Despite improvement in recent decades, maternal and newborn mortality in Bangladesh remain high. A community-based intervention package was initiated in 2009 in Netrokona, a rural district in Bangladesh, to engage individuals, families and communities to improve maternal and newborn health. In this article, we present the effect of the intervention package on improvement of women’s capacities with regard to maternal and newborn health, their husbands’ capacities to effectively support them and use of skilled services during pregnancy, childbirth and after childbirth.We adopted a quasi-experimental design to evaluate the effect of the intervention package. A cross-sectional household survey was conducted in the intervention and comparison sites at baseline in 2014 and at endline in 2016. A total of 725 women were interviewed at baseline  and 737 at end-line . A total of 317 of their husbands were interviewed at baseline  and 731 at endline . Propensity score matching (1:1) was performed and the subsequent analysis was restricted among 235 matched women at baseline and 217 matched women at endline. Descriptive analyses were performed for the covariates for matching. Bivariate analyses between baseline and endline were done for reporting women and their husbands’ knowledge regarding pregnancy and childbirth, birth preparedness and complication readiness practices and utilization of health services.There was significant increase in awareness of danger signs during pregnancy, childbirth and following childbirth among women and their husbands, as well as increase in awareness of rights related to maternal and newborn health. There was also significant increase in birth preparedness and complication readiness practice among pregnant women and their husbands in the intervention site. Regarding use of skilled health services, there was significant increase in early initiation of antenatal care, attending at least one antenatal care contact and attending at least four antenatal care contacts. No notable improvement was observed in giving birth in the presence of skilled attendant or use of postnatal care.We conclude that the intervention package was effective in building the capacities of women and in engaging their husbands positively in maternal and newborn health. This may have translated into increased use of skilled care during pregnancy. Despite being mostly preventable, an estimated 303 000 women and 2.7 million newborns continue to die each year due to conditions related to pregnancy and childbirth, with the vast majority of these deaths occurring in low- and middle-income countries -5. RecogDesigned to be coherent with the UN Agenda 2030 and the Sustainable Development Goals (SDGs) , the GloSimilar to many other low- and middle-income countries, Bangladesh has made considerable improvements in maternal and newborn health (MNH) over the past two decades ,10; howeIn 2009, a Swiss NGO Enfants du Monde and its local partner, PARI Development Trust, began supporting the Ministry of Health and Family Welfare (MOHFW) to implement a programme for improving MNH in selected areas of Netrokona district in Bangladesh. This programme was based on the World Health Organization’s (WHO) framework for Working with Individuals, Families, and Communities (IFC) to improve MNH, which provides a concrete model and tools for governments and implementing organizations to operationalize health promotion for MNH, thereby building the capacities of women and engaging families and communities in improving MNH. Moreover, the IFC approach also aims to stimulate collaboration between community actors and health services, as well as improvements in health services . In thisThe intervention package was implemented in a selected sub-district  of Netrokona district, a resource-poor, hard-to-reach area located in the northern part of Bangladesh along the border with India. The intervention package was designed based on the WHO’s IFC framework  and was Specific interventions were identified and co-designed through consultation with programme stakeholders, including local MOHFW managers, NGO implementing partners, as well as community leaders and representatives. The programme was initially implemented in the first phase (2009-2012) in four selected unions  of Kalmakanda upazila. During the initial phase, the implementation of the intervention package was undertaken with the local implementing NGO taking the lead and their community health workers playing a crucial role. Over time, their role increasingly evolved into support activities for MOHFW staff working in the area as local public health managers took on increased responsibility for the programme.Beginning in 2013, the programme was expanded to the four remaining unions of Kalmakanda upazila to cover the entire sub-district and the International Centre for Diarrhoeal Disease Research, Bangladesh  was included to evaluate the effectiveness of the program focusing on these expansion areas. At this time, the implementation strategy also evolved and was aligned with the existing Health, Population and Nutrition Sector Development Program, a sector-wide approach initiated by MOHFW in 2011. As such, the programme aimed to shift the entry point of the intervention package to the government community clinics. In this new phase, the implementing partner NGO assumed a supporting role to support local MOHFW health care providers to take responsibility for delivering the intervention package. MOHFW facility-based health service providers and community-based health workers became the main service providers, while the NGO community health workers were reduced to a total of one per union in 2016 from three to four per union in 2009.Based on the consultative process and the evolution over time of the programme, the following key interventions (most of which were being implemented in the previous interventions unions) were planned and subsequently implemented in the new intervention unions from 2013 onwards to build the capacities of pregnant women and engage communities in MNH , increasing their awareness of the rights and needs associated with MNH, and increasing health care providers’ capacities to effectively counsel pregnant women and their families on MNH care.The BPCR intervention was co-designed through a consultative process with national technical experts, local MOHFW managers, facility-based health service providers, community-based health workers and representatives from the communities which ensured the reflection of local preferences and context. The BPCR components prioritized through this process were as follows: identification of a desired place for birth, identification of the nearest health facility to consult in the case of complications, identification of a preferred birth attendant, arrangement of transportation to reach the birthplace, saving money to cover potential costs which could be incurred when availing routine and emergency MNH services, and identifying a potential blood donor. This covered six of the eight components recommended by WHO and all of the components promoted by the Bangladesh Maternal Health Strategy ,15. In aAll facility-based health service providers and community-based health workers of MOHFW were trained in BPCR, following which they assisted pregnant women to develop an individualized plan either during ANC contacts in health facilities or through outreach visits in the community. The intervention was supported by a team of community health workers employed by the main implementing NGO.A card referred to as the “Birth and Emergency Preparedness Plan card”, or “BEPP card”, was developed as a key tool in the intervention package. This BEPP card illustrated the main components of planning for birth and potential complications prioritized by the programme and proposed locally-relevant categories for each component, eg, locally available health services and transport. The card also included illustrations of the most common danger signs in women during pregnancy, labour and after childbirth, as well as danger signs in newborns for which skilled care should immediately be sought.The BEPP cards were distributed to all identified pregnant women by health service providers during the ANC contacts at health facilities and by community health workers (both government- and NGO-employed) during the scheduled household visits. The BEPP card was used by the facility-based health service providers and community-based health workers to assist pregnant women to develop a plan across the key components of BPCR. If the husband or other family members were present with the woman during the consultation, they were included in developing the plan. Health care providers prioritized decision making by the women during birth preparedness planning. The plan was then reviewed with the woman  during each subsequent contact with the health service provider during pregnancy. In addition, she was specifically counselled on key danger signs during pregnancy, childbirth and during the postpartum period, and the importance of seeking care from appropriate health facilities if they experienced any of these danger signs.Community-based health workers conducted courtyard meetings with women in the community to discuss rights related to MNH and the special needs of women and newborns during pregnancy, childbirth and after childbirth. The courtyard meeting were gatherings of 20-30 rural people from the community, especially women, their husbands and other family members, organized at a designated place, usually a person’s house in a village. The government community-based health workers, with support from NGO health-workers, organized 1-3 courtyard meetings per community clinics per year. The courtyard meeting usually lasted from half an hour to two hours. Rights topics which were included during these discussions include the right to access MNH services, rights related to decision-making, right to respectful care and right to information. In addition, they discussed the needs of women during pregnancy, childbirth and following childbirth, including BPCR practices and danger signs for which skilled care should be immediately sought.Finally, the intervention package aimed to build the capacities of facility-based health service providers and community-based health workers (government) to more effectively counsel pregnant women and their families on MNH and support women to act as agents of change for their health. Health service providers and community-based health workers were trained to improve their communication and counseling skills, and thereby their capacities to respond to the needs of women and families. Specifically, the training focused on moving beyond simply providing information during MNH contacts toward increased responsiveness through active listening, two-way communication, demonstrating respect, pre-assessing and building on the knowledge of service recipients, understanding women’s situation and assisting them to develop and follow through on their plans to improve MNH .The intervention package also aimed to increase the participation of the community, and the involvement of men specifically, in contributing to a supportive environment for MNH.The intervention package specifically targeted men and aimed to increase their involvement in MNH. This was done through the courtyard meetings conducted by community-based health workers to discuss MNH