Background: Tactile and somatic hallucinations are distressing phenomena that have hardly been researched. The few studies that have been published focus on their occurrence in neurodegenerative disorders and substance use, and, surprisingly, not on schizophrenia spectrum disorders.Objective: To fill this gap in our knowledge, we sought to explore the phenomenological characteristics of tactile and somatic hallucinations in a group of psychotic Muslim patients. Since many Muslims attribute such experiences to jinn (invisible spirits) and jinn are often perceived in multiple sensory modalities, we not only charted the involvement of the tactile and somatic modalities but also their interrelatedness with hallucinations in other sensory modalities.Methods: We performed a cross-sectional study using a semi-structured interview and dedicated questionnaire.Results: Of the 42 Muslim inpatients mostly diagnosed with a schizophrenia spectrum disorder, 62% reported to suffer from tactile and/or somatic hallucinations. Their phenomenological characteristics varied, with 96% being multimodal in nature and 38% taking the form of full-blown entity/jinn encounters. In comparison to other entity experiences, the involvement of the tactile and somatic modalities was exceptionally high, as was the level of ensuing distress. Regarding the order of recruitment of the various sensory modalities, we suggest the involvement of an underlying stochastic process.Conclusion: Muslim patients with severe psychosis can have tactile and somatic hallucinations, of which a large number are multimodal or full-blown entity/jinn encounters, which are almost invariably appreciated as harrowing. On the basis of our findings we make recommendations for further research and clinical practice. When pan = 26) reported bodily, i.e., tactile and/or somatic, hallucinations. Of these, 69% (n = 18) were men. Most participants reporting hallucinations  were diagnosed with a schizophrenia spectrum disorder following the DSM-IV criteria. In nine cases (35%) a second diagnosis was made  experienced tactile hallucinations. Fourteen patients experienced somatic hallucinations (33%).n = 25 of 26 patients) in this subgroup focused on. In the total group of patients who were interviewed, 60%  had experienced multimodal hallucinations.Of the 26 patients with tactile/somatic hallucinations, all but one experienced multimodal hallucinations, in essence in 96%  (88%) and 14 who experienced somatic hallucinations (54%). In the group of 26 patients, there were 12 who experienced tactile and somatic hallucinations simultaneously or serially ,Bserial, congruent multimodal hallucinations, with the involvement of at least two sensory modalities, meaning that the hallucinations were attributed to the same source  but experienced at different moments in time. In 39% they were described as simultaneous, congruent hallucinations, reflecting that they were attributed to the same source and experienced at the same moment in time, in conformity with the multimodal nature of entity experiences. In the case of somatic hallucinations, 43% were serial and congruent, and 36% simultaneous and congruent. In eight of the 23 cases (35%) having tactile hallucinations, these consisted of and suffering electrical shocks). In The way in which the participants experienced their tactile and somatic hallucinations showed considerable interindividual variation. n = 15, 58%) were fully convinced (100%) that their experiences were caused by a jinn, while in the remaining 10 patients (38%) this conviction was lower than 90%, with the majority  rating the degree of conviction at 30–60% and one participant indicating that he could not tell whether this should perhaps be 0% even though he insisted on having (had) personal experience with jinn. The participants expressing doubt about the involvement of jinn mentioned alternative causes for their tactile and somatic sensations such as Allah, God, Iblis, a ghost, an actual person, their own brain, and “disease”.The patient with unimodal tactile hallucinations was in doubt whether his hallucinations were caused by jinn, with a conviction of 50%. Most patients . In clinical practice, Western health professionals may be inclined to treat these phenomena as hallucinations and delusions in the context of psychotic disorder. In the literature, evidence for the effects of antipsychotics on tactile and somatic hallucinations is only presented in case reports, with a favorable role for olanzapine  acknowledged to have tactile and somatic hallucinations, the far majority of which were denoted as unpleasant, threatening and/or painful, and all of them being attributed to jinn . Our patient group mainly reported tactile, somatic, and sexual sensations. Although not actively probed, proprioceptive and kinesthetic hallucinations, for example, went unreported. Nonetheless, the severity and impact of the tactile and somatic hallucinations imparted to us were impressive. Moriyama et al.  already anzapine , 25. Howanzapine , 26, 27.The examples above suffice to illustrate the impact of tactile and somatic hallucinations on the population we studied. We did not formally quantify the levels of experienced distress, but the far majority of our participants were so terrified that they had taken refuge to religiously and culturally sanctioned treatments—often for years or even decades on end, spending considerable amounts of money in the process—before seeking the advice of biomedical