Neurofeedback (NF) and brain-computer interface (BCI) applications rely on the registration and real-time feedback of individual patterns of brain activity with the aim of achieving self-regulation of specific neural substrates or control of external devices. These approaches have historically employed visual stimuli. However, in some cases vision is unsuitable or inadequately engaging. Other sensory modalities, such as auditory or haptic feedback have been explored, and multisensory stimulation is expected to improve the quality of the interaction loop. Moreover, for motor imagery tasks, closing the sensorimotor loop through haptic feedback may be relevant for motor rehabilitation applications, as it can promote plasticity mechanisms. This survey reviews the various haptic technologies and describes their application to BCIs and NF. We identify major trends in the use of haptic interfaces for BCI and NF systems and discuss crucial aspects that could motivate further studies. Over the past decade, advances in brain science and computer technology have led to a growth in the development of neurofeedback (NF) and brain-computer interface (BCI) applications. Recent technological advances, such as machine learning analyses, wireless applications, and real-time neural recordings, have increased interest in NF and BCI approaches, especially EEG-based NF/BCIs. One of the cornerstones of NF and BCIs is the feedback given to the subject, which the subject uses to learn and improve their mental strategy. Traditionally, BCI/NF applications have mostly employed visual feedback, but its use may be questionable in some cases. For example, visual feedback is not always suitable for individuals with an impaired visual system or during a mental motor imagery task, which requires great abstraction from the subject. In such situations, tactile feedback would seem more appropriate and more intuitive than visual feedback ; also, by definition NF is biofeedback from brain areas  and was pioneered by Chatterjee et al.  and was . The terThe purpose of feedback in a standard BCI/NF protocol is to give cues for a specific type of brain activity in order to have a beneficial impact on the learning of a BCI/NF task  discriminate very fine surface properties, such as small shapes and fine textures and have a particularly high density under the palm and the fingers , the body position, and the underlying tissues. The use of oscillating pressure  also adds new DOF to the design of vibrotactile stimuli, such as waveform and amplitude modulations at different modulation frequencies of the carrier frequency , and to display contact forces and positions to the user. These haptic interfaces are usually composed of rotating joints that connect rigid links , also known as electrical muscle stimulation, is a more intensive type of stimulation [up to 150 V , have also been used in association with haptic interfaces. These haptic sensors are used to stimulate various parts of the body (at different frequencies), and the elicited electroencephalogram (EEG) signals are processed to generate control commands. Haptic displays therefore have different purposes in these two kinds of BCIs: in sensorimotor paradigms they provide haptic feedback from the brain activity of the subject, whereas for P300 and SSSEP haptic interfaces they are used as stimulation, and the evoked brain activity is further decoded to produce a command .BCIs can be divided into three classes: active, reactive, and passive , usually accompanied by changes in synchronization in the beta band (13–25 Hz)  and discretely (where the feedback is given after reaching a threshold). For example, Murguialday et al.  proposedThe use of tactile feedback for SMR-based BCI/NF systems has also been developed, because of its greater portability, comfort, and affordability relative to kinesthetic interfaces. Tactile interfaces have been used to unload the visual channel . Most BCIs using ERPs can be employed without any prior training and do not exhibit the so-called “BCI illiteracy” problem . The following paragraph will deal with external paradigms (P300 and SSSEP) and their relationship with the haptic modality. To the best of our knowledge, in contrast to SMR-based BCI/NF systems where haptic technologies are used to provide the feedback, in external stimulation paradigms haptic interfaces are mostly employed as a stimulus.P300 is a positive deflection of the EEG signal occurring around 300 ms after presentation of a given stimulus . A major strength of the P300 paradigm is its reproducibility and stability as a feature of rBCIs  haptic-based SMR, which mostly employs kinesthetic feedback and is used for stroke rehabilitation; (2) haptic-based P300, where tactile stimuli are generally used to elicit a brain response for the control of an object; and (3) haptic-based SSSEP, in which vibrotactile stimuli are employed. In each of the paradigms discussed in this review, clinical applications have been tested with promising results. Nevertheless, there are limitations and challenges that must be addressed by the haptic-based BCI community. In this section, we discuss some points regarding the design of haptic systems adapted to BCIs, the utility and interest of haptic feedback for BCI and NF applications , and limitations of the current solutions.Most BCI studies involving haptics have used the MI paradigm, often in conjunction with visual feedback. This general trend is mostly explained by the fact that in an MI task, closing the sensorimotor loop has the potential to improve the quality and pertinence of the feedback provided, thus enhancing user engagement and NF performance. On the other hand, for the SSSEP and P300 paradigms, haptic feedback is seen more as an alternative to the visual channel. Concerning the applications of haptic BCI/NF, this review indicates that there is a major tendency toward using these systems for rehabilitation, especially for stroke patients, and that the vast majority of studies used kinesthetic feedback, with the goal of reproducing a real and complex movement. On the other hand, tactile feedback is mainly used with the aim of restoring comfort for patients with LIS or visual impairments, rather than for rehabilitation purposes. The majority of kinesthetic feedback involves the upper limbs, with orthoses placed on either the hand or the arm; this is not necessarily the case for tactile feedback, which can be placed on different parts of the body. The visual modality is also commonly employed in these studies, either to provide a visual clue  or as feedback complementary to the haptic feedback. The visual feedback either takes a classic form  or is a more realistic kind of proprioceptive feedback representing, for instance, a hand. The gain of the haptic modality with respect to the visual modality in different paradigms still needs to be more accurately assessed, although several studies have paved the way and seem to converge on the finding that haptic feedback is either equivalent to or more effective than visual feedback in certain applications.Haptic-based P300 mostly uses tactile vibration as a stimulus, and rarely other modalities. Visual stimuli are used together with haptic stimulation in the P300 paradigm mainly to assess the gain of a haptic stimulus. There is still no consensus around this gain, as some studies show an equivalent effect on the classification performance while in others haptic-based paradigms have reduced performance relative to visual ones. The use of a haptic stimulus is often motivated by the fact that haptic stimulation is the only possible communication channel for some patients , for whom use of the visual channel is not always possible. In contrast to haptic-based SMR paradigms, for P300 applications there is a richer literature dealing specifically with the design of the haptic interface.Applications based on haptic SSSEP are very similar to P300 paradigms, but limited research has been done on the design of such systems. Since P300 and SSSEP share similar objectives, it would be interesting to compare these two paradigms in future studies.The integration of haptics in BCI/NF environments can be complex and entails some challenges at different levels. This is also because haptic-based BCI/NF studies are usually designed by imitating visual feedback protocols, even if the design may be sub-optimal for the haptic modality. In this section, we discuss some issues that should be addressed in the design of haptic BCI/NF protocols adapted to specific applications.The basis of human-computer interaction is the use of feedback, which underlies the interactions occurring between the user and the system  for delivering information been explored . We recommend that further research be done on the design of more realistic haptic training.In our daily environment we encounter many simultaneous and multimodal stimuli. It is therefore of interest to test a multisensory feedback approach in a BCI context. One might hypothesize that multimodal feedback, such as visuohaptic or audiovisual feedback would be more effective than simple unimodal feedback (Sigrist et al., Haptic interfaces are undergoing major technological progress, and the BCI/NF community is looking at the haptic modality with increasing interest. In this review we have summarized and discussed the state-of-the-art research on haptic-based BCI/NF applications. We have outlined different paradigms using haptic interfaces, such as SMR, P300, and SSSEP, as well as methodologies for the design of pertinent haptic applications. We have identified major trends in the use of haptics in BCIs and NF and discussed the limitations of current solutions. To date there is no consensus on the effectiveness of haptic feedback for BCI and NF systems. This review shows that haptic interfaces have the potential to enhance performance and increase the pertinence of the feedback provided, in particular for the SMR paradigm, which is used in the context of motor rehabilitation. Further studies are, however, needed to test the use of innovative haptic technologies for BCI and NF and to assess the utility of the haptic modality, used either alone or in combination with other modalities.MF, GL, CB, and AL contributed the conception and design of the review. MF wrote the first draft of the manuscript, wrote the sections of the manuscript, and organized the database. GL wrote the sections of the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