rights and needs of women during pregnancy and childbirth. During these meetings, the roles and responsibilities of men in MNH were also discussed. This was meant to destigmatize men’s involvement in MNH, which is traditionally relegated to the women’s sphere. In addition, husbands were encouraged to participate in BPCR actions. If a husband was present during a contact with a pregnant woman, the health care provider sought to involve him in BPCR, either in elaborating the plan with the woman or in reviewing the plan if it had already been developed. If the husband was not present, the woman was encouraged to discuss her health and BPCR plan with her husband and invite him to participate in future ANC contacts.Actions were identified to build awareness of the broader community on needs and rights related to MNH, and to mobilize communities to identify and implement solutions to overcome barriers to accessing MNH services. Courtyard meetings conducted by community-based health workers were used as the main platform for dialoguing with the community to discuss the rights and needs of women related to MNH. In addition, communities were mobilized through courtyard meetings and through meetings with community leaders to address barriers to health services access related to transportation and finances. Through these mobilization efforts, some community groups worked together to mend broken roads or build small roads to connect the health facilities with central roads. Some communities mobilized resources to purchase and manage rickshaw vans (non-motorized three-wheeled vehicles) reserved for transporting women to health facilities for childbirth or to receive emergency obstetric or neonatal services. Other communities generated funds in order to offer support to women with limited financial resources to cover costs related to care-seeking for obstetric and neonatal emergencies.A quasi-experimental design was adopted to evaluate the effect of the intervention package. A cross-sectional household survey was conducted in the intervention and comparison sites at baseline in 2014 and at endline in 2016.The site of the study was in the Kalmakanda sub-district of Netrokona district in Bangladesh (approximate population 300 000), where the intervention package was implemented. Netrokona is a haor (wetland) area, with weak transportation systems and infrastructure. It is among the 14 lowest-performing districts of Bangladesh with poor coverage of MNH services and high newborn and child mortality rates ,16. The Eligible respondents were married women between 15 and 49 years of age with a history of childbirth in the 12-month period preceding the date of survey. Their husbands were also included as a secondary study population.The study was designed to evaluate the effect of the intervention package on MNH. Skilled attendance at birth was selected as the primary outcome of interest for the sample size calculation and women with a recent history of childbirth were regarded as the primary study population. As per the Bangladesh Maternal Mortality Survey (BMMS) 2010 report , coverage of birth with a skilled attendant was 15.6% in Netrokona. It was assumed that the intervention package would increase the coverage of birth with a skilled attendant by at least ten percentage points (absolute) between baseline and endline. We also wanted to ensure a higher representation from the intervention site (intervention: comparison = 1.5:1), which would allow us to generate more precise estimates of MNH-related knowledge and practices from the intervention site. The unadjusted sample size was 404 from the intervention site and 269 from the comparison site at 80% power and 5% error probabilities. The sample size was then adjusted for design effect/cluster effect (1.25) and non-response (5%). The final sample size was 425 women with a recent history of childbirth from the intervention site and 283 from the comparison site at baseline and at endline. Based on this sample size, we interviewed 725 women with a recent history of childbirth at baseline (444 from the intervention site and 281 from the comparison site) and 737 at endline (442 from the intervention site and 295 from the comparison site). In addition, as an exploratory component of the study, we approached all husbands of the women interviewed during the survey. A total of 317 husbands were interviewed at baseline (178 from the intervention and 139 from the comparison site) and 731 at endline (440 from the intervention site and 291 from the comparison site). The non-response rate among husbands was 56% at baseline and 1% at endline.We adopted a multi-stage cluster sampling technique to select the eligible respondents  2011 and the BMMS 2010 ,18. SepaData analysis was conducted using Stata 13.0 . We used the standard steps of principal component analysis to generate the socio-economic indices of the households that we have interviewed, based on which the wealth quintile was generated ,20. HousSince we adopted a quasi-experimental design, we used propensity score matching to match comparison and intervention respondents to create a valid and counterfactual comparison group ,22. The Ethical approval to conduct the study in Netrokaona was obtained from the Institutional Review Board of icddr,b (Protocol Number: PR 14024). Written informed consent was obtained from each participant before beginning the interview after they were fully informed as to the objective of the study and the way in which the data would be used. They were also informed that participation was voluntary and could be terminated at any time without reason and without any penalty. Privacy, anonymity and confidentiality of the participants were strictly maintained during data collection and analysis.P < 0.001). Similarly, in the intervention area, the percentage of women aware of at least three danger signs related to childbirth increased from 24% at baseline to 68% at endline. In contrast, the knowledge level did not increase in the comparison area (32% at baseline vs 22% at endline). There was a two-fold increase in the awareness of at least three postpartum danger signs (30% at baseline to 51% at endline) in the intervention area, while the level of knowledge decreased in the comparison site. Regarding newborn-related danger signs, the knowledge of at least three danger signs increased from 63% to 83%, with a declining trend in the comparison area. For all knowledge categories, the intervention had a significant effect . There was also a substantial increase in husbands’ awareness of at least three danger signs during pregnancy (6% at baseline vs 57% at endline), during childbirth (11% at baseline vs 44% at endline) and after childbirth (27% at baseline vs 77% at endline). In contrast, knowledge remained stagnant in the comparison area between baseline and endline. For all knowledge categories, the intervention had significantly increased levels .P < 0.001. Similarly, a significant increase was observed regarding the awareness of the right to respectful treatment by health care providers. Less than 10% of women at baseline were aware about their rights to receive information from health care providers in the comparison and intervention areas. However, around one-quarter of women were aware of this right at endline in the intervention area with no apparent change in the comparison area (DID P < 0.001). Around 98% women in the intervention area at endline were aware of at least two out of the four key messages related to rights associated with MNH (DiD P < 0.001). Similar trends were observed among husbands regarding their awareness of rights related to MNH.P < 0.001  than the husbands in the comparison area (62%) at endline (DiD P < 0.001).We asked the women and husbands regarding their practices related to BPCR. P = 0.709). Less than one-third of the women and less then one-fifth of the husbands mentioned that they discussed BPCR with a health care provider during pregnancy at baseline (no difference between the comparison and intervention area). Although this trend did not change in the comparison area, around three-quarters of the women reported having discussed BPCR with a health care provider during their pregnancy in the intervention area at endline . Similarly, two-thirds of the husbands reported having engaged in this dialogue in the intervention area at endline .It is worth noting, however, that while planning for a desired place for childbirth and preferred birth attendant was high, a lower percentage of pregnant women planned to give birth in a health facility or with the assistance of a skilled birth attendant at home and the DiD estimator was not significant . Similarly, less than one-tenth of pregnant women atended four or more ANC contacts with a skilled health care professional at baseline (no difference between the comparison and the intervention area) which increased to 34% in the intervention area at endline, with no notable increase in the comparison area . In terms of early initiation of ANC (within the first 12 weeks of pregnancy), there was a significant increase in the intervention area (14% at baseline vs 57% at endline), which remained unchanged in the comparison area .Regarding birth with a skilled birth attendant (either facility-based birth or birth attended by trained provider at home) and PNC from a skilled health care professional within two days of childbirth, there was no notable improvement between baseline and endline in either the comparison or intervention areas.P = 0.164). There was significant difference between the comparison area (41%) and the intervention area (68%) (P = 0.047) at endline. However, the difference was not significant after DiD adjustment (P = 0.135).Among women who experienced complications during their most recent pregnancy, 22% in the comparison area and 33% in the intervention area sought care from medically trained provider at baseline . This can be explained by the presence of the routine MNH program by MOHFW in the comparison site. However, these improvements were random and had sporadic effect on select number of MNH indicators as the intervention components in the routine program were not comprehensive enough and inefficiently implemented. In contrast, the intervention package implemented in the intervention site had a comprehensive set of interventions targeting a range of MNH domains. The findings presented in our article demonstrates that the intervention package successfully improved MNH across all domains  in the intervention site compared to standard practice. This highlights the gaps in routine programmes and the importance of having a comprehensive package of community-based and facility-based interventions for improving MNH. The alternate explanation could be contamination. However, it is difficult to explain the improvements in selective indicators through the contamination theory.Finally, the results of our study indicate that the intervention package was effective in improving care-seeking practices during pregnancy. Indeed, a significant increase was detected across all indicators related to ANC: pregnant women attending at least one ANC contact from a skilled health care professional, pregnant women attending at least four ANC contacts with a skilled health care professional and early initiation of ANC. These findings are consistent with other studies assessing BPCR interventions which have overwhelmingly