents between 2009 and 2013 in Norway (n = 7695) were linked to six national registers. The registers included information on decedents’ living situation (days at home, in short- or long-term institution or in the hospital), their total health care utilization and costs in the secondary, primary and home- and community-based care setting. The effect of informal care was assessed through marital status (never married, currently married, or previously married) using regression analyses (negative binominal, two-part models and generalized linear models), controlling for age, gender, comorbidities, education, income, time since diagnosis and year of death.ResultsThe average patient spent four months at home, while he or she spent 27 days in long-term institutions, 16 days in short-term institutions, and 21 days in the hospital. Of the total costs (~NOK 400,000), 58, 3 and 39% were from secondary carers (hospitals), primary carers (general practitioners and emergency rooms) and home- and community-based carers (home care and nursing homes), respectively. Compared to the never married, married patients spent 30 more days at home and utilized less home- and community-based care, but more health care services at the secondary and primary health care level. Their total healthcare costs were significantly lower (−NOK 65,621) than the never married. We found similar, but weaker, patterns for those who had been married previously.ConclusionEnd-of-life care is primarily provided in the secondary and home-and community-based care level, and informal caregivers have a substantial influence on formal end-of-life care provision. Excluding aspects of care such as home and community-based care or informal care in economic analyses of end-of-life care provides a biased picture of the total resources required, and might lead to inefficient resource allocations.

Ukrainian response to the COVID-19 pandemic: governmental interventions

In this article, the governmental response to the COVID-19 pandemic in Ukraine is described, starting from the first detected cases, up until the summer of 2020. Pandemic caught Ukraine’s health care system in the midst of a reform. At the time of COVID-19 outbreak, the first steps of primary health care reform were already being implemented while the reform at the secondary health care level were about to started. However, changes of the political environment (due to the elections 2019), two changes of the Minister of Health (since the beginning of the pandemic), the absence of the general plan of action followed by the inconsistent political decisions, and the uncertainty in financing mechanisms of the secondary health care facilities, made the COVID-19 pandemic challenging for Ukraine. The Ukrainian government had difficulties in devoting additional recourses to medical facilities to protect medical professionals and provide treatment for patients. Instead, as a main intervention to combat COVID-19, the government implemented lockdown from 12 of March to 12th of May that only postponed the raise of infections, preserved lives. While the pandemic still had a highly negative impact on the economy, initial analysis indicate that lockdown could be considered effective from the economics point of view.

Child health care system in Ukraine.

The child healthcare system in Ukraine is coordinated and managed at a central level by the Ministry of Health and at a local level by the regional health authorities. The Ministry of Health has executive the power for the implementation of state health policies and controls and manages state-owned health facilities. The system of public funding for the pediatric healthcare system is divided into two sources: central and local. Primary healthcare is organized by the National Health Service of Ukraine. Secondary level healthcare is mostly organized by the Ministry of Health, which gives money for hospitals and medical centers. Since 2014, due to reform and decentralization in Ukraine, local, regional, and city administrations received money from the Ukrainian government for the formation of decentralized budgets.

Determinants of perinatal mortality in public secondary health facilities, Abuja Municipal Area Council, Federal Capital Territory, Abuja, Nigeria.

Introductionin Nigeria, perinatal mortality rate remains high among births at the health facility. Births occur majorly at the secondary healthcare level in Abuja Municipal Area Council (AMAC) of the Federal Capital Territory (FCT). Identifying factors influencing perinatal deaths in this setting would inform interventions on perinatal deaths reduction. We assessed perinatal mortality and its determinants in public secondary health facilities in AMAC.Methodsdelivery and neonatal data from two selected public secondary health facilities between 2013 and 2016 were reviewed and we extracted maternal socio-demographics, obstetrics and neonatal data from hospital delivery, newborns´ admissions and discharge registers. Data were analyzed using descriptive statistics and Cox proportional hazard models (α = 5%).Resultsperinatal mortality rate was 129.5 per 1000 births. Asphyxia 475 (34.0%), neonatal infection 279 (20.0%) and prematurity 242 (17.3%) accounted for majority of the 1,398 perinatal deaths. Unbooked status [aHR = 1.8 (95% CI 1.4 - 2.2)], antepartum haemorrhage [aHR = 2.8 (95% CI 1.2 - 6.7)], previous perinatal death [aHR = 2.3 (95% CI 1.7 - 3.1)] and maternal age ≥ 35 years [aHR= 1.4 (95% CI 1.0 - 1.8)] were associated with increased risk of perinatal death.Conclusionperinatal mortality in the studied hospitals was high. Determinants of perinatal death were unbooked antenatal care (ANC) status, antepartum haemorrhage, previous perinatal death and high maternal age. Reducing perinatal deaths would require improving antenatal care attendance with healthcare staff identifying and targeting women at risk of pregnancy complications.