The world has witnessed rapid advancement and changes since the COVID-19 pandemic emerged in Wuhan, China. The significant changes experienced during these times remain unprecedented. The African continent has initiated significant responses to curb the spread of the pandemic. However, there is an increasing concern that rural Africa is facing serious challenges in their responses to the COVID-19 pandemic. This is due to the uncertainty if the populations are detached from or in synch with information on COVID-19. The findings reported here suggest that rural Africa is burdened with misinformation and infodemic regarding COVID-19 due to widespread misconceptions and anecdotal reports. It is, therefore, necessary to engage with community leaders to provide awareness campaigns in rural communities to ensure access to reliable information issued by local and international health authorities. It is pertinent to set up avenues that improve health literacy in communities in rural Africa as it is a major determinant of information assimilation. Since the COVID-19 pandemic emerged from Wuhan, China, the world has experienced rapid transformation and changes. The major changes that occurred during these times remain unprecedented. In light of these recent changes throughout the world, it is, however, becoming particularly difficult to ignore the existence of the COVID-19 pandemic in rural Africa alongside its resulting impact. There is an increasing concern that rural Africa is suffering several setbacks in their responses to the COVID-19 pandemic due to the uncertainty if the populations have access to accurate and evidence-based information on COVID-19. Although observations within the region have indicated a serious decline in access to information on COVID-19 in rural Africa, the mechanisms that underpin these observations are not fully understood. There is an urgent need to investigate the overall impact of the COVID-19 pandemic in Africa as well as provide novel insights on access to information on COVID-19 in rural Africa.1 particularly the rural communities.2 From the first case of COVID-19 in Africa specifically in Egypt, on February 14, 2020, to date, there have been more than 1.5 million cumulative cases reported in all countries within the continent.3 Likewise, there have been more than one million cumulative recoveries, leaving the number of active cases amounting to more than 150,000, with about 35,000 deaths recorded.3 The gap between rural and urban Africa regarding the health workforce, infrastructure, and awareness is wide, making rural communities increasingly susceptible to the pandemic. A public health concern worth highlighting is the aged populations of rural communities who are often afflicted with comorbidities which make them more susceptible and prime candidates for COVID-19, particularly where precautionary measures are difficult to enforce. Such measures are often rejected because of strict cultural or religious beliefs followed by certain rural populations.Although Africa was the last continent to be hit by the COVID-19 pandemic, the weak healthcare systems that are grossly underfunded in addition to the high burden of infectious and noncommunicable diseases (NCDs) make the continent extremely vulnerable,1 In rural settings, access to social media and other information tools is limited to a selected few.2 On the other hand, many countries in the African region have poorly developed strategies and mechanisms for crisis and risk communication4 which presents several challenges to effective health communication in under-resourced settings in Africa. Noteworthily, these challenges translate to poor access to accurate and evidence-based information, and hence, misinformation and infodemic are widespread.2 Rural dwellers, unable to ascertain what is reliable and what is not, tend to believe whatever information is trending in their community. This creates an additional challenge of promoting precautionary measures and safety guidelines which will resultantly hamper the prevention efforts that have been made toward COVID-19 transmission in rural areas in Africa.As a means of curtailing the community transmission of the COVID-19 pandemic, governments in various African countries adopted precautionary measures in accordance with the WHO guidelines including but not limited to lockdown, travel restrictions, and curfews. This has profoundly affected the rural communities, leading to a drop in agricultural output, incomes, and resultant food insecurity as well as poverty. In addition, regular access to health facilities is cut off, and in rural communities where a vast amount of the population suffers from NCDs such as hypertension and diabetes, the health of the inhabitants further deteriorates, leading to death from these comorbidities.5 Common areas of mass gatherings such as marketplaces and hospitals were required to be cleaned and fumigated at regular intervals to eliminate residual pathogens. Local leaders who are the moral compass and guides of the community were instrumental in capacity building and spreading awareness on the existence and disease control in rural settings. Although media outlets especially those broadcasting in local languages were used to spread information on the mode of transmission, prevention, and myths associated with the virus, these proactive efforts did not come without challenges.The first cases of COVID-19 in Africa were imported from other continents, and urban areas being the entry points, as international travelers were affected first. However, in a relatively short time span of the disease entry, the disease found its way to rural Africa because of delayed testing and poor contact tracing. These areas are the backbone of the continent’s agricultural outputs and where the larger percentage of the continents’ populations dwell. Key strategies were implemented to mitigate community spread in rural Africa. For instance, in Nigeria, physical distancing protocols characterized by restriction of movement were enacted. In Uganda, complete lockdowns and restriction of movement were enforced, and in Kenya, there was a complete ban on nonessential gatherings (not more than 15 people) for community events such as burials. Personal hygiene was also a key measure involving the use of hand sanitizers and handwashing areas. This approach witnessed the innovation and involvement of healthcare providers such as pharmacists in the production of sanitizers in Africa.6 Also used was the context from past pandemics and epidemics such as SARS and Ebola.6 In the early days of the pandemic, it was predicted that Africa will be severely hit. Although the number of infections in Africa remains comparatively lower than that in most other parts of the world, this assertion remains debatable. It is believed that low testing capacity and poor reporting foreshadow the reality of a wider spread.6 The proactive approach of government and health agencies in Africa to tackle COVID-19 in rural Africa has been met with a number of challenges that can be linked to misinformation or a lack of accurate health information. Factors such as poor living conditions, poor health literacy, ease of access to unambiguous information, influence of culture and religion, demography, and political instability greatly weigh in on the probability of prevention strategies to stay effective.7Interventions and strategies to prevent widespread transmission of COVID-19 in African countries were based on evidence-based methods  adapted from areas first hit: Asian and European countries.7 The paucity of accurate health information in rural areas is largely due to Internet unavailability and the inability to access television, social media—which serve as a medium for passing reliable health information by local and national health authorities. These act as a potential setback to governments’ effort to curb the spread of COVID-19.People living in rural areas have little or no access to accurate health information and as such are likely unexposed to the reality of the risk of COVID-19.7 These have posed as challenges hampering the improvement of health literacy regarding COVID-19 in rural Africa.Globally, basic health literacy regarding COVID-19 is low because of limited access to health information. This is evident in low- and middle-income countries, especially in rural areas. As a result, individuals are unable to believe or reconcile the abstract notions of germ theory, invisible living organisms causing infections, infectivity despite being asymptomatic, and the concept of prophylaxis, vaccines, clinical trials, and placebo due to the lack of sufficient and reliable health information.8 In an event of messages being unclear, people are often misinformed and also disregard other valuable information. The study8 identified that most awareness messages discouraged contact with animals. This, however, was not evidence-based and could affect how rural dwellers, particularly livestock farmers, perceived the information.A review of broadcast messages aimed at COVID-19 awareness in African countries revealed confounding in the messages, propagating doubt and hostility from the populace, as well as mistrust for health authorities.7Globally, people attach a lot of sentiment and reverence for religious institutions and their leaders. If a religious leader misconstrues scientific facts, which is a common occurrence, there is a risk that the congregation would violate health-promoting behaviors. In Nigeria and Uganda, for instance, religious leaders have high credibility among their followers, and, as such, this serves as a means by which misinformation is propagated.9 Also, the salience of COVID-19 risk is not as important as that of the instability already being experienced.7 There is as such no motivation to adhere to prevention strategies when information is available.In areas plagued with unrest and political instability (war and civil strife), there is limited access to COVID-19 information.7 financial instability of the population, influence of culture, and inadequate research capacity, and cross-border dependence.6 Financial instability is often met by the need to defy lockdown to make money through the informal sector. Beliefs, culture, knowledge, and memory can also affect decision-making as regards obeying laid down prevention strategies. Furthermore, with a high population density, access to food, clean water, and sanitation is poor in rural Africa. Policies such as lockdown, therefore, meant that people with limited resources had to remain confined to small living