found a link between BPCR and increased utilization of ANC ,29,34-36In our study, few pregnant women planned to give birth in a health facility in the comparison and intervention areas and this did not change over the intervention period. Therefore, it is perhaps unsurprising that we did not detect an increase in facility childbirth as women were not planning for it. Several factors may be responsible for this. In rural Bangladesh, women have traditionally given birth at home with a traditional birth attendant. The strong socio-cultural norms and preferences during the childbirth and postpartum periods play a particularly instrumental role in determining the care-seeking practice during childbirth and after childbirth ,45, and Another explanation could be the service availability and readiness of health facilities to provide skilled attendance at birth and manage obstetric emergencies. As per the last national health facility survey (in 2014), less than 10% public hospitals and facilities have have demonstrated readiness for performing all nine signal functions for providing comprehensive care related to childbirth . The conMoreover, we did not detect an increase in care-seeking after childbirth or for routine PNC. Again, this can likely be explained by socio-cultural factors, as the common practice is to limit mobility of women who have recently given birth and their newborns to within the home for approximately a month following childbirth . It is wIt is important to point out some of the limitations and strengths of this study. One of the limitations is the inability to attribute the change in knowledge, awareness, and practice related to MNH to individual components in the intervention package. However, we can attribute some of the changes that we have observed over the intervention period to the total intervention package. Since there is a dearth of evidence regarding operationalization of the WHO IFC framework for a district model of implementation, the novel attempt of developing an intervention package based on this framework and implementing it through routine systems and structures can be regarded as a major strength of our study. Another limitation of the study is the lack of randomization of the intervention clusters. However, we tried to address this by conducting propensity score matching between women from comparison and intervention areas based on their background characteristics. Therefore, the results demonstrating the effect of the program are adjusted for the co-variate differences between comparison and intervention, which adds further strength and more validity to the study findings. We also acknowledge the limitations regarding recall bias and reporting errors. However, we believe that these will not have any impact on the results of the study (difference between comparison and intervention) as the biases would likely be similar with respondents from the comparison and intervention areas. Moreover, we have considered a recall of only 12 months for assessing the knowledge, awareness, and practice related to MNH, whereas other globally and nationally accepted surveys consider three years of recall for such assessments ,17. ThisIn addition, our study was designed only to measure change among women, while we know that household members  are also important gate-keepers within the household. However, we have included husbands in our study and presented their knowledge and involvement in MNH; which is one of the important strengths of the study. We were also unable to measure change at the community level, which was an important focus of the intervention package. Moreover, we were not able to assess programmatic aspects of implementation in this study since the evaluation strategy was not designed to address that. Indeed, the high number of partners collaborating in the programme introduced a level of complexity to implementation which may have influenced results.A final limitation of our study was the short period of implementation of between baseline and endline. Social transformation is a long-term process which requires a significant amount of time to affect change and be able to detect it. This may be one explanation for the limited change in use of skilled health services for childbirth and postpartum.The results of our study suggest that the intervention package based on the WHO IFC franework was effective in building the capacities of women and in engaging men positively and in MNH. This may have translated into increase use of skilled care during pregnancy. At the policy level, actions to increase the individual capacity of women to act to improve their health and that of their children and to increase the participation of men and the community in MNH should be prioritized along with efforts to increase the provision of skilled MNH services as the country moves forward toward reaching the SDG targets.


Cancer is a growing public health concern in low-income countries (LICs). From 14 million new patient cases identified worldwide each year, 8 million are diagnosed in LICs. The fatality rate is 75% in LICs compared with 46% in high-income countries. Causes are low literacy levels, lack of awareness and knowledge about cancer, and limited education of health care professionals that leads to late detection and diagnosis. In Tanzania, cancer incidence will double to 60,000 in 2030. The referral hospital of Northern Tanzania established a new cancer unit in December 2016 to meet these needs. However, there is limited knowledge about perceptions of health care professionals toward cancer care in LICs. This study aims to understand attitudes and perspectives of those professionals and the treatment-related challenges in a newly established center to assist future efforts in this field.A qualitative method approach using in-depth interviews was chosen to achieve inductive conceptualization. Analysis of data was performed according to qualitative content analysis.Eleven interviews were conducted. Five main categories were found: training and education of staff, availability of financial support, challenges in management, interests in future developments, and job satisfaction. Subcategories elaborated in more detail within the main categories.Limitations in staffing, training, and education were major concerns. The importance of sustainable funding and the needed cooperation of the government with international aid were identified as key points. The involvement of different stakeholders requires guidance by health care management. Health care professionals expressed their satisfaction with the possibilities of treating cancer and the rewarding feedback from patients. Misconceptions and poor knowledge by patients were mentioned as reasons for delayed health-seeking behavior. Screening and awareness programs were seen as useful interventions. A report by the Tanzanian National Bureau of Statistics in 2013 indicates that 28.2% of the population lives below the basic needs poverty line; 68% live on less than 1.25 US dollars a day, according to the World Bank.7Another important barrier to seeking early medical attention is poor literacy. Lack of awareness and knowledge about cancer is highlighted by the fact that only a minority of the population in Tanzania considers cancer a major health problem.5 but has only 0.31 doctors per 10,000 people to provide medical services.8 Until recently, Tanzania was home to only two specialized cancer hospitals: Ocean Road Cancer Institute (ORCI) in cooperation with Muhimbili National Referral Hospital in Dar Es Salaam and Bugando Medical Centre in Mwanza. Both hospitals face staff and equipment shortage,9 which makes it more challenging to provide quality health services to a large number of patients.Tanzania has a total population of almost 55 million10Regarding training and education, two postgraduate Masters programs at Muhimbili National Referral Hospital are available: Master of Medicine in Clinical Oncology and Master of Medicine in Hematology and Blood Transfusions. Postgraduate hematology-oncology education for nurses is not available in Tanzania, but efforts have been made to introduce short educational courses.7In the past decade, the Tanzanian government has recognized the need for cancer treatment and accordingly started funding ORCI to support early detection programs and to provide services to patients who need chemotherapy and radiation treatment. However, the number of patients is exceeding the capacity of the hospital.With the initiative to address the needs of patients with cancer, Kilimanjaro Christian Medical Centre (KCMC), the tertiary hospital of the Northern Zone of Tanzania, established a new cancer care center (CCC) in December 2016.Establishment of the CCC is planned in three phases. The first phase, which started in December 2016, provided an outpatient clinic and chemotherapy infusion unit. Although many patients are also treated as inpatients in their respective departments, these inpatients are seen by the specialists on a consultation basis. The second phase, which is starting in 2019, will be the construction of an oncology inpatient ward and a patient hostel, which will be instrumental for patients who do not need inpatient care but need to travel long distances for treatment. The final, third phase, which is planned for 2021, will be a radiation unit.During the first year of operation, two specialized physicians, four nurses with oncologic training, one specialized palliative care nurse, two pharmacists, one administrative staff, and one public health officer were employed at the CCC. Approximately 900 patients attended the service at CCC in more than 3,000 appointments, and 400 patients received chemotherapy in 2017.Funding of the CCC is a joint effort lead by the US-based Foundation for Cancer Care in Tanzania, the Tanzanian Government, and the Evangelical Lutheran Church of Tanzania with their partnering organizations in Germany.Cancer treatment with all its implications has not been widely studied in Sub-Saharan Africa. Cancer treatment is a new medical service provided by the CCC, so this study aims to document and analyze the attitudes and perspectives of health care staff toward chemotherapy and the challenges they face on a daily basis at their workplace. This understanding will help explore the service-related spectrum of challenges that occur in LIC settings.11 This approach assures an understanding of the participants’ viewpoints and their own concepts of work in cancer care. By using in-depth interviews as a qualitative and comprehensive approach, an inductive conceptualization of the topic can be achieved.The research field is widely unknown, so we chose the grounded theory approach to “elicit each participant's interpretation of his or her experience.”All professional staff members working for the new CCC when the study was conducted were interviewed. The characteristics of the participants are listed in 12 The interview guideline was based on literature review and discussions made with key persons in and outside KCMC before data collection. The professional background of the interviewees was taken into consideration during the guideline design and during the interviews.After extensive narratives of the participants were obtained through open-ended questions, semistructured interviews followed to focus on specific topics: the experience of each participant about handling chemotherapy