Prevalence and profile of persons with burn injuries in rural field practice area of Rajarajeswari Medical College and Hospital, Bengaluru

Background: Burn injury is one of the common medical emergencies admitted to any hospital and is an important public health problem globally. Although most burn injuries are preventable, the general lack of safety consciousness, lack of knowledge on first aid measures, compounded by the absence of organized burn care at primary and secondary health-care level, hinder the curbing of this preventable problem. Objectives: (a) To estimate the prevalence of burn injuries in the rural field practice area of RajaRajeswari Medical College and (b) To determine the sociodemographic profile of burn injury victims and describe the burn injuries in the rural field practice area of RajaRajeswari Medical College. Subjects and Methods: A community-based cross-sectional study was carried out among 1220 randomly selected participants in the rural area using a semi-structured, pretested questionnaire. Data were analyzed adopting descriptive statistics, univariate and multivariate statistical techniques using the Statistical Package for the Social Sciences version 22. Results: The prevalence of burn injuries was found to be 9.5% in the present study. Logistic regression analysis showed that various sociodemographic characteristics of participants such as age, type of family, educational status, and socioeconomic status had a statistically significant association with burn injuries. Conclusion: The prevalence of burn injuries was 9.5% among the study participants. There existed a statistically significant association between burn injuries and various sociodemographic determinants.

Deca sa posebnim potrebama u stomatološkoj ordinaciji

People with disabilities may experience negative relation between their own personal potentials compared to environmental expectations and potentials of healthy peers in terms of functional participation and activity limitations. Therefore, they usually need an individualized dental treatment plan. Dentists have an important role in maintaining and improving oral health in this vulnerable group. Having in mind the United Nation's Declaration on Human Rights, patients with disabilities have human rights to achieve equal health outcomes as their healthy peers. Therefore, all preventive, prophylactic, and therapeutic interventions need to be carefully planned. In addition to precise medical history, the dentist should also have basic psychological knowledge to adjust the approach to patient's needs. Improving the oral health of patients with disabilities involves a primary, secondary, or tertiary level of oral health care, depending on patient's abilities and needs. The team work and a multidisciplinary approach, with the cooperation of experts of different profiles and specialties, is the only approach that gives satisfactory results.

IDENTIFICATION OF RISKS IN THE FIELD OF HEALTHCARE AND THEIR INFLUENCE ON THE FUNCTIONING OF TERRITORIAL COMMUNITIES IN THE CONDITIONS OF IMPLEMENTATION OF MODERN REFORMS

Introduction. Among the measures to ensure the well-being of communities, one of the most important is health care, which in Ukrainian reality is largely due to high mortality rates, reduced life expectancy and low satisfaction of community residents with the quality of health care. Goal. Identification of health risks, identification of their impact on the functioning of local communities and development of a set of measures aimed at their leveling. Method (methodology). Methods of logical generalization, analysis, comparison and synthesis are used to identify risks in the health care system and justify measures to minimize them. Results. Identified organizational and institutional, functional, financial risks in the health care system; an analytical study was carried out and the peculiarities of their influence on the functioning of territorial communities were clarified. A set of measures aimed at the effective functioning of health care at the territorial community level and minimization of negative consequences in terms of identified risks, namely: organizational and institutional (legislative definition of secondary and tertiary levels of health care, taking into account administrative and territorial features of primary health care). Assistance in determining the capitalization rate and the abolition of limitation of declarations in rural areas); financial (establishment of an effective mechanism for financing primary health care in the local community, elimination of inefficient expenditures, application of financial incentives for employees of health care facilities of the local community); functional risks (establishing partnerships between local governments and the management of the primary care institution, stimulating and encouraging local governments to develop medicine in the local community, control over the conditions of remuneration of primary care physicians).