spaces.Some other factors that pose barriers to the implementation of prevention and control strategies in rural Africa include high population density,10; thus, they do not adhere to any precautionary measures like social distancing or the use of nose masks. Others believe that the COVID-19 pandemic is a political conspiracy to receive aid and monetary support from health organizations.10 In Kenya, people in rural communities believe that the government uses the COVID-19 pandemic as an avenue to siphon donor funds,11 as well as a widespread belief that drinking alcoholic beverages can kill the virus.11 In Tanzania, it was reported that inhaling steam is highly effective against the coronavirus.12 In Nigeria, it is believed that the disease only affects people of higher socioeconomic status; thus, those residing in rural communities are immune to the disease. A distressing misconception in Africa of great public health concern is the belief that the genetic makeup of Africans provides strong immunity against the virus13; hence, there was no need to adhere to COVID-19 prevention protocols. These misconceptions, on the other hand, had a potential impact on COVID-19 management strategies in rural Africa, and this has led to setbacks in flattening the curve in most rural settings.As already emphasized, there was a myriad of widespread misconceptions and misinformation about COVID-19 in several communities in rural Africa. For instance, in Sudan, people are convinced that the virus is yet to be a reality in the country and that it cannot spread in extreme temperatures14 and this has made it easy for COVID-19 to wreak havoc on the system.14 It took 90 days for Africa to reach 100,000 coronavirus cases and about 19 days to exceed 200,000 cases in Africa.3 The disparity betwixt rural and urban Africa in terms of healthcare services has been described, and little or nothing has been done to bridge this gap. The misconceptions being spread has led many who need health services to stay back from health facilities with the perception of being immune to the disease.13 This in turn has made the proactive efforts being put by rural health workers futile and, as well, hampered disease management strategies amid the pandemic. A possible implication is that in the absence of evidence-based management strategies, this misinformation and widespread infodemic will result in a lot of deaths.Africa’s healthcare system is known to be overstressed and underfunded,15 Even as the world is now in hope of potential vaccines for the coronavirus, a 6.4% drop in the United Kingdom and 2.4% drop in the United States regarding the willingness of citizens to take vaccines when there are available have been observed due to COVID-19 misinformation.16 Undoubtedly, these misinformation-related casualties have further intensified the COVID-19 crisis in rural Africa, and much is needed to be done to prevent a consequent second wave.Following the speculations hovering in nearly every nation that the consumption of highly concentrated alcohol could disinfect and rid the body of the coronavirus, more than 2,000 cases of methanol poisoning and 264 deaths have been recorded in Iran.Our article suggests that communities in rural Africa are detached from information on COVID-19 because of widespread misconceptions and anecdotal reports. The major challenges stem from the relatively poor access to information, culture and religion, political instability, living conditions, and poor health literacy. These findings suggest various realistic and novel courses of action. A reasonable intervention to tackle this issue will be to engage with community leaders to provide awareness campaigns in rural communities to ensure access to reliable information issued by local and international health authorities. It is necessary to set up avenues that improve health literacy as it is a major determinant of information assimilation. There is also a crucial need for an increased provision of resources (information and testing kits), training, and palliative to rural healthcare workers to aid their responses to COVID-19 and disease management skills. Furthermore, trained COVID-19 task force professionals should be deployed to rural settings to ease the pressure of the pandemic on rural healthcare workers and directly create an avenue for them to focus on disease management.


In the Netherlands, Youth Health Care services (YHC) have been carrying out neonatal hearing screening (NHS) in newborns since 2006. The aim of the NHS is to identify children with permanent hearing loss, so that intervention can be started before the age of 4 months. Early detection of hearing loss is important, as children who start intervention early have been shown to develop better. This article describes the structure and performance of the NHS carried out by the YHC, the quality of the program, and the timeliness of the start of intervention. Since its implementation, the NHS has been audited annually in order to monitor the program’s quality. Monitoring reports and data from the Dutch Foundation for the Deaf and Hard of Hearing Child were used in this study. For many years, results have shown the NHS to be a stable screening program of high quality. The participation rate is high, refer percentage low, and the timeliness of the program is continually improving. Although the timeliness of post screening diagnostics and intervention need most improvement as they do not always meet the target times, this has improved over recent years. In the Netherlands, the Youth Health Care services (YHC) have been performing neonatal hearing screening (NHS) in newborns since 2006 ,2. NHS hIn addition, the development of new screening apparatus has enabled newborns to be screened at home, meaning that identification methods of children with hearing loss have been undergoing a great change internationally. Most importantly, not only has detection itself been fundamentally changed by the introduction of NHS, but also hearing diagnostics, hearing rehabilitation, and the early intervention of children with hearing loss—and if we also include the rise and effect of early cochlear implantations, we can see that there has been an even more radical change. Moreover, the increased accessibility of early interventions for children with moderate hearing loss (40–60 dB) and developments in the quality of hearing aids have also contributed to the series of changes that have considerably increased the developmental opportunities of children with hearing loss.However, these changes have not evolved on their own—a lot of hard work has gone into accomplishing them. Possibly the most important factor in this process has been that since the introduction of NHS, the focus has consistently been on maintaining and improving the quality of the screening program, diagnostics, and intervention. The Dutch Institute for Public Health and the Environment’s Center for Population Screening (RIVM-CvB), directs the NHS on behalf of the Dutch Ministry of Health, Welfare and Sports. The underlying principle is that every population screening program should satisfy the public values of quality, accessibility, and affordability. To this effect, national guidelines, the organization of delivery, and quality requirements are laid down in a procedure manual . In turnA set of quality indicators has been created for the NHS, and each year the program is evaluated on behalf of RIVM-CvB. Since its implementation, this monitoring procedure has been carried out by The Netherlands Organization for Applied Scientific Research (TNO) . The maiThis article describes the structure and performance of the NHS delivered by YHC services, the quality of the program, and the timeliness of the start of intervention. The hearing screening carried out in NICUs falls outside the scope of this article as this is a standard part of NICU treatment delivered by the hospital.Two screening methods are used in the Netherlands: the otoacoustic emission (OAE) method, and the automated auditory brainstem response (A-ABR) method. Both methods have a high level of sensitivity and specificity.The OAE method measures sounds (emissions) that are produced by the outer hair cells in a well-functioning inner ear, during, and for a short time after, the processing of a sound . These eThe neonatal hearing screening test may be carried out in three stages, i.e., up to three separate screening sessions take place, as needed. Based on uniform and timely information, parents make an informed decision about their child’s participation in the program. At the first and second screening sessions, the OAE method is used. In most parts of the Netherlands, the first screening test is carried out by a member of the YHC staff at the same home visit as the heel prick test. In areas where midwives perform the heel prick test, the first screening test is done at a Well Baby Clinic at around three weeks after birth. If a satisfactory result for both ears is not obtained at the second OAE screening, then the third screening test is carried out by a regional coordinator using A-ABR. There is a 4–7 day period between each screening session. If, after the third screening, satisfactory results for both ears have not been obtained, the child is then referred to a SHC for further diagnostics. The screening procedure should be completed within 42 days of birth. Those children who are admitted to the hospital (but not to NICU) for a long period after birth, or children who have risk factors for auditory neuropathy syndrome disorders (ANSD) follow a separate NHS screening protocol. These children are screened with A-ABR screening in the first stage, because ANSD is not detected by OAE screening. This protocol is also carried out by YHC Staff.The quality of the NHS is closely monitored by a regional coordinator. A regional coordinator also manages the OAE screeners, organizes training, and coaches the screening teams. In the monitoring process, the regional coordinator makes use of a number of functions of the Central Administration System Neonatal Hearing Screening (CANG). See data collection for more information.At the SHC, diagnostic tests are performed in accordance with a uniform diagnostic protocol for neonates. In this protocol, the following diagnostic tests are stipulated: auditory brainstem response measurements, impedance testing, frequency specific otoacoustic emission measurements, and behavioral/observation audiometry.In the Netherlands there are 26 SHCs where neonatal diagnostics are carried