practitioners. The belief in jinn is an integral part of Islamic faith and of the body of folk beliefs prevalent in Muslim societies . They arThe cause of weakness toward djinns is always a combination of factors. The susceptibility to djinns increases when the orifices grow wider and the protecting light diminishes. Various circumstances can cause this, but fear, confusion, doubt and pollution are often involved [ , entitieThe order in which the various sensory modalities are engaged in multimodal hallucinations is a topic of emerging interest , 35. In The group of patients participating in our study was relatively small and, moreover, comprised a subgroup at the severe end of the psychosis spectrum. The generalizability of our findings—even to other Muslim patients with psychosis—is therefore questionable.For the purpose of charting the phenomenological characteristics of bodily hallucinations we did not consider PANSS scores and medication histories as strictly necessary at this point, and therefore refrained from including these methods in our study design. In the future, these sources of information might have the potential of adding valuable information.and to entity experiences of the jinn type, and (iv) functional imaging to shed further light on the brain networks implicated in the various types of hallucination.Also, since the structure of the questionnaire we used did not allow us to chart the full spectrum of bodily hallucinations, proprioceptive and kinesthetic hallucinations, for example, remain to be explored. Also, the cross-sectional nature of our study prevented us from establishing the order in which the various sensory modalities were recruited. What is more, the lack of a control group—and the scarcity of published studies on bodily hallucinations in other populations—prevents us from drawing any firm conclusions regarding the question whether these phenomena are overrepresented in Muslim patients. Finally, although the majority of our participants reported high levels of distress, we did not formally quantify its extent. As a consequence, we were unable to relate the intensity of distress to the types or number of sensory modalities involved. This work provides a first step of describing the phenomenology of tactile and somatic hallucinations. These descriptions can be very useful in the further development of culturally appropriate assessments and treatments. Future research might benefit from (i) broadening the scope of this research by including all varieties of bodily hallucination , (ii) a prospective design that would allow the order in which the various sensory modalities are recruited to be determined, (iii) a quantification of the extent of distress in relation to the sensory modalities involved Bodily hallucinations have long been neglected by clinicians and researchers. This may have to do with the fact that touch is traditionally ranked as one of the “lower” senses but also with the prominence of auditory and visual hallucinations in psychiatric and neurological conditions, ranging from psychotic disorder to Parkinson's disease and Charles Bonnet syndrome. We have shown that at least in a subgroup of psychotic patients tactile and somatic hallucinations deserve our full clinical attention. Of the 42 Muslim patients clinically admitted with severe psychosis, 62% reported to suffer from such hallucinations, with several describing sexual hallucinations. In 96%, the hallucinations were of a multimodal nature, of which almost 40% took the form of full-blown entity experiences. The involvement of the tactile and somatic modalities was exceptionally high in our group, as was the level of concomitant distress, which may be due to the strong belief most claimed to have in the objective existence of jinn. This, along with the anxiety generally associated with these beings, may have helped to shape their hallucinations, explaining the prominent role of bodily sensations. Also or alternatively, the relatively long duration of illness in our group may have allowed for the recruitment of the tactile and somatic modalities, which we believe become involved in a relatively late stage compared to other sensory modalities when people experience hallucinations in the context of schizophrenia spectrum disorders. Although the cross-sectional nature of our study does not allow for firm conclusions regarding this issue, we found indirect evidence for a stochastic process underlying this recruitment process. The high levels of distress our participants reported indicate that both bodily hallucinations and jinn (encounter) experiences deserve closer attention in clinical practice, as do similar phenomena in patients with analogous culturo-religious backgrounds.