Observations on healthcare workers & SARS-CoV-2 infection

Sir, In an interesting case-control study by Chatterjee et al1, the authors suggested the role of hydroxychloroquine (HCQ) in the prevention of SARS-CoV-2 infection among healthcare workers. Here are some of our observations that we would like to highlight. In this case-control study, symptomatic healthcare workers (HCWs) testing positive on reverse transcription-polymerase chain reaction (RT-PCR) for SARS-CoV-2 were defined as cases, whereas controls were symptomatic HCWs who tested negative on RT-PCR for SARS-CoV-2 under similar considerations. Given the fact that up to 5-80 per cent patients with COVID-19 infection remain asymptomatic23, the major population that may qualify for cases were left from the study. As the ICMR's advisory for the use of HCQ prophylaxis was released on March 22, 20204, assuming that the high-risk workers started prophylaxis from the next day, it was unlikely that the patient pool in this study received six or more doses of HCQ prophylaxis, assuming even distribution of patients being tested between the first week of April and the end of the first week of May 2020. The findings of 56 participants from control group taking six or more doses of HCQ remained unexplained. It was also worthwhile to note whether the question about number of HCQ doses consumed was asked till the diagnosis of COVID-19 or till the time of data collection? Cases and controls seemed to be not matched in this study. Cases had inadequate infection control practices and were more exposed to aerosol-generating procedures like endotracheal intubation, and a greater percentage of cases were in intensive care unit (ICU) having patients on ventilators. In addition, stratification of HCWs was also not mentioned. Probably, HCWs from primary or secondary level healthcare centres were more exposed due to inadequate personal protective equipment or lack of infection prevention control (IPC) training. At the same time, the sample size of this study was inadequate for subgroup analysis leading to unexplained apparently erroneous conclusions such as increased risk of infection in up to three doses of HCQ. We consider that increased risk at lesser number of doses and protection at a greater number of doses do not indicate a dose-response relationship as claimed by the authors, but it rather indicates contradictory and inconclusive finding. The authors also mentioned that the role of HCQ in severe COVID-19 patients was obscure contradictory to the role of HCQ in prophylaxis as concluded by them due to biological possibility of starting the medication before the onset of infection. However, the management guidelines released on March 31, 2020 have suggested that HCQ along with azithromycin may be considered in patients with severe disease and requiring ICU management5. Now, the guidelines released on June 13, 2020 recommended HCQ for mild and moderate COVID-19 cases6. The recent guidelines recommended to avoid it in severe disease. Similarly, one more contradictory finding was HCQ alone and with vitamins and non-allopathic drugs decreasing risk but not with azithromycin combination. There was a possibility that HCWs started taking combination of HCQ and azithromycin based on the results of a study by Gautret et al7 which was available online on March 20, 2020, rather than the recommendations given by the ICMR in its advisory released on March 22, 20204. All that one can conclude from this study is that overall HCQ group is showing a trend towards protection which is not significant (P=0.087). An elucidation from the authors about the results and interpretations taking into account the above observations will benefit the scientific community.

Rashtriya Swasthya Bima Yojana (RSBY) and outpatient coverage.

The healthcare industry worldwide is undergoing a radical transformation. An enthusiastic healthcare system of the Government of India (GOI) continually tries to tackle numerous challenges facing the system. The Rashtriya Swasthya Bima Yojana (RSBY) program has provided secondary level healthcare facilities to more than 36 million families across most states in India. This particular health insurance initiative was taken by the GOI with the purpose to safeguard the pitiable or marginalized Indian population or those households who are facing economic risks due to hospitalization and their everyday expenditures. RSBY provides affordable and accessible healthcare services along with insurance coverage for secondary care. However, it is limited to inpatient treatment or hospitalization. For outpatient coverage many strategies have been applied but low enrolment is still an existing flaw under this streamer. The present paper discusses various features of RSBY, outpatient projects undertook, and various obstacles that can be removed to integrate this insurance scheme with primary healthcare in India.

Knowledge and Practices of Doctors About Patient Safety Working at Primary and Secondary Level Health Care Facilities in Bangladesh

Aim: This descriptive type of cross sectional study was conducted with an objective to evaluate the views of doctors regarding knowledge and practices about patient safety working at primary and secondary level health care facilities in Bangladesh.
 Methods: Study period was from August 2016 to December 2016. Multistage, convenience sampling was done . Sample size was 550. Self administered semi structured questionnaire was used for data collection after pre testing. Data was collected by principle investigator , co-investigator & data collectors. Data was also collected by sending questionnaire by postage followed by a focal group discussion.
 Results: Result showed 70 % were male and 57% were primary level medical officers. 44.9% understands patients safety. 51.1% understands medical errors . 37.5% agreed that less duty hours will reduce medical errors . 62% strongly agreed that Learning about patient safety will enhance competency. 44.5% agreed that undergraduate course prepared them to ensure patient safety. 37.5 % agreed that they learned about medical errors during their undergraduate course. 40.6% stated that they were assigned to perform the tasks for which they were not trained competently, 34% said that they were assigned to perform the tasks which could have resulted easily in medical errors . Most of the respondents strongly agreed that teaching about patient safety should be an important priority. 46% stated that these should be in clinical teaching and 40% stated the same to be in bed side teaching . 24% stated that there were not enough topics in the existing curriculum regarding patient safety. 46% confessed that they made medical errors during their practices. 33% stated that they want patient safety education in their professional practice, 76.9% strongly agreed that patient safety is an important issue in their professional practices and 44% sensitizes their colleagues about patient safety to learn & practices. 54.7% stated that they did not have error reporting system/ death review/ medical audit in their hospital, 89.7% did not have attended any training on patient safety . 90% thought that training on patient safety is essential for doctors 67.2% respondents opined that there should be a competent organization / body who can take care of patient safety & medical errors in Bangladesh.
 Conclusion: The study reflects that many primary level medical officers do not understand patients safety and medical errors. The study also showed that most of them has a positive attitude torwards patient safety. Study recommended that doctors serving at primary and secondary level healthcare facilities to be oriented/ trained on different aspects of patient safety
 J Bangladesh Coll Phys Surg 2020; 38(1): 5-11