out, which include both academic and regional centers. The aim is to have all diagnostic hearing testing completed within 92 days after birth. The results of the diagnostic tests are stored in the SHC’s electronic dossiers, and when parental permission has been obtained, also in the CANG.According to Dutch healthcare legislation, children with hearing loss of a minimum of 35–40 dB in the best ear are eligible for intervention by specialist centers for children with sensory handicaps. This is in accordance with the year 2000 position statement of the Joint Committee on Infant Hearing, which was used as a guideline for the screening program . AlthougChildren with unilateral hearing loss receive a follow-up at an SHC. Parents receive counselling from the SHC, and the child’s hearing loss is monitored in order to identify any deterioration over the years.The aim was to start the intervention within 4 months for children with bilateral hearing loss, whether it be an early intervention with hearing aids via an SHC, and/or an early intervention via a specialist center for people with sensory handicaps. The Netherlands has six early intervention centers that offer a range of services, including family counselling, courses for parents (including sign language courses), group intervention, and individual intervention . The results of the interventions were stored in (electronic) dossiers.The results of the screening for hearing testing were obtained from a report that evaluated its national implementation 2002–2006), and also from national monitoring reports 2008–2016) 002–2006,. The dat6 002–200The number of children with permanent bilateral hearing loss of a minimum of 40 dB detected annually, varies year by year . In 2015Of the hard of hearing children with bilateral hearing loss who had a loss of 40 dB or more in the best ear, and were born in 2014–2016, 94 were known to the NSDSK early intervention center. It is striking that a substantial percentage of these children had not been detected by the NHS. The average age at which children attended an intake appointment at the early intervention center was 6 months, with a very wide spread of 1.1 to 31 months. At the start of early intervention, the average age of the children was 6.6 months (1.4–32 months). See Where the age of starting an intervention is exceeded, there is often a clear reason for this. These were children in whom unilateral hearing loss was originally found, or in whom hearing loss of a temporary nature was suspected. After some time it became clear that these children required early intervention. The quality of the delivery of the NHS program is safeguarded at two levels—at screener level by the regional coordinator, and at national organizational level by the RIVM-CvB. If necessary, the regional coordinator gives feedback to the screeners. Each year, the RIVM-CvB sends national monitoring reports to all youth health services organizations and SHCs. A letter setting out the main results and key points for further attention is included in this. The YHC, the SHCs, and the institutes for early intervention each feel responsible for their own link in the NHS chain. They are open to discussing quality control and points for improvement. If the NHS has taught us anything about factors of success for screening programs, it is that continued focus, setting high standards, and working with specialized dedicated teams is crucial.Long-standing key points for improvement were around timely completion of diagnostic testing and the timely start of an intervention if necessary. After the introduction of the NHS, Leiden University Medical Center’s DECIBEL study reported on the ages at which children first received a hearing aid . Of all In 2008, 2010 and 2012, RIVM-CvB commissioned NSDSK to carry out an evaluation of the timeliness of the NHS program for fitting hearing aids in newborns in whom hearing loss had been detected. Their analyses showed that in 2012, the average age of fitting a hearing aid was 5.3 months, and 55% of all children diagnosed as having permanent hearing loss had hearing aids before the age of 4 months. In comparison with 2005, this was a considerable improvement—however, these analyses were based on relatively incomplete data from the feedback reports of the SHCs about the ages at which hearing aids were fitted. In 2017, the RIVM-CvB commissioned a study from the Platform for Audiological Clinical Testing of the Federation of Dutch Audiology Centers. They investigated the timeliness of hearing aid rehabilitation in children born in 2014. In addition, for the first time, timeliness was included in the early intervention program. An important factor of the study was that an intervention (hearing aids/family counselling) had been started with all children who had a hearing loss of 60 dB or more, at around the age of 4 months. Interventions were given later for children with less severe degrees of hearing loss. This was partially due to the fact that some parents had difficulty accepting the diagnosis. In addition, logistical factors of the SHCs and co-morbidity and/or illness in the children were found to play a role [However, the high quality of the NHS program in the Netherlands is not a reason to sit back and relax. In practice, continual adaptations are necessary and developments that could potentially influence the quality of the program which arise need to be addressed, as was the case with the introduction of new screening devices that required a new training program and instruction materials. A new European privacy law  was introduced in May 2018, thus making it necessary to adjust the program to meet the specific requirements of this law. One important point for the YHC is that the NHS does not guarantee lifelong good hearing. The OAE screening cannot detect hearing loss if the cause lies within the brain, which does occur occasionally. In addition, there are some cases where the hearing loss manifests itself after the screening has taken place, or where initially minor hearing loss progressively worsens over time. Thus, it is important that the YHC, parents, and others involved in the care of the child remain aware of the possibility of hearing loss developing after the neonatal period. The Dutch YHC guidelines on the early detection of hearing loss in children and young people (0–18 years) offers more guidance on this matter.The NHS program, carried out by the YHC, is a long-standing, stable screening program with a demonstrably high level of quality. Results have shown that participation levels were high, while refer percentages stayed low. Only 0.3% of screened children were referred for further testing, and 35–40% of them were proven to have unilateral or bilateral hearing loss of a minimum of 40 dB. Where timeliness is concerned, there is still room for improvement in both diagnostics and the start of intervention. The average age of children starting out in the early intervention program was 6.6 months (1.4–32 months). For children whose early intervention starting date with hearing aids was known, the average age at which they got a hearing aid was 4.5 months, and these averages are above the target of 4 months for starting rehabilitation.


To increase the accessibility to healthcare services among migrant workers with Compulsory Migrant Health Insurance, public health policymakers are recommended to cooperate more with healthcare staff and the workers' employers to enhance the distribution of information about the health insurance to decrease barriers to get care.Accessibility to health service and experience of healthcare are important factors for public health policymaking. The current study aimed to describe the status of accessibility and barriers to getting care as well as policy literacy among Myanmar migrant workers and ultimately to identify the predictors of accessibility to healthcare services among this population through Thailand's Compulsory Migrant Health Insurance (CMHI). A cross-sectional survey was used to collect data from 240 Myanmar migrant workers who were 18 years or older, resided in Songkhla Province, and had Compulsory Migrant Health Insurance. The instrument was a set of questionnaires consisting of a Personal Data Form, Policy Literacy Questionnaire, Barriers to Get Care Questionnaire, and Accessibility to Healthcare Services Questionnaire. Descriptive statistics, correlation analysis, and multiple regression analysis were used to analyze data. The majority of participants had a high level of policy literacy (36.3%), barriers to get care (34.2%), and accessibility to health care services (35.8%). Policy literacy ( Due to its rapid economic growth, Thailand has become a popular destination country for migrant workers. Thailand's 2019 migration report estimated nearly 3.9 million migrant workers from neighboring countries including Myanmar, Laos, and Cambodia are working in Thailand [To look after the health of migrant workers, the Thai government provides two types of health insurance: Social Security Scheme and Compulsory Migrant Health Insurance (CMHI) scheme. The Social Security Scheme is limited to migrants who have valid work permits, whereas the CMHI scheme serves both migrants and their dependents , 4. UndeMoreover, improving the health status of migrant populations is beneficial to the host country's health security and economy. Promoting the health status of migrants and their accessibility to health care services is thus significant to Thailand. This study aimed to describe the status of ability and barriers to getting care as well as policy literacy among Myanmar migrant workers with CMHI. The study ultimately aimed to identify the predictors of the accessibility to healthcare services among this population. The study results provide a better understanding of the accessibility to healthcare services by Myanmar migrant workers along with its predictors and guidance to design proper interventions and policies to promote their health.The theoretical framework of the accessibility to healthcare services was based on the framework of access to health services developed by Peter et al. , which wFor this study, the factors considered to be determinants of the accessibility to healthcare services were based on the findings of previous studies. Individual characteristics, policy literacy, and barriers to getting care are viewed as predictors of the accessibility to healthcare services. Among individual characteristics, gender, education, marital status, income, and health status have