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.AL and JB both contributed to the conception and design of the work, collected data for the work, contributed to the analysis and interpretation of data for the work, drafted and revised the work, gave approval for the final version to be published, and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. During this work, we sought the collaboration with colleagues with a Muslim background, trained as physicians, others as anthropologists or as theological counselors, and followed the tenet of what they taught us when describing sociocultural attributions. Both 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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This research analyzed the Sixth Five-Year Economic, Social, and Cultural Development Plan of the Islamic Republic of Iran (6NPD) to shed light on how the plan addresses the Universal Health Coverage (UHC).This research was a qualitative study. We systematically analyzed ‘Secs. 14 -Health, Insurance, Health & Women, and Family’ in the 6NPD. Through a content analysis, we converted this section into meaning units and coded them. Coding was guided through the conceptual framework ‘Six Building Blocks of Health System’ and the key principles of UHC.financing include a fair and secured process of resource pooling, payment methods, revenue generation for the health sector, and a definition of a basic benefits package. The subthemes of governance and leadership consist of social insurance policies’ integration, compliance of providers, a designation of the Ministry of Health and Medical Education (MoHME) as the regulator and the steward of health resources, a payer-provider split, and stakeholders’ participation. The subthemes of health workforce emphasizes balancing the quality and quantity of the health workforce with populations’ health needs and the health system’s requirements. The subthemes of health information systems consist of the electronic health records for Iranians, information systems for organization and delivery functions, and information systems for the financing function. The subthemes of the organization and delivery consider improving effectiveness and efficiency of healthcare delivery, strengthening the family physician program and referral system, and extending the pre-hospital emergency system. Lastly, access to medicine focuses on the design and implementation of an essential drug list and drug systems for approving the coverage and provision of generic medicine.Six themes and twenty-one subthemes were identified. The subthemes of The 6NPD introduced policies for strengthening the 6 building blocks of the health system. It introduced policies to improve financing particularly resource pooling and the sustainability of financial resources. As mandated by 6NPD, centering the health system’s governance/leadership in MoHME may exacerbate the existing conflict of interests and provoke various arguments, which impede the enforcement of rules and regulation. The 6NPD is a step forward in terms of improving financial protection, yet several other policies need to be made to adequately meet the requirement of UHC regarding equity and effective coverage. Expanding Universal Health Coverage (UHC) is a paramount goal of health systems . Simply The world health report 2000 defines UHC as the “ability to use health services that individuals need and that those services are of quality that improves health status” . This deUHC provides a way to frame health system strengthening efforts for improving health system building blocks . The sixGiven the importance of UHC, it should be addressed by the head of state plans and strategies. In the Islamic Republic (IR) of Iran, the Health Vision (2005) and the General Health Policies (2014) are two primary legal documents in which achieving UHC is highlighted . To operThis research was a qualitative content analysis study. It systematically analyzed Section 14 “Health, Insurance, Health & Women, and Family” of the 6NPD to elicit key policies related to UHC in Iran. It considered the official release of the 6NPD in July 2016 for . The docThe plan’s contents were analyzed through four steps: decontextualization, recontextualization, categorization, and compilation . ThroughWe followed guidance on best practice qualitative research to design, analyze, and interpret data . The stuFindings are presented for 6 themes. These themes consist of healthcare organization and delivery, health workforce, health information systems, access to essential medicines, financing, and governance and leadership Table .Table 1The subthemes of the organization and delivery included improving effectiveness and efficiency of healthcare delivery, family physician and referral system, stakeholder participation in service delivery, and extending pre-hospital emergency system. The 6NPD introduced policies for extending or fine-tuning existing structures and infrastructures of health services delivery. The 6NPD emphasized clinical practice guidelines, family physician program, referral systems/gatekeeping, and effective distribution of tasks between three health system levels. The development of clinical practice guidelines is mandated so that health services are provided based on the best available evidence. The law pointed out building a comprehensive health system with a clear role of family physicians in the referral system. Family physicians are expected to be the basis for the referral system and as gatekeepers to control unlimited access to specialized care in tertiary care. Particularly, a policy is introduced to limit the overutilization of tertiary care when primary care or secondary care can effectively meet the demands. The 6NPD also mandated the Petroleum Industry Health Organization and the Ministry of Industries, Mines, and Trade to compensate for the likely harmful impacts of petroleum and mining operations on the population’s health by taking a greater role in providing health services in remote areas and offshores.The 6NPD introduced policies to balance the quality and quantity of the health workforce with population health needs, health system’s requirements for effective functioning, family physician program’s strategies, and