and working at the CCC, the challenges he or she faced on a daily basis, and possible suggestions for improvement.13 Analysis was conducted by two researchers independently to assure validity.Analysis of data was performed according to qualitative content analysis and followed the steps of inductive theme formation, context analysis, and structuring.The study was approved by the board of the Ethic Committee of Kilimanjaro Christian Medical College. The study also followed guidelines of Good Research Practices according to the Declaration of Helsinki of the World Medical Association.In total, 11 interviews were conducted between March and May 2017. Interviews were conducted by the first author and lasted between 20 and 60 minutes.As a result of the interview analysis, five main themes were identified: training and education of staff, availability of financial support, challenges in management, interests in future development, and job satisfaction; corresponding subthemes were explored . CorrespThis main theme contains all assertions about professional training of the interviewees themselves or of the CCC staff in general. In addition, the theme contains related issues connected to professional education.One of the most prominent findings, mentioned by every participant, was fear of handling chemotherapy. Health care staff expressed distress about handling chemotherapy: they feel concerned about a high risk of suffering toxic effects of the medication in the future as a result of exposure, especially when they prepare the chemotherapy without using proper protective equipment. This issue was not asked about by the interviewer in particular; however, it was mentioned in response to the open-ended question.Because this was a new field for the staff, they mentioned a critical need for guidance about how to handle chemotherapy safely and properly and how to store it.The interviewees shared a common view that the CCC was understaffed, especially with the increasing number of patients. In addition, the staff expressed their need for more training.Conversely, some nurses mentioned their worries about not giving patients optimal counseling because of limited time capacities. They also expressed that adequate training and increased staff members would lead to a better outcome.Some of the nurses expressed their difficulties in venipuncture, especially when under time pressure. Sometimes venipuncture required more time for each patient, so it added more stress about the understaffing issue.Financial difficulties and limited resources were mentioned by the CCC staff in different ways. They expressed the need for more financial support to improve health care facilities, to increase the availability of medications and equipment, and to provide assistance to patients with cancer.CCC staff noted their need for improved facilities that would offer better infrastructure, such as a laboratory for the cancer center with standardized testing procedures and more equipped chemotherapy rooms.Some of the health care staff stated their concerns about the availability of medications and of necessary equipment for safe-handling procedures. Although donations can be helpful for the newly established CCC, especially because it operates in an LIC setting, some donations were not fit for the purpose and not suitable for the setting.Apprehensions were expressed about the sustainability of the CCC service, because it is based mainly on international funding.The staff faced various operational issues that were hindering efficiency in the work place. In particular, the dynamics of a newly established cancer treatment facility, with many different stakeholders involved, would lead to unforeseeable hurdles. The following subthemes were identified:Staff noted that division of labor and definition of tasks were not clearly enough defined between different specialties, which caused duplicate or unattended responsibilities.The other management issue mentioned was lack of organizational arrangements on a day-to-day basis at the CCC, and its effects were noticed in many aspects, such as delays in the patient test results. A physician mentioned that CCC was still going through phases of out-of-stock equipment because of the lack of organizational skills to audit the stock and order equipment timely. Use of more standardized measures was mentioned as a way to enhance efficiency for the daily work routine.Unprecedented, overwhelming numbers of patients for diagnosis and treatment created more challenges in the management of the center, as mentioned by many interviewers.The health care providers expressed their huge interest in the development of the CCC, and they identified some of the intertwined factors that played a paramount role in the development process:The care providers mentioned the importance of the local government’s role in providing future support to the CCC. This support could be manifested in policy making, such as financial support to the Tanzanian citizens diagnosed with cancer.Another way in which the government could play a role is by assisting in the provision of medications and by making medicine available on a local level. One of the participants mentioned that the financial support was directed to the government-run ORCI. However, as per the government plan, the target was to decentralize cancer services to other regions in the country. This process, however, has not yet reached KCMC, and the delay was creating financial strains.The health care staff expressed their current worry about their dependency on international donors to provide the needed medications and equipment. This dependency raises concerns about sustainability and continuity of the provision of services in the future.Some of the health care providers proposed learning from other hospitals that have experience in this field and a similar low-resource setting, like ORCI or the Bugando Medical Centre. This suggestion could be helpful because of the common context that these centers share.Besides the challenges and obstacles in the delivery of chemotherapy, the interviewees expressed their satisfaction about working at the CCC.The possibility of having an effective treatment of cancer, which was lacking, was an exciting experience for the health care professionals (HCPs). The joy of getting a rewarding feedback by curing patients or at least by reducing their burden of symptoms also was mentioned, especially by the nurses.Regardless of the problems mentioned, the staff of the new established CCC appreciated the progress in their field of work.Generally, the answers of the HCPs were consistent throughout all professional groups. With regard to the fear of handling chemotherapy, responses depended on previous experience and level of exposure to chemotherapy. Those HCPs involved in handling, reconstitution, or administration of chemotherapy expressed more concerns. Female professionals were especially concerned about the influence of handling chemotherapy on their reproductive health.This study explored the attitudes and perspectives of health care staff toward cancer care in a newly established treatment facility in a low-resource setting.14 Rick et al15 displayed that the baseline knowledge among HCPs about cancer was limited in an urban Tanzanian setting. Additional studies have shown that poor baseline understanding of cancer and chemotherapy exists among medical staff in Tanzania and concluded that there was a need for continuous medical education and training.17 The same findings were highlighted by Makani et al18 about knowledge in hematology among Tanzanian HCPs.One theme mentioned by all participants was the strong need for more oncology training. This finding resembles results of previous research. In a Knowledge, Attitudes, and Practices study conducted with medical staff in Uganda, less than 40% were aware of the risk factors for cervical cancer.In this study, many participants mentioned that sufficient oncology training was lacking before they started working at CCC. Thereby, the nurses in particular played an important role to provide care and deliver services to patients through monitoring of physical conditions and administration of chemotherapy. In addition, they helped counsel patients and families about medical conditions and the expected adverse effects of the treatment.Despite partial funding by international donors, the insufficient level of financial support at CCC was another main concern. That manifests itself in two dimensions: the lack of proper facilities and shortages of medication and equipment, and the concern about future sustainability of these international funds and so the continuity of the CCC itself.19The financial concern is closely interlinked with the above-mentioned fear of handling chemotherapy: When inadequately trained staff and a lack of standard operating procedures are coupled with equipment shortages , HCPs lack confidence to perform daily tasks, and their fear is reinforced.20 among Turkish oncology nurses, in which nurses indeed expressed their exhaustion but also their increased levels of empathy, patience, awareness about priorities in life and job satisfaction. Despite an excessive workload, Australian oncology nurses showed high levels of personal satisfaction and personal accomplishments in a survey among 234 nurses.21 That job satisfaction among this group can be enhanced by a good physician-nurse relation, the freedom to make patient-care decisions, and appropriate staffing was stated in a Canadian survey.22However, the interviewees expressed satisfaction with the achievements so far, especially that effective treatment options were available for patients with cancer. Furthermore, rewarding feedback from the patients was another positive aspect for the HCP. These findings are consistent with a study from Kamisli et alHealth care management was another concern for the HCPs. This concern manifested as difficulties in efficient provision of services, such as having test results prepared before the next chemotherapy cycle, having an electronic inventory system for medications to have necessary stock always available, and not having standardized treatment protocols.23 Organizational strains, lack of recognition and support from management, and unrealistic expectations were also associated with lower job satisfaction and higher burn-out rates among New Zealand oncology HCPs.24Management and leadership are vital for good health governance. As a health governance report by the United States Agency for International Development stated, it is important to have governance in addition to operational capacity when delivering health services.26 This increase could create more strains on the availability of medications and equipment and also may affect the quality of services.Limited management capacity was negatively affected by the unprecedented number of patients visiting the center. When the study was conducted, only four nurses and one full-time pharmacist were assigned to CCC to provide services for approximately 180 chemotherapies monthly. As of 2018, after the increased public awareness of cancer that resulted from media coverage of the services provided, CCC expected to receive approximately 600 additional patients annually, according to the executive director of KCMC.The study results were used to shape the functionality of the center. Standard operating procedures for chemotherapies