also been shown to be associated with the accessibility to healthcare services of migrant workers in Thailand –9.The concept of policy literacy in this study was based on the literature and evidence of health literacy, which seems to be a part of policy literacy , 11. KwaBarriers to getting care in this study included personal barriers, financial barriers, social barriers, health system barriers, healthcare provider barriers, and work situation barriers which were modified from two studies , 15. BarThis study aimed to explore the policy literacy, barriers to getting care and ability to get the care and to examine the predictability of policy literacy, barriers, and individual characteristics such as gender, education, marital status, income, and health status on the accessibility to healthcare services among Myanmar migrant workers living in Songkhla Province of Southern Thailand.A cross-sectional design was used for this study.The study was conducted in Songkhla Province which is one of the major cities in Southern Thailand. Due to its vibrant economy, the city attracts many migrant workers from various ethnic groups, beliefs, and cultures. The study population was comprised of Myanmar migrant workers who had Compulsory Migrant Health Insurance. The required sample size was calculated based on the formula proposed by Green (1991) for regression analysis. The estimated sample size required for this study was 111 while 7 predictors were used. However, to obtain an equal distribution number of two groups of migrant workers, those who had experience using the service and no experience on using the service, 9 more subjects were added to be 120 subjects then proceeded to double the sample size to gain more generalizability. Overall, 240 migrant workers were selected from the four main sectors of employment representative of such population including agriculture, construction, seafood processing, and services. The sampling process consisted of two steps. First, the migrant workers' residence or workplace was located by purposive sampling. This method was used because migrant workers in these occupations are widespread hence hard to reach. Second, after selecting the locations, quota sampling was used to represent the population as much as possible by distributing the Myanmar migrant workers according to their experience with health services, occupational status, and gender.Data were collected between March and May of 2019 and the interviews were conducted at the locations of work or residences depending on the convenience or preference of the workers. The questionnaires were distributed to the literate migrant workers and questions were explained by the interviewer. For those who were unable to read or write the Myanmar language, the interviewer completed the questionnaire on their behalf via a face-to-face interview.Permission was obtained from the Institutional Review Board of Health System Management Institute from Prince of Songkla University, Thailand. Informed individual consent was obtained from all participants after explaining that their participation was entirely voluntary. Moreover, the participants were assured that their responses would be kept strictly confidential while their anonymity guaranteed.A questionnaire with four sections, personal characteristics, policy literacy, barriers to getting care, and the accessibility to healthcare services, was designed for the study. Twelve items of personal characteristics were collected using a separate questionnaire designed by the researchers.The questionnaire of policy literacy was developed by the researchers based on previous studies on health literacy since there is no instrument ever developed for policy literacy , 10, 11.Barriers to getting care were measured using a 28-item questionnaire developed by the researchers based on previous studies investigating barriers to access healthcare , 20, 21.The questionnaire measuring accessibility to healthcare services consisted of four parts, geographic accessibility, availability, financial accessibility, and acceptability, and also included 24 items, 18 positive and 6 negative items. The questionnaire was also developed by the researchers based on previous studies on accessibility to get care and information provided by the CMHI scheme , 6, 22. The English version of the questionnaire was examined for content validity by a panel of three experts in areas of community health, health system, and public health. Modifications were made on each expert's recommendations. The questionnaires were translated into Myanmar and then into English again using back translation technique by two bilingual speakers. The differences of two English versions  were discussed with those two translators. Finally, the Myanmar version was modified based on agreement of the translators to maintain language congruency with the original version approved by those three experts.p < 0.05.Data analysis was conducted using SPSS 17 for Windows. Descriptive statistics such as frequencies, percentages, means, and standard deviations were used to describe personal data, policy literacy, barriers to getting care, and the accessibility to healthcare services. For a better understanding of the policy literacy scores, barriers to getting care, and the accessibility to healthcare services, all scores including subdomains were categorized into low, moderate, and high using tertile calculation . Multiple linear regression models with a forward stepwise method were fit to determine significant predictors of the accessibility to healthcare services. The level of significance was set at A total of 240 Myanmar migrant workers were included in this study. p < 0.001). Therefore, Myanmar migrant workers with high policy literacy, low level of barriers, and female migrant workers had high accessibility to healthcare. A comparison of the two models is shown in In the current study, the majority of participants were young adults (mean age = 31.6 years). This is consistent with previous studies performed in Thailand , 23. YouMost migrants perceived high levels in overall policy literacy. This result was consistent with other studies conducted among migrant workers in the northeast of Thailand . The stuThe findings on moderate and high levels in overall barriers to getting care among majority of migrants reflect limited access to healthcare services. Migrant populations, especially those working in low-skilled sectors, encounter barriers to get care at all three levels  . This maThe majority of participants had a high level of accessibility to healthcare services. This can be influenced by the marital status of migrant workers. Most of the participants were married thus able to get support from their partners to access the health services. A systematic review using Andersen's behavioral model of healthcare utilization revealed that married people use health services more than single people . BesidesThis study's finding which indicated that policy literacy was the strongest predictor of accessibility to healthcare services suggests that migrant workers with higher policy literacy level are more likely to access healthcare. Such finding supports previous studies on determinants of access to healthcare in which literacy was one of the demand-side determinants that helped to increase the ability to perceive the need for care . SimilarMoreover, barriers to getting care were found to be negatively associated with the accessibility to healthcare services. The participants who had low barriers to getting care were more likely to access healthcare, a result that is consistent with previous studies , 18, 24.Among the selected variables for personal factors, gender was found to be the only significant predictor of the accessibility to healthcare services. According to Aday and Andersen (1998), gender is one of the predisposing factors in accessing healthcare . In thisFinally, this study highlights the need for increasing migrant workers' perceived level of information about Thai health insurance and reducing their barriers to getting care. Information on healthcare programs should be proclaimed clearly by the policymakers and healthcare providers to the migrants. Besides, healthcare providers must establish an understanding of the migrant patient's culture, beliefs, and economic background.This study presented some limitations. First, interviewing participants who were unable to read or write the Myanmar language may have caused social desirability bias. Second, selection bias may occur due to the sampling method, thus the results may not be considered representative of Myanmar migrant workers in general. Third, the study being conducted only in Songkhla Province, which is located in Southern Thailand, may limit the generalizability of the findings to the population of Myanmar migrants in Thailand as a whole. Finally, a cross-sectional study on causal relationships in migrant workers' perceived level of policy literacy, barriers to getting care, and the accessibility to healthcare services may present inconclusive findings.The findings of this study provide information about the ability to get the care and its determinants among Myanmar migrant workers in Songkhla Province of Thailand. The results indicate that policy literacy, barriers to get care, and gender can significantly predict the accessibility to healthcare services. Therefore, to improve the overall accessibility to healthcare services among the migrant population, healthcare programs should include strategies to maximize the distribution of information about the Compulsory Migrant Health Insurance scheme while minimizing the barriers to get care. Public health policymakers and government officials should cooperate with healthcare providers and employers of migrant workers to provide effective and better healthcare services for migrant workers. Besides, information about the Compulsory Migrant Health Insurance scheme should be made available in Burmese language and displayed at the hospitals and other places where migrant workers can easily access. It is recommended that future studies should explore more influencing factors on the accessibility to healthcare services while also adopt a random sampling method to improve the generalization of the findings. Furthermore, it is recommended that qualitative studies using in-depth interviews and focus group discussions will provide essential information for policymakers and healthcare providers to develop effective healthcare programs for the migrant population.