referral system functions. These policies are categorized into two subthemes: health workforce development to meet health needs and health workforce development to support the health system’s strategies and structures. The law mandated MoHME to adjust the capacity of all medical universities and higher educational institutions by the national and local health needs. The 6NPD even allows the dual practice of specialist physicians and dentists in deprived provinces and communities. MoHME also provides health/medical graduates for the healthcare system of the Iranian Social Security Organization.The subthemes of the health information system consisted of electronic health records for all populations, information systems for organization and delivery function, and information systems for financing function. The 6NPD mandated establishing an electronic health record for all Iranians. It also required MoHME to facilitate health services delivery through web solutions or to substitute the traditional brick-and-mortar structure of health service delivery with health information technologies. On the one hand, preparation should be made to deliver health services through electronic systems, online platforms, and health portals. On the other, information systems should be provided for health centers to facilitate health service delivery. A national online data warehouse of health insurance enrollees will be constructed to strengthen the financing function. Under this function, the law required preparation to run an online system for strategic purchasing of health services. Furthermore, for revenue collection and transparency of tax on tobacco products, the National Tax Organization would get online access to data regarding the import and distribution of tobacco products.Subthemes for access to essential medicine addressed the design and implementation of a system for approving and inclusion of medicine and the provision of generic medicine. Under this theme, the 6NPD mandated designing and implementing generic medicine, designing and implementing a national drug system, and developing a list of medicines for reimbursement purposes.Subthemes for financing included the fair and sustainable process of resource pooling, effective payment methods, revenue generation, and defining a benefits package. The 6NPD introduced various measures for the fair and sustainable process of pooling. These measures consist of prepaid arrangements for basic social insurance, relying on the mandatory enrolment in a basic health insurance scheme, determining individual contributions based on income level through a means test, using health information, i.e., online access to the national tax system to track revenues collectible from harmful products, and mandating the government to allocate subsidies to pay for the premium of extremely poor when the means test indicated the person is eligible for the government subsidy. Effective payment methods prescribed strategic purchasing of health services from non-governmental providers, purchasing health services based on clinical guidelines, pay for performance for outsourced health services, and reimbursement for only drugs included in an approved list of generic medicine. Revenue generation comprises the use of state subsidies to pay for the premium of the extremely poor, tax on the import and production of tobacco products, and allotting a 10 % increase in the fee for handling divorce cases through the judiciary system to reimburse costs of before-marriage genetic examinations.The subthemes under governance and leadership included mandates for social insurance policy integration, compliance to fee schedules, compliance of medical specialists to practice in the public sector only when employed by the public sector, designating MoHME as the regulator, central policymaking body, and steward of health resources, payer-provider split, and attracting stakeholders to participate and bear responsibility for health. The 6NPD prescribed the integration of social health insurance policies. It indicates that health insurance organizations keep functioning with current organizational structures, but they should follow a similar set of rules and regulations for financing arrangements. Based on this, insurance policies and procedures will be unified between insurers. Insurance policies and procedures, e.g., premium calculation method, will be standardized. The law emphasized the compliance of all providers to fee schedules and stressed punishing noncompliance. It also highlighted that all insurers should comply with policies that MoHME makes for health insurance schemes. Another key regulatory function of MoHME that is noted in the 6NPD addresses the financial management of health resources. The law stipulates the centralized management of financial resources and designates MoHME as the steward of that centralized resource management system.The 6NPD introduced measures to outsource activities of MoHME that have non-governance features. It mandated MoHME to take a greater governance role and move away from functions that involve ownership and doing business with healthcare. With the current structure of the healthcare delivery system, which MoHME mostly owns, the law highlighted strategic purchasing as a mechanism to purchase services from the non-governmental sector; meanwhile, MoHME outsources healthcare provision. The 6NPD also emphasized reducing the ownership of health organizations by MoHME.The 6NPD introduced several