have been implemented, and managerial issues were resolved by implementing the position of a clinic administrator who oversaw funding, procurement, and patient flow. A training about safe handling of chemotherapy conducted by the German Institute for Medical Mission was extended to respond to the fear of handling. Continuing medical education for the staff was implemented as internal and external trainings in regular intervals. Currently, staff numbers have increased and the government has contributed to medication on a large scale.Although all interviewees received their professional education in the English language, a limitation could be loss of information by not presenting information in Swahili. The study was conducted shortly after the opening phase of the CCC. Therefore, the results must be interpreted with this background. Nonetheless, this timing is also a strength, because it provided insight about the problems during the implementation phase and could serve as a guidance for similar centers.27—as well as the national guidelines of Tanzania, which are expected to be released in 2019—could be instrumental. Because cancer care in an LIC is costly, coordination with health insurances, donors, non-governmental organizations, pharmaceutical companies, and other stakeholders is an important management task that must be addressed by health care management professionals.As cancer burden increases continuously, increasing numbers of patients in the few available cancer treatment facilities in Tanzania are expected. Adequate numbers of qualified HCPs must be trained and available from the early stages of new facilities. Provision of standard operating procedures for cancer treatment could help streamline daily work tasks. The NCCN guidelines for Sub-Saharan Africa28 showed that a 1-day interventional workshop has the potential to enhance resilience, prevent burn-out, and increase satisfaction with current self-care.Collaboration with existing cancer treatment facilities in an LIC can provide expertise and synergy for new centers. To create resilience among oncology nurses, an interventional study from Poulsen et al


Job stress is considered one of the critical causes of construction workers’ unsafe behaviors. As a mainstay industry in many countries, the construction industry has a considerable number of employees and the research on how job stress affects workers’ unsafe behaviors has important theoretical and practical significance to improve construction safety performance through better job stress management. In this study, the authors thoroughly reviewed the literature and conducted semi-structured interviews to identify the dimensions of job stress, designed the job stress scale and cited the safety behavior measurement scale. After that, a questionnaire survey was developed using the proposed measurement scale and distributed to the construction employees from a project in Beijing. One hundred fifty responses were collected and analyzed using reliability analysis to validate the scale’s internal consistency. Results from factor analysis indicate that the scales of job stress measurement can be grouped into six dimensions. To demonstrate the applicability of the developed scale on construction safety management research, the collected data was used to test the hypothesis that job stress has a negative correlation with safety behavior. Results show that the hypothesis is valid, and there is a negative correlation between job stress and safety behavior. In addition, finer results of the relationship between the six dimensions of job stress and safety behavior can be obtained. In summary, this study developed an improved stress scale for construction workers in China, and the proposed scale was validated by analyzing the data from an empirical study in Beijing. With the rapid increase of construction projects in the past several decades, the safety challenges in the construction industry have become increasingly large ,2. AlthoJob stress refers to an extension of general stress: the nature of job stress is different from general stress in that job stress is specifically a result of work settings. In work settings, various factors can cause stress, such as the work task, the workplace, the job characteristics, role conflict, or worker capabilities . Job strTherefore, this study aims to revise the existing job stress scale, which can be used for China’s construction projects to study the relationship between job stress and safety behavior. The rest of the paper is organized as follows: first, relevant research in the job stress and safety behavior is summarized in In this section, a literature review was conducted to explore the structural dimensions of the job stress of construction workers, to enable the development of an appropriate job stress measurement questionnaire. The related works in the application case of job stress scale, the study of the relationship between job stress and safety behavior, is also summarized to propose the hypotheses to be tested in the case study.The definition of stress is that it is the individual’s response to the imbalance between the demands of external events and the resources available to them to handle these demands . Stress Taking into account the different cultural backgrounds and knowledge levels of the construction workers, combined with the background of the Chinese construction industry, the initial version of the job stress scale is similar to the Occupational Stress Indicator , and theTraditionally, safety behavior has been measured primarily by lagging indicators such as accident rates and mortality rates. However, these methods have limitations. They can form a skewed distribution by using accident frequency measurements. In addition, they cannot provide advanced warnings for pressure related accidents. Griffin and Neal  further The relationship between different job stress and two kinds of safety behavior (safety compliance and safety participation) may be different. This may be because when under job stress, the performance of safety compliance and safety participation may be both undermined, construction workers may try their best to first finish the required work (safety compliance) with limited time and energy, while having less time and energy to engage in participatory activities (safety participation). Thus workers under high job stress will reduce safety participation to a greater degree than safety compliance . In addiAs job stress increases, the worker’s safety behaviors deteriorate accordingly. For instance, Research  has showThrough the literature review and interview process, the authors explored dimensions of the job stress of the construction workers, designed the job stress measurement questions, and cited the safety behavior measurement scale. Next, the authors interviewed the construction workers to verify the reliability of the items in the job stress questionnaire. The data on the job stress of the construction workers were obtained through the questionnaire survey. Finally, the authors used the data analysis method to study the relationship between the dimensions of the job stress and two kinds of safety behavior, and therefore demonstrate the applicability of the developed job stress scale in construction safety research.To study the correlation between job stress and other factors, job stress must be quantitatively measured. Several tools ,33,41 weSimilar to job stress, safety behavior also needs to be measured quantitatively. Griffin and Neal  developeThe existing two scales have been widely utilized, but their application fields are not quite consistent with the areas involved in this study (construction projects). Therefore, some modifications were needed through semi-structured interviews. Twenty construction workers were randomly selected to participate in the semi-structured interview. In this process, combining the working characteristics of construction workers, some basic questions were raised and then answered by the workers. For example, “Do you think the job you do will bring corresponding job stress? If so, what are the aspects of stress?” “Do you have interpersonal pressure with colleagues and leaders at the job?” The purpose is to modify the existing scale and then make it applicable to the area of construction projects.This study identified a construction project in Beijing for the questionnaire distribution. Before distributing the questionnaire to the workers, a briefing of the study was provided to the workers to address any potential concerns that the workers might have. The items in the questionnaire were also explained to the workers to make sure that the workers understood the questions correctly.Similar to the Occupational Stress Indicator (OSI), the initial version of the job stress scale covers six dimensions  but with different question items. There are 20 items in total, measured using a 5-level Likert Scale.Similar to the safety behavior scale developed by Griffin and Neal , the iniA total of 150 questionnaires were distributed, and 132 responses were received. The response rate was 88 percent. After removing eight invalid responses, the number of valid responses became 124, and the effective response rate was 83 percent. Among the 124 responses, 90% of the respondents were male, 34% of the respondents were at an age between 41 and 50, 44% of the respondents had 10–15 years working experience, 49% of the respondents had a high school degree, and 85% of the respondents were married.Using the 124 valid responses, the following analysis was conducted.The primary task of factor analysis is to extract and synthesize the overlapping parts of the original variables into factors. It requires a strong correlation between the original variables. Otherwise, if the original variables are independent of each other, the degree of correlation is very low. If there is information overlap, there is no common factor, and no factor analysis is needed. Therefore, before the factor analysis, KMO (Kaiser-Meyer-Oklin Measure of Sampling Adequacy) and Bartlett test of sphericity method are used to analyze whether the original variables correlate, meaning whether it is suitable for factor analysis. The KMO method indicates that the higher the value of the measure, the more common factors between the variables. The KMO and Bartlett tests are performed on the recovered working pressure gauge. The KMO value is 0.86 (between 0.8 and 0.9), and the significant level of Bartlett test is 0, indicating that the job stress questionnaire is suitable for factor analysis. The results of factor analysis using SPSS are presented in Through rotation component matrix of job stress questionnaire, eight factors are obtained. As the correlation of factor 7 and factor 8 is small, they are removed. The remaining six factors include, for the job itself (Factor #1), family-work conflict (Factor #2), career development (Factor #4), organizational style (Factor #3), interpersonal relationship (Factor #5) and role management (Factor #6).As shown in The internal consistency of the scale was validated through Cronbach’s Alpha coefficient . As showThe overall relationship of construction workers’ job stress on safety behaviors was analyzed using the correlation analysis. The Pearson correlation between job stress and safety behavior is −0.27 with at a significance level of 0.05, indicating a negative correlation between job stress and safety behavior. In another word, the higher the job stress, the worse the safety behavior. This result aligns with the conclusions drawn in most of the early research, but it is different from the conclusions in recent research. The Correlation between the six dimensions of job stress and the two dimensions of safety behavior of construction workers was analyzed using correlation analysis, and the results are shown in In this study, a job stress scale of the construction workers was developed, and the recovered job stress questionnaire was tested by KMO and Bartlett. The KMO sample measure was 0.86, which is suitable for factor analysis. After factor analysis, six dimensions of job stress are identified, including the job itself, family-work conflict, career development, organizational style, interpersonal relationship, and role management. These six dimensions of job stress can summarize 72.50% of the information contained in the original variables of the job stress. In addition, the Cronbach’s alphas of the Job Stress Scale were 0.74, which demonstrates its high internal consistency. Therefore, the applicability of the job stress scales was better.Through the correlation analysis, it is found that the Pearson correlation between job stress and safety behavior is −0.27 with at a significance level of 0.05, indicating a negative correlation between job stress and safety behavior. In another word, the higher the job stress, the worse the safety behavior. This means that the proposed hypothesis is valid. There are also different levels of negative correlation between the six dimensions of job stress and the two dimensions of safety behavior. As The job itself was the greatest negatively related to safety behavior. The reason behind this may be that the construction workers devote all their effort to finish the jobs, and not much effort is allocated to job safety when the projects have tight schedules, high intensity, and heavy tasks. For some workers, they do not even have enough time for rest; at the same time, they are less likely to prioritize safety participation. Role management, organization style, and interpersonal relationships were the second lowest negatively related to safety behavior. This indicates that they have the second most significant negative impact on the safety behavior of construction workers. Safety role ambiguity refers to the poor cognition of an individual’s role that is related to the task required and its norms. Poor interpersonal relationships usually lead to job stress and burnout, or even unsafe behaviors . SampsonThe findings are like a study case in Hong Kong. In construction, Leung, and Liang  et al. sConsidering the negative relationship between job stress and safety behavior, managers should be aware of high job stress that workers may experience and take measures to reduce it. Attention should be paid to two dimensions of job stress, especially job itself and role management. Construction organizations should be a reasonable arrangement of construction workers’ tasks and rest time, and overwork should be forbidden. There should also be a reasonable arrangement of workload, so as not to overload workers, taking responsibility for the security of the construction workers at the same time. Organizations should provide adequate safety equipment and create a good atmosphere to guarantee that workers can work in a safe environment and be fully absorbed in the job. In China, as the educational level of construction workers is generally low, unclear communication with foremen and colleagues may easily lead to ambiguous understandings of job responsibilities and objectives . The orgDespite these contributions, this research has several limitations, which also inspire potential future research. First, the use of self-reporting measures may affect the reliability of the results and undermine the validity of the data. In this regard, all the measurement scales used in the survey were adopted following an extensive literature review. In addition, the Cronbach’s alphas for all factors were greater than 0.5, which demonstrates the reliability of the measures used. However, we still suggest future research on using multiple data sources for assessing construction workers’ safety behavior to minimize the possible problems of self-report. Second, only six dimensions of job stress were selected, although they are considered the most influential stress in previous studies. Further research will expand the scope of research on job stress. Furthermore, the magnitude of the negative correlation between each dimension of the job stress and safety participation is stronger than that between each dimension of job stress and safety compliance, which requires further examination. Thus, future research is suggested to explore a deeper relationship between job stress and two kinds of safety behavior. Third, semi-structured interviews are intended to modify the scale and then make it applicable to the area of construction projects, there are no results of semi-structured interviews reported or discussed. Future research can conduct a more in-depth analysis of it. Finally, the generalization of the current results still needs to be cautious, as the sample is mainly from Beijing of China and was collected from the construction industry. Thus, future research can expand the sample by including more areas and verified by undertaking several industrial case studies.Construction workers usually work in complex physical environments amid various hazards such as poorly maintained equipment and unsafe machinery. This directly influences their stress levels and safety behavior. Given this situation, this study was conducted to develop the job stress scale and demonstrate its applicability by investigating the relationship between job stress and safety behavior on a construction work site in Beijing.This study contributes to the current stress-management research by developing a reliable factor structure of construction workers’ job stress, including the job itself, family-work conflict, career development, organizational style, interpersonal relationship, and role management. The case study shows that the developed job stress can support the study on the relationship between job stress and safety behavior. The job itself has the most significant negative impact on the safety behavior of construction workers. Role management, organization style, interpersonal relationships, career development, and family-work conflict have a relatively low influence on safety behavior, compared to the job itself. Moreover, it was also found that the magnitude of the negative correlation between each dimension of the job stress and safety participation is stronger than that between each dimension of job stress and safety compliance.


The inequity of healthcare utilization in rural China is serious, and the urban-rural segmentation of the medical insurance system intensifies this problem. To guarantee that the rural population enjoys the same medical insurance benefits, China began to establish Urban and Rural Resident Basic Medical Insurance (URRBMI) nationwide in 2016. Against this backdrop, this paper aims to compare the healthcare utilization inequity between URRBMI and New Cooperative Medical Schemes (NCMS) and to analyze whether the inequity is reduced under URRBMI in rural China.Using the data from a national representative survey, the China Health and Retirement Longitudinal Study (CHARLS), which was conducted in 2015, a binary logistic regression model was applied to analyze the influence of income on healthcare utilization, and the decomposition of the concentration index was adopted to compare the Horizontal inequity index (HI index) of healthcare utilization among the individuals insured by URRBMI and NCMS.There is no statistically significant difference in healthcare utilization between URRBMI and NCMS, but in outpatient utilization, there are significant differences among different income groups in NCMS; high-income groups utilize more outpatient care. The Horizontal inequity indexes (HI indexes) in outpatient utilization for individuals insured by URRBMI and NCMS are 0.024 and 0.012, respectively, indicating a pro-rich inequity. Meanwhile, the HI indexes in inpatient utilization under the two groups are − 0.043 and − 0.028, respectively, meaning a pro-poor inequity. For both the outpatient and inpatient care, the inequity degree of URRBMI is larger than that of NCMS.This paper shows that inequity still exists in rural areas after the integration of urban-rural medical insurance schemes, and there is still a certain gap between the actual and the expected goal of URRBMI. Specifically, compared to NCMS, the pro-rich inequity in outpatient care and the pro-poor inequity in inpatient care are more serious in URRBMI. More chronic diseases should be covered and moral hazard should be avoided in URRBMI. For the vulnerable groups, special policies such as reducing the deductible and covering these groups with catastrophic medical insurance could be considered. Amartya Sen once noted that “health is the necessary basis for people to realize other capabilities”. Healthcare service, as the post intervention in diseases, is the last “safety net” to guarantee health, and the equalization of healthcare utilization is an important approach to guarantee health equity . Since tIn China, the inequity in healthcare utilization is more serious in rural areas because there are a large number of low-income groups there . MoreoveAlthough the coverage of NCMS has been above 90% since 2008, its services coverage and financial protections are less than those of the Urban Resident Basic Medical Insurance (URBMI) available to the urban populations. According to statistics, “urban residents per capita healthcare expenditure paid by medical insurance is around three times as much as that of the rural residents in 2012”.Therefore, the integration of urban-rural medical insurance has gained governmental attention since 2008, and the government established the Urban and Rural Resident Basic Medical Insurance (URRBMI) based on NCMS and URBMI to make residents participate in the same medical insurance regardless of household registration. In 2016, the central government announced that the URRBMI was gradually implemented nationwide in China. Against this backdrop, comparing the inequity in healthcare utilization between URRBMI and NCMS can provide important information for the implementation and development of URRBMI.Previous studies have revealed that inequity in healthcare utilization exists widely in the world , 6, 16. Theoretically, medical insurance can reduce inequity as it provides a financial support in healthcare utilization and covers a large proportion of medical expenses for low-income groups. In China, although medical insurance schemes are a major payment system for healthcare utilization, there are conflicting opinions about the relationship between medical insurance and healthcare utilization inequity. First, some of the studies claim that the implementation of medical insurance narrowed the gap of healthcare utilization –13; secoThe reason that medical insurance fails to reduce healthcare utilization inequity is that the top-level design of the Chinese medical insurance system pays more attention to economic efficiency during the period of primitive accumulation of capital. Studies have shown that the income gap, the fragmentation management of medical insurance and the difference in medical insurance benefits have become the main factors of healthcare utilization inequity , 15, 24.The aim of URRBMI is to provide the same services coverage and financial protections to both urban and rural residents. We assume that the healthcare utilization inequity in rural areas will be reduced as URRBMI improves the medical insurance benefits of rural populations. Referring to URRBMI, some studies found that the opportunity inequity of healthcare utilization was reduced in URRBMI , and it In summary, the previous studies have analyzed the influence of socioeconomic factors on the inequity of healthcare utilization comprehensively, and most of them employed the Concentration Index (CI) to quantify the degree of inequity. Moreover, they also revealed the profound reasons for the healthcare utilization inequity in rural areas by analyzing the urban-rural segmentation of medical insurance, which provided a reference for this article. However, few of them focus on the healthcare utilization inequity in rural areas under URRBMI. Although Ma Chao et al. measured the opportunity inequity of healthcare utilization between urban and rural areas after the integration of urban-rural medical insurance, their research was only limited to three counties in Jiangsu Province of China and did not analyze the inequity within rural areas .Based on the existing studies, this paper analyzes the relationship between URRBMI and the inequity of healthcare utilization in rural areas by comparing the inequity in healthcare utilization under URRBMI and NCMS. Theoretically, the degree of inequity in URRBMI will be lower than in NCMS in that the services coverage and financial protections of URRBMI are better than those of NCMS, but the assumption needs to be verified by data analysis in the next section. This paper is organized as follows:First, as the fact that healthcare utilization is mainly affected by health status and socioeconomic factors, we use the chi-square test to make a comparison of differences in healthcare utilization and other influence factors among the individuals who were insured by URRBMI and NCMS.Second, as the dependent variables in this paper are discrete, and the inequity in healthcare utilization is income-related, the binary logistic regression model is employed in this paper to analyze the differences in healthcare utilization among different income levels under the two medical insurance schemes.Third, the concentration index (CI) and horizontal inequity index (HI index) are used to quantify the degree of inequity in healthcare utilization under the two groups, the decomposition of the concentration index is used to present the contribution of each independent variable to the concentration index.The data analyzed in this paper are from the China Health and Retirement Longitudinal Study (CHARLS) in 2015.In general, healthcare utilization includes outpatient and inpatient care. Based on the characteristics of the selected data, this paper selects “outpatient visit in the last month” and “inpatient visit in the last year” as indicators to measure healthcare utilization. In addition, referring to previous studies, health need factors include gender, self-assessed health and chronic morbidity; socioeconomic factors include education level, per capita household income, living areas and community. The detailed definition of variables can be seen in Table First, this paper uses the chi-square test to examine whether there are significant differences in healthcare utilization and other influence factors among individuals insured by URRBMI and NCMS.Since the dependent variables are discrete and the inequity in healthcare utilization is income-related, we employed binary logistic regression to analyze the differences in healthcare utilization among different income levels under the two medical insurance schemes. The marginal effect estimated in this model will be used to decompose the concentration index in the next part. The model is as follows:xji indicates health needs variables; xki indicates the socioeconomic variables; εi indicates the error term. The income variable in xki is the focus in this model.p/(1-p) indicates the healthcare utilization; The Concentration Index is employed to quantify the inequity degree of healthcare utilization relating to socioeconomic characteristics, reflecting the changes in the distribution of healthcare utilization among different socioeconomic groups . The Conyi represents the status of healthcare utilization of individual i; ri indicates the scoring rank of income of individual i; and μ is the mean of healthcare utilization. The Concentration Index is defined as twice the area between the concentration curve and the line of equality.C is the Concentration Index; The concentration index indicates the overall inequity in healthcare utilization. However, healthcare utilization is influenced by a variety of factors, including health needs and socioeconomic factors. The World Health Organization defines the equalization of healthcare utilization as “People who have similar health needs should have the same healthcare utilization”, which indicates that differences in healthcare utilization caused by different health status is reasonable. Therefore, this paper employs the horizontal inequity index to quantify the healthcare utilization inequity caused by the differences in socioeconomic factors, rather than the differences in health needs. By decomposing the concentration index, the contribution of health needs and socioeconomic factors to the inequity of healthcare utilization can be measured separately. The horizontal inequity index can be obtained by subtracting the contribution of health needs from the total concentration index, and the absolute value of it measures the degree of inequity. The specific definitions of variables are shown in Table The decomposition formula of the concentration index is:xj and zk, respectively; Cj and Ck are the concentration index of the health needs and of the socioeconomic variables, respectively; and GCu is the concentration index of the error term. The first part of the formula represents the contribution of health needs to inequity, and the second is the contribution of socioeconomic factors.C is the total concentration index; Table Before measuring the inequity of healthcare utilization, we used binary logistic regression to explore the influence of income on healthcare utilization. Table Table Table Table The horizontal inequity index can be obtained by subtracting the contributions of health needs variables from the concentration index in healthcare utilization. Table The urban-rural segmentation of medical insurance schemes has become an important factor of healthcare utilization inequity in rural China. To provide better coverage services and financial protection for the rural population and to reduce the healthcare utilization inequity in rural areas, China began to establish Urban and Rural Resident Basic Medical Insurance (URRBMI) based on Urban Resident Basic Medical Insurance (URBMI) and the New Cooperative Medical Scheme (NCMS) nationwide in 2016. Against this backdrop, it is worth analyzing the changes in inequity in healthcare utilization after the implementation of URRBMI.Using the national representative data from the China Health and Retirement Longitudinal Study (CHARLS) that was conducted in 2015, this paper compares the inequity of healthcare utilization between the URRBMI insured and the NCMS insured in rural China. The results reveal that there is no significant difference in healthcare utilization under the two medical insurance schemes. When comparing the inequity under the two medical insurance schemes, we find that the richest utilize more outpatient care in URRBMI, but the difference is not significant. Besides, in the NCMS group, the high-income group tends to utilize significantly more outpatient care. The horizontal inequity index (HI index) also shows that there is a pro-rich inequity of outpatient care in both the URRBMI and NCMS groups and that the HI index of URRBMI is larger than that of NCMS; the result is similar to Chen’s study, which also found that the individuals insured by NCMS have a pro-rich inequity in outpatient utilization . The reaIn terms of inpatient utilization, binary logistic regression shows no significant difference among different income levels in both URRBMI and NCMS. However, the horizontal inequity index (HI index) reveals the inequity behind it, that pro-poor inequity exists in inpatient utilization under the two medial insurance schemes, indicating that the poor utilize more inpatient care than the rich. The absolute value of the HI index in URRBMI is larger than the absolute value in NCMS, meaning that the degree of inequity of URRBMI is higher than that of NCMS. Additionally, the degree of inequity in inpatient is higher than that in outpatient care. The result on inequity of inpatient care among those insured by NCMS is different than those reported for other studies, such as Chen 2018) and Pan 2017), who both found a pro-rich inequity in inpatient care in NCMS , 18. The and Pan , who botIt is also important to bear in mind that there is limitation in this paper. Since the implementation of URRBMI is not a ‘natural experiment’, it is hardly to avoid the problem of self-selection in this process. Therefore, the results of this paper are statistical analysis rather than ‘causal’ analysis. Although the PSM method can solve the self-selection problem to some extent by matching the treatment and control groups, it cannot control the unobservable characteristics . Besides, the PSM has several candidate matching methods, such as one-to-one, one-to-four, radius and kernel matching et al. If the PSM method was applied, we must use the matched data to calculate the concentration index of healthcare utilization among the treatment and control groups, respectively. Against this backdrop, only the one-to-one method can be applied. However, the results we get will not be accurate because large numbers of samples are deleted, and it is also difficult to test the robustness of the PSM matching effect only by the one-to-one matching. As a result, the ‘causal’ relationship cannot be attained in this paper. Meanwhile, there are few studies to analyze the inequity of healthcare utilization in URRBMI and to compare it with that in NCMS. It is reasonable to make a statistical analysis firstly, and the future study could further identify the ‘causal’ effect between the inequity of healthcare utilization and URRBMI.This paper shows that inequity still exists in rural areas after the integration of urban-rural medical insurance schemes, and there is a certain gap between the actual and the expected goal of URRBMI. Specifically, compared to NCMS, the pro-rich inequity in outpatient care and the pro-poor inequity in inpatient care are more serious in URRBMI. Thus, comprehensive measures to reduce the inequity should be taken: first, covering more outpatient diseases in URRBMI, especially chronic diseases; second, setting a reasonable reimbursement ratio in inpatient care to avoid the moral hazard in URRBMI; and third, for the vulnerable groups, special policies such as reducing the deductible and covering them in catastrophic medical insurance could be considered.


In the first part of this paper we review the evidence that suggests that both genetic and non-genetic information contribute to inheritance in livestock  and discuss how the environment may influence non-genetic inherited factors. Then, in a second step, we consider methods for favoring the transmission of non-genetic inherited factors by estimating and selecting animals on their extended transmissible value and/or introducing favorable non-genetic factors via the animals’ environment.Evolutionary biologists studying wild species have demonstrated that genetic and non-genetic sources of information are inherited across generations and are therefore responsible for phenotypic resemblance between relatives. Although it has been postulated that non-genetic sources of inheritance are important in natural selection, they are not taken into account for livestock selection that is based on genetic inheritance only. According to the natural selection theory, the contribution of non-genetic inheritance may be significant for the transmission of characters. If this theory is confirmed in livestock, not considering non-genetic means of transmission in selection schemes might prevent achieving maximum progress in the livestock populations being selected. The present discussion paper reviews the different mechanisms of genetic and non-genetic inheritance reported in the literature as occurring in livestock species. Non-genetic sources of inheritance comprise information transmitted  Learning from conspecifics or adaptation to the environment may occur through observation, imitation, teaching or interactions in the form of play behavior, aggressive encounters, cooperation, or competition to access a resource  and that causes phenotypic differences between individuals of a population  leading It is well established that DNA is transmitted from one generation to the next through the sexual reproduction process (meiosis). Offspring receive one half of their DNA from each parent apart from mitochondrial DNA that is transmitted by the dam only . Based oDGAT1 gene induces a modification of its expression which has a major effect on the milk fat content and other milk characteristics  and heterozygous individuals for the mutated allele carried by the paternal chromosome (patIGF2mut|matIGF2wt) show hypermuscularity (DLK1 mutation in sheep (mut|matDLK1wt) express the phenotype of muscular hypertrophy  in order to better comprehend the relationship between genotype and phenotype . Numeroueristics . Nonetheeristics . In live in pigs  and a muin sheep . The IGFcularity . A more in sheep . In thisertrophy .To sum up, genes are inherited by the transmission of genetic material, DNA, and their expression plays an important role in the development of all phenotypes. Genetic inheritance thus contributes to phenotypic resemblance between relatives.in utero exposure of developing embryos may directly impact phenotypes at birth and later on of individuals of the first generation (F1); it is called intergenerational transmission. Secondly, the prenatal exposure of fetuses may alter their gametes and affect performances of offspring produced in the second generation (F2); it corresponds to a multigenerational transmission. Thirdly, a phenotypic effect persists in individuals of the third generation (F3) while a modification of the environment occurred only on F1 embryos and gametes; this is a true transgenerational inheritance. In addition, if a male or non-pregnant female adult animal is subjected to an environmental exposure, then changes seen in the F2 generation or later are considered transgenerational.The epigenome consists of all the molecular processes that interact with the genome of an organism and contribute to the regulation of gene expression without modifying the DNA sequence. Epigenetic modifications include DNA methylation or hydroxymethylation of CG dinucleotides, chemical modifications of histones, interactions between the DNA and small RNAs, and different states of chromatin condensation . Epigenevia epigenetic mechanisms such as histone modifications and microRNA expression  they imply to wait until the third generation, ii) germ cells are more heterogeneous, and iii) gametes sampling is much more difficult. In addition, the idea that the paternal experience may have direct implications for the fitness of the offspring is quite recent. Besides the nuclear genome, sperm and semen contain a range of epigenetic elements  that are delivered to the zygote upon fertilization  that reside in and on the bodies of animals.In utero, the mammal digestive tract is practically sterile and the main microbial taxa that reside within the mammalian gut do not develop outside their host (vs. Cesarean section) and suckling type  impact greatly on the gut microbiota colonization process (vs. building vs. in an isolator with antibiotic treatment) results in differences in microbiota composition that persist until after mother-piglet separation  resemblance between parents and offspring . Inherite exists . Moreovee exists . Thus, tA focal individual can benefit from social learning acquired during social interactions and will be influenced by the  behavior of the conspecifics it is raised with, i.e. reciprocal influences of individuals sharing a common environment over short or long periods of time. This transmission of social skills and innovations at the group level refers to cultural inheritance  in its  studies . The infffspring . Maternavia different means of transmission.To sum up, we described four different sources of inheritance that differ according to their mean of transmission. It is important not to confuse the mean of transmission with the mean of action. Such distinction is particularly relevant in the case of indirect effects . For insIn livestock, selection is aimed at improving numerous phenotypes in order to increase animal production, facilitate breeding, reduce animal mortality and morbidity, increase animal welfare, etc. Selecting, as parent of the next generation, animals that will transmit their good skills to their offspring for the characters of interest proved to be an efficient way to enhance the above characters. Only genetic values are accounted for selection in livestock. The inclusion of the other sources of inheritance, by predicting the extended (genetic and non-genetic) transmissible value of an individual in the selection of the future reproducers, would be an added value. In addition, since non-genetic inherited factors are sensitive to the environment, amending the animals’ environment to promote non-genetic inherited factors that are transmitted to the next generations is key for improving performances.yi of individual, is decomposed into its different components by: For selection in livestock species, knowing the potential that an animal can transmit to its offspring is crucial to select the best animals  as parents for the next generation. This potential can be predicted by analyzing the phenotypic resemblance between relatives using a linear mixed model. The phenotype β is the vector of fixed effects and xi the vector that links the fixed effects to the observation of animal i. ai, iepi, and imic are the additive genetic, epigenetic, cultural/behavioral, and microbiotal transmitted values of individual i, respectively. Distribution of the different transmitted values, under the assumption that the variance of the transmitted effect is constant over generations, is written t = a,epi,cult or mic and t of different individuals. To predict the transmitted values of an individual, the variance components of the aforementioned model have to be estimated. To do so, phenotypic records recorded in a proper design, genealogic information and the distributions , i.e. the average relationships assuming infinite loci. Using SNP markers, it is possible to compute the “real” IBD relationships matrix (genomic relationship matrix G) which is slightly different given the finite genome size  in order to increase the reliability of the predictions of the transmittable genetic value of individuals  that reside in and on the bodies of animals  influenced by the environment  and ii) dynamic and modulated during the animal’s lifetime. This means that breeders can initiate favorable epigenetic marks, microbiota, or behavior that will be later transmitted across generations by controlling the animal’s environment. It is too early to clearly define the breeding practices to be implemented to influence such factors positively and research is still underway on the subject. However, given current knowledge on non-genetic inherited factors, it is possible to identify different key moments in the lives of the future reproducers when non-genetic inherited factors may be influenced  for species in which it is possible . Indeed,Withdrawal is a critical period for the young animal, especially in terms of stress. The benefits of early social separation and socialization to the development of social skills have been reported in pigs and related to less damage later in life . But earIn several livestock species , offspring are separated from their mother. Nonetheless, it has been shown that after birth, the mother's absence disrupts microbiota transmission to the offspring and the intestine is colonized by microorganisms from environmental metacommunities . DisruptEarly life is also the time when interactions with the breeder begin. The effect of early experience on temperament, learning ability, and cognition is a complex phenomenon that requires further investigation, and depends upon the major role of stressors. In our opinion, breeders should ensure that first experiences are positive no matter when the handling of animals begins. At a higher level of complexity, sex-specific differences in the intergenerational transmission of non-genetic effects should be considered. Later in the career of the animal, it has been shown that epigenetic mechanisms are key regulators underlying the neuroendocrine control of puberty . Howevervia other animals, and actions that modulate non-genetic inherited factors via favorable environmental conditions  selection will remain the main lever for improving livestock characters. However, recent knowledge about the other sources of inheritance in livestock offer the possibility to favor the transmission of non-genetic inherited factors across generations. Combining genetic and non-genetic inheritance will surely improve the benefit of selection.ID, LC, SC, and JD wrote the manuscript.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.