Background: Data in Nigeria suggests a high level of dissatisfaction among women attending maternity care in health facilities due to long wait times, disrespectful care, and poor attention by healthcare personnel.Objective: To examine the effectiveness of a multifaceted intervention in improving self-reported indicators of maternal healthcare satisfaction by women who use referral facilities in two regions of Nigeria.Method: The design was quasi-experimental and consisted of two intervention facilities and two control facilities. The interventions included strategic planning, staff re-training, a computerized appointment system, health education/feedback, maternal death reviews and surveillance, and advocacy. A random sample of 2262 women was selected (1205 in the intervention sites and 1057 in the two control sites) to respond to a 24-item questionnaire on service satisfaction as they exited the health facilities. Adjusted Poisson and binary regression analyses were used to assess and compare proportions of reported satisfaction by women between the intervention and control sites.Results: Women in the intervention sites were 54% more likely than those in control sites to report overall satisfaction with services. They were significantly less likely to report inadequate security arrangements in accessing the health facilities (p < .1); and three times more likely to agree that health workers were extremely thorough and careful in attending to them (p < .1).Conclusion: The interventions had positive effects on improving women’s satisfaction with care. The findings from this study have implications for the design and implementation of interventions that address women’s concerns relating to the provision of care and consequently improve service utilization. The reduction of maternal mortality is an important component of the Sustainable Development Goal (SDG) 3 . With hiAmong several reasons proposed to explain the limited use of skilled birth attendants in Nigeria, women’s dissatisfaction with services offered in health facilities was predominant . ReportsOur previous formative research in Nigeria revealed that a large proportion of women reported being dissatisfied with services offered in health facilities ,11. ConcWhile there is ample report of women’s dissatisfaction with maternal health in many African countries ,19,20, tWe addressed these concerns in the intervention we assessed in this study, conducted in referral hospitals over two years. We hypothesized that a multifaceted intervention that addresses all concerns is better suited to improve women’s satisfaction with care rather than a single action intervention. Therefore, we implemented a set of multifaceted (complex) intervention in two referral hospitals in two regions of Nigeria, and two hospitals of comparable status in similar regions served as the control sites. This paper aims to report the effectiveness of the interventions in improving self-reported indicators of service satisfaction by women, one of the outcome indicators of the intervention. We believe the results have implications for designing policies and programs for improving women’s access to skilled maternity care in Nigeria and other parts of sub-Saharan Africa.The study is drawn from an intervention research aimed at improving the quality of maternity care in Nigerian referral hospitals. Baseline data were collected from eight referral hospitals, the details of which have been reported elsewhere ,23. The The Central Hospital in Benin City, South-South Nigeria, and the General Hospital in Minna, Niger State, in the North-Central region, were the intervention hospitals, while Central Hospital Warri, South-South Nigeria, and the Suleja General Hospital, Abuja, in the North-Central region were the control hospitals. The four hospitals serve large populations of women in two geopolitical zones of Nigeria.In 2014, the Women’s Health and Action Research Centre (WHARC), Benin City, Nigeria, constituted a research team that received a grant from the World Health Organization to conduct implementation research for improving the quality of obstetric care for the prevention of maternal and perinatal mortality in referral hospitals in Nigeria. The formative research phase of the research was completed in December 2015, and the report was documented in March 2016. The results were presented at a workshop for stakeholders such as policymakers, facility managers, and to solicit inputs for the design of the intervention phase of the study. Using the inputs from stakeholders, the final intervention activities were designed by the research team. All the intervention activities started in October 2017 and ended in June 2019, except strategic plan development, which started three months earlier. In all, the intervention period was 24 months.1) The development and implementation of a strategic plan in collaboration with health providers and policymakers responsible for policy oversight: This activity took place over three months before the commencement of the intervention. The plan included shared strategies for improving women’s satisfaction with maternity care, followed by workshops where we disseminated copies of the strategic plan to staff.2) Staff re-training: We delivered three-day workshops on knowledge and skills training for doctors and midwives. The training focused on providing quality maternity care, including training on respectful and non-abuse care, proper counseling of women, the use of treatment algorithms for clinical decision-making, prompt attention to patients to reduce delays, and the management of pregnancy complications. Multimodal learning methods used were lectures, discussions, role-plays, demonstrations, and hands-on sessions.3) Computerized appointment system: We implemented a computerized automated appointment system to reduce the time spent by women during visits to the hospital. Each woman pre-scheduled for a visit received automatic multiple reminders to reduce missed visits and to improve pre-visit planning by the doctors. The appointment system enabled the doctors to see the patients as soon as they arrived in the hospital.4) Implementation of a composite health education program: A redesigned health education program for pregnant women and their partners was delivered outside clinic hours to reduce the time spent on providing health education to women on clinic days. Monthly health talks were delivered by experts, with health providers and policymakers in attendance. We shared Behavioral Change Communication materials to pregnant women and their partners. The booklet was translated to the Hausa language for those who speak Hausa only.5) Maternal death reviews and surveillance: Staff of the intervention hospitals was trained to use the Federal Ministry of Health protocol for conducting maternal death reviews and surveillance (MDRS), as described elsewhere . All mat6) Advocacy to policymakers and hospital administrators: We paid regular advocacy visits to policymakers and health administrators responsible for providing services in the two Hospitals. Advocacy focused on resource mobilization and the need to provide an adequate budget for improving service delivery in the hospitals.Data were collected for 21 months using a questionnaire.All women who used the intervention and control hospitals for maternal care  during the study period were eligible for inclusion in the study. The exclusion criteria included women who used the intervention and control hospitals for services not related to maternal care, met the inclusion criteria but declined to be interviewed, and do not speak English, Nigerian Pidgin English, or the dominant local language. Using the Yamane formula , a samplIn total, 2262 exit interviews were conducted, comprising 777 for antenatal care, 752 for intrapartum care, and 733 for postnatal care. The non-response rate was 5.8%. The exit interview questionnaire was adapted from Health Results-Based Financing Nigeria 2017 Exit Interview questionnaire used by the World Bank, Federal Ministry of Health, and National Bureau of Statistics [The outcome variable, satisfaction with care, was measured in two different ways. First, the respondents were asked, ‘overall, would you say you are satisfied with your experience in this hospital.’ Not satisfied and uncertain responses were coded 0, while satisfied and fairly satisfied were coded 1. Second, the respondents were asked questions on 24 items addressing six dimensions: physical access, hospital environment, respectful care , financial cost, waiting time, and technical skill. The importance of assessing care satisfaction with these measures has been documented ,27. The The characteristics of the respondents for each arm were described using summary statistics, frequency, and percentages as applicable. The difference between sites was examined using the non-parametric alternative of t-test (Mann-Whitney test) for continuous variables and Chi-square test for categorical variables. The likelihood of being satisfied overall was estimated using adjusted binary logistic regression, and Poisson regression was used to determine the likelihood of reporting the sum of the 24 items on satisfaction. To compare responses in each of the 24 items by site, a logit model that adjusted for statistically significant characteristics of the respondents and month of the exit interview was estimated with each item as the dependent variable and site as the independent variable. The net effect of each independent variable on overall satisfaction with care was estimated using a logit model for the intervention and control site, adjusting for personal and other statistically significant characteristics of the respondents and the time of the interview. This analysis was necessary to compare the effect of various independent variables on overall satisfaction with care. All the analyses were conducted with Stata13 for windows. The results of logistic regression were presented as odds ratios (OR), whereas the Poisson regression result was presented as incidence rate ratios (IRR) with their 95% confidence interval (CI). All the analyses were two-tailed, and the p-value was set at 0.05.The characteristics of the respondents are presented in Relative to respondents at the control sites , satisfaThe odds of satisfaction in two of the three physical access factors were significant at the intervention compared to the control sites. The likelihood of agreeing that ‘the opening hours is adequate to meet their needs’ was significantly higher at the intervention site (OR 2.83 CI:2.18–3.69), and disagreeing that the level of security in the hospital area makes it difficult for people to access the hospital was 25% lower at the intervention sites. Satisfaction with the hospital environment, which was measured with whether the hospital was clean, was significantly higher at the intervention site (p < .5)Respectful care was measured with seven items of providers’ interpersonal and communication skills. In all of the seven items, the odds of satisfaction were higher at the intervention compared to the control sites. For instance, the odds of agreeing that the health workers are courteous and respectful were 2.09 times higher at the intervention site. The odds of reporting that laboratory fees and medication fees were reasonable were 74% and 80% less likely, respectively, at the intervention site.Technical skill, which included clinical competency and overall assessment of the quality of care, was measured with eight items. The likelihood of satisfaction was significantly higher at the intervention site in seven of the items. For instance, the odds of agreeing with the statement that the health workers were extremely thorough and careful was 3.28 times higher at the intervention compared to the control sites.Analysis of the net effect of potential determinants of overall satisfaction for both sites and within intervention and control sites separately, is presented in Results of the within site analysis show that none of the physical access items was significant at the intervention site, but security in the hospital area was a significant factor at the control site. The hospital environment cleanliness was an important determinant in both sites. Respectful care in the form of privacy was significant in both sites; easy contact with health providers, health workers care about respondent’s health were significant determinants at the intervention site, whereas the issue of providers equally treating all patients, was a significant factor at the control site. The financial cost was not a significant predictor at the intervention site, but medication fees were significant for respondents at the control site. Waiting time was not a determinant at the intervention site, but it was at the control site where respondents who agreed that waiting time was reasonable were more likely to be satisfied overall (OR 2.28 CI: 1.55–3.34). Concerning technical skills, getting the medicines prescribed by health workers easily was a significant determinant at the control site, but overall satisfaction with the quality of services and complete trust in health workers were significant at both intervention and control sites.The objective of this study was to determine whether a set of multifaceted intervention activities would be effective in improving the satisfaction of women with maternal healthcare services in referral facilities in Nigeria. The results show that women in intervention sites were 54% more likely to report satisfaction with services compared to women in the control sites. In this study, we measured the level of satisfaction with a 24-item questionnaire that was sub-divided into three categories. These included questions relating to the physical environment, access to the hospitals, and respectful maternity care/staff-client interactions. The results showed that women in the intervention facilities were 22% more satisfied with the physical environment than women in the control sites. For physical access, the results show that women in the intervention sites were nearly three times more likely to report that the opening hours at the facilities meet their needs. They were also significantly less likely to report that the security arrangements in the health facilities posed a challenge to them in accessing the facilities. The finding for assessment of respectful care also showed better results in the intervention sites compared to the control sites. Women in the intervention sites were twice more likely to report that health workers are courteous and respectful. Similarly, women in intervention sites were at least three times more likely to agree that health workers were extremely thorough and careful compared to women in the control sites.These favorable results may be attributable to the composite nature of our interventions and the fact that intervention components were identified after intense formative research in collaboration with women and other relevant stakeholders. Multifaceted interventions that simultaneously address various barriers has been shown to improve some health outcomes in sub-Saharan Africa . HoweverOur formative research included interviews with health managers in the referral hospitals  that werThis study indicates that the improvement of maternity care and prevention of maternal mortality requires a collaborative approach and the participation of committed stakeholders. To the best of our knowledge, this is one of the first reports of the development and implementation of an institutional strategic plan in Nigeria aimed at reducing maternal mortality in health institutions. We believe this approach is scalable and can improve the quality of all elements of maternal health care in referral hospitals in Nigeria, and can be adopted by other low-resource countries.Further analysis of the data showed that the most important determinants of women self-reporting of satisfaction with care were: adequacy of opening hours at the facilities, cleanliness of the physical environments, providers being friendly and approachable, adequacy of facilities, medicines being readily available, and not waiting too long to receive care. Most interestingly, social equity turned out to be an essential expectation by women, an expectation that rich and poor women were treated equally without differential attention because of financial status. This was an important issue that the women in both intervention and control sites considered critical to their satisfaction with health care. Equitable and respectful care as a predictor of satisfaction with health care has been shown in previous studies ,19. We rOf interest was the finding that financial consideration was not a significant predictor of women reporting satisfaction with care in the intervention sites. This suggests that when other factors are satisfactory, women will not consider costs as burdensome. This finding is supported by previous reports that indicate that cost consideration is secondary to other indicators of quality of care ,14. HoweTo date, there has been limited evidence of effective interventions that promote women’s satisfaction with maternal health care in African countries. The World Health Organization reported a single cluster randomized trial that concluded that interventions might have little or no effect on women’s satisfaction with maternal health care . FurtherThe major strength of the study is the comprehensive and multifaceted nature of the intervention, which addressed key concerns on satisfactory care raised by women in prior research. Also, involving multiple stakeholders in the project development and implementation and the large sample of women interviewed during the exit interviews enabled the collection of varied perspectives. However, the study was confined to four hospitals in only two out of the country’s six geopolitical zones, which is a limitation. Our desire to ensure effective implementation of the project activities and accurate data collection, prompted us to limit the scope of the project. Nevertheless, we believe that the results are generalizable to the rest of the country, as the participating health facilities serve large populations of women in two major regions of the country.We conclude that interventions that addressed women’s multiple concerns on the provision of care and implemented in a multi-disciplinary manner with the involvement of facility managers and policymakers are effective in improving women’s satisfaction with maternal health care. The results have implications for the design of policies and programs to improve the quality of maternal health care services in all parts of Nigeria and other less developed countries.


In late 2019, novel coronavirus (SARS-CoV-2) caused pneumonia in Wuhan was spread to the whole country and was identified by World Health Organization (WHO) as “public health emergencies of international concern” . On the Since the novel pneumonia outbreak, China National Health Committee issued seven editions of diagnosis and medical treatment planIn the 7th edition of diagnosis and medical treatment plan issued by National Health Commission (NHC) of China, many TCM remedies are recommended for COVID-19 patients in medical observation period. Huo Xiang Zheng Qi capsule is recommended for patients when there is clinical manifestation of “fatigue accompanied by gastrointestinal discomfort”; and Jin Hua Qing Gan granule, Lian Hua Qing Wen capsule, and Shu Feng Jie Du capsule are recommended for patients when fatigue with fever occur. According to a news release from the National Administration of TCM, the integration of traditional Chinese and Western medical treatment can achieve satisfactory results for resolution of symptoms of COVID-19In the medicine field of China, there is always a dispute between the modern medicine and the traditional medicine for a long time. The pros and cons of debate have its own perspective and opinion. We are pleased to see that in the face of severe epidemic situation, there are mixed teams of modern medicine doctors and TCM doctors. The majority of COVID-19 patients in China have been treated with integrated Chinese and modern medicine. Hundreds of herbal remedies have been used throughout the country . The ChiUnfortunately, the experience of TCM in the treatment of epidemic situation has not been widely recognized and used for reference in the western Occident developed countries. The lack of high-quality scientific evidence may be one of important reason that would lead to reject. Another fundamental reason is that the whole theory system of TCM is not acknowledged by western–trained audience. It might be due to different culture, more specifically, different treatment philosophy. TCM has its strong material base from single monomeric compounds to Chinese herb extracts in COVID-19 treatment. Psychosocial pharmacological effect probably plays an important role in the traditional medicine .So what is the exactly treatment philosophy in TCM culture to the novel coronavirus disease?Chinese public in general are always long taught that TCM is a national quintessence with an ancient historical origin. In addition to TCM, Peking Opera, martial arts, and calligraphy are well-known as the “four quintessence of China” both at home and abroad. National quintessence itself is more related with culture and social custom than with natural science. TCM has been played an indispensable role in the prevention and treatment of epidemic diseases in history. During the SARS epidemic in 2003, the intervention of TCM has also achieved therapeutic effect , 10. In In TCM culture perspective, COVID-19 is an epidemic disease caused by an epidemic evil with dampness and heat, which is called Li-Qi in Chinese . After LThere seems to be something in common between virus and Li-Qi. Both think that there is an external cause of disease. Modern medicine refer it virus, they usually hope to find specific drug to cure the disease. However, TCM does not know microbiology and could not capture the virus entity, they could only focus on Li-Qi-induced symptom with herbal remedies. The aim of TCM treatment is simple, so long as TCM remedies provide effective way to regulate functional disorders of the human body. Therefore, TCM remedies are used to detoxify poisonous dampness and heat, to strengthen body to resist pathogenic factor, to adjust the harmony of the internal relationship of the human body. That is to say, when TCM doctors treat this kind of disease, they do not have to make the cause clear to start. It is of importance to solve the symptoms for most patients.A small, non-randomized, single center retrospective observational study reported a shorter average duration of viral shedding and faster resolution of radiological pneumonia in hospitalized COVID-19 patients prescribed Jin Hua Qing Gan granules for more than 2 days as compared with those receiving conventional care . The potThe understanding and description of TCM is based on the ancient macro understanding of nature and the use of speculative philosophy such as Yin-Yang. In the course of history, since TCM started and developed without synchronizing with modern chemistry, biology and physics, it had to takes the road of philosophical thinking. However, by the aid of advanced science, modern medicine embarks another road of development. It can be said that TCM and modern medicine are two trees growing up in the soil of two different cultures.Although high-quality clinical trial evidence is lacking at present, the efficacy of TCM remedy on symptom improvement cannot be ignored. To treat COVID-19, TCM and modern medicine should complement each other and cooperate with each other since TCM can contribute as an alternative measure.ZL, CH, HH, ZG, and FX were responsible for the design of this work and interpretation of finding and drafting the work. FX approved the final version to be published and is accountable for all aspects of the work to ensure its accuracy and integrity. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Global climate change is a clear and present danger to our environment, but the impacts of climate change on human health are less known. People in Asian countries are more susceptible to the negative impacts of climate change and the subsequent environmental exposures because of the high population density, rapid urbanization, and natural geography of the region. The objective of this multidisciplinary collaborative ecological study was to explore the impact of environmental exposures such as temperature (°C), noise (db), humidity (%rh), air conditioning exposure time (hours), and distance traveled to school (km) on the comfort and academic success of school children in Singapore. Analysis of a large dataset from the Singapore National Science Experiment revealed a positive correlation between the distance traveled to school and favorable environmental conditions  and student academic performance. The analysis revealed that the distance traveled between home and school for public school students falls within a larger range than that for independent (private) school students. On average, students traveled farther distances to attend schools of higher academic caliber thereby increasing their exposure to environmental pollution. Student exposure to pollution can be minimized if all schools adhere to higher standards of environmental comfort and standardized academic caliber. If students can attend the school closest to their homes, they can minimize their daily pollution exposure due to traffic/commute, thereby mitigating the resultant negative health consequences. It is well known that global climate change is a clear and present danger to our environment and living conditions. However, less is known about the impacts of climate change and the subsequent environmental exposures on human health and disease. Experts feel that some existing health threats will intensify and new health threats will emerge . Asian cThe American Public Health Association (APHA) has been vocal about the global, negative impacts of environmental exposures that children face in school, stating that child behavior and physiology make them more susceptible to these exposures ,8. ChildA recent study conducted on university students taking online courses amidst the COVID-19 pandemic demonstrated that noise, lighting, and temperature all have a profound negative effect on students’ academic outcomes as well as their comfort and concentration . AnotherThe objective of this ecological study was to examine the effects of various environmental exposures on Singapore schools and how these exposures varied with respect to gender, grade, whether the school is public or independent, and the average distance traveled from home to school. We analyzed a large volume of environmental data collected through a national study from school students in the Republic of Singapore with the goal of understanding the relationships between environmental comfort, environmental exposures in and out of school, and access to quality education.The de-identified data used in this study were provided by the National Science Experiment (NSE) and used after securing appropriate permissions from the concerned agencies ,16,17. TWe also utilized an NSE dataset containing the school attended by each of the students. By merging this dataset with the environmental dataset and aggregating the data by school, we were able to create a master dataset containing the average values of each of the environmental exposures  for each school. We also determined whether the schools were all-girls, all-boys, or co-educational institutions, as well as whether the schools were independent (private) or public schools. The final dataset consisted of 8 all-girls schools, 7 all-boys schools, and 104 co-educational schools. Of the schools, 24 were independent schools and 95 were public schools.The primary school education system of Singapore is structured in the following manner. Students are required by law to attend primary school for six years, approximately from ages six to twelve. At the end of primary school, students take the Primary School Leaving Examination (PSLE), and, until 2019, their scores would be a major deciding factor for the secondary school they would attend ,19.To infer the relative rankings of the secondary schools, we used the official PSLE cutoff scores for secondary school admissions. Although the concept of PSLE exam score cutoffs has since been removed as a criterion for secondary school admissions, we used PSLE data from before 2016 as our public health indicator, since the exam score cutoff rankings provided insight into the caliber of the school.A limitation that we faced is that the PSLE cutoff established by any secondary school depends on the PSLE results of students who come from any of the numerous primary schools in Singapore. Although the PSLE score cutoffs for admission may be an indirect indication of the caliber of the school, the scores are not directly indicative. Rather, they are indicative of the caliber of the students who were admitted to the school, not the ones who are currently enrolled in the school. As a result, instead of using the 2016 score cutoffs, we averaged the score cutoffs for the years 2012, 2013, 2014, and 2015 ,22,23.Our study complies with research and publication ethical guidelines, as the purpose of the study was explained to all respondents to assure them anonymity and confidentiality. For data curation, cleaning, and analysis, we used the Python libraries Pandas, NumPy, and Scikit-Learn. Since we were conducting an ecological study, we aggregated the data by school, rather than examining individuals. For each school, we averaged the environmental exposures and distances traveled between home and school for every student attending that school. We calculated the average distance traveled by calculating the home-to-school distance for each of the students and averaging the results for every student that attended a particular school. We then added to the dataset relevant information regarding the gender of the schools and whether they were public or independent schools. We chose to examine four environmental exposures that are highly descriptive of the humid, hot, urban environment of Singapore: noise (db), temperature (C), humidity (% rh), and air conditioning exposure time (hours) ,25,26. WWe wanted to understand the relationship between each of the four environmental exposures and the average distance traveled between home and school. We plotted the average environmental exposure values for all of the schools against the average distance traveled between home and that school. We subsequently plotted the environmental exposures against distance for smaller cohorts (with respect to gender and independent/public) of schools in order to understand how these relationships change with respect to demographics.We studied the relationships between environmental exposures and academic performance as quantified by the academic rank of the 35 secondary schools in the dataset. We used only secondary schools to do this analysis because secondary schools in Singapore are definitively ranked, and those rankings are available publicly. We used the PSLE score rankings to order the secondary schools by rank and then plotted the environmental exposure levels and distance traveled from home to school against the rank.p < 0.001), mean temperature , and mean humidity  and directly correlated with mean AC exposure time .As shown in n = 24) and public schools (n = 95), the distance traveled from home to school by students was inversely correlated with mean temperature  and mean noise , as shown in p < 0.001) and directly correlated with mean AC exposure time . In independent schools, there was no discernible association between distance traveled to school and mean humidity  or distance traveled to school and mean AC exposure time . As shown in We found that for both independent (p = 0.637), mean noise , and mean humidity . Rank also tended toward direct correlation with mean AC exposure time  and mean distance traveled . From these results, we observed a strong correlation between the distance traveled between home and school and the rank of the school, implying a perception of higher academic quality in schools at a farther distance from home.As shown in This work is unique because it is a large study involving 35,536 students studying in 119 schools in the Republic of Singapore. Of these schools, eight schools are all girls, seven schools are all boys, and 104 schools are co-educational schools. Additionally, of these schools, 24 are independent and 95 are public schools. We plotted each of the exposures against both academic performance and distance traveled to investigate the relationships between environmental comfort (as quantified by temperature (°C), noise (db), humidity (%rh), and air conditioning exposure time (hours) and academic success (based on PSLE scores)) in Singaporean school children from diverse backgrounds. This study represents the first time that NSE data has been used to better understand primary, secondary, and post-secondary school student health.Our data showed that overall, school students were likely to travel greater distances to attend schools of high environmental comfort and strong academic caliber. We also found that compared to public school students, students who attended independent schools typically traveled shorter distances between home and school. While public school students traveled anywhere between 2 and 12 km between home and school, independent school students traveled between 2 and 8 km between home and school. These findings imply that students from lower socioeconomic status likely attended public schools and had to travel farther to attend a school of higher quality. As demonstrated in previous studies, as children have to travel farther to attend school, they will be exposed to more pollutants and will become more tired compared to those who attend school closer to their homes ,27. StudTo combat inequity in access to education, we need to implement a system by which a high quality of education is available through every single school in Singapore. This system will ensure that children can go to local schools close to their homes. Fortunately, the government of Singapore has already taken a strong step toward equity in education by removing emphasis from the PSLE exam scores in order to place more emphasis on student well-being. As PSLE exam scores no longer inform the caliber of school that a student will attend, it can be assumed that the standard of education in schools will normalize and become more equivalent to one another. Quality of education and quality of a student’s thermal environment should not be contingent on the distance traveled to reach school ,27,28.Finally, environmental comfort should be held to the highest standard. Due to the urban air pollution and noise pollution present in Singapore, schools must institute the highest quality of environmental comfort, to ensure a conducive learning environment for students. As suggested by a 2020 study in Mexico about how environmental exposures  affect student performance, ergonomically designing classrooms to provide optimal temperature, humidity, and noise levels would be a strong step towards improving environmental comfort standards in schools .The imbalanced nature of the dataset with respect to gender was a limitation of this study and made it difficult to reach definitive conclusions concerning the relationship between gender and equity in access to quality education. In the future, we hope to further explore how gender and socioeconomic factors play a role in gaining access to quality education. We also hope to continue this work and learn how distance traveled between home and school and the related environmental exposures may be affecting student health and school absences.According to the World Health Organization (WHO), between 2030 and 2050, the direct and indirect effects of climate change and the subsequent environmental exposures are expected to cause approximately 250,000 additional deaths per year. Singapore’s location and urbanization make it particularly susceptible to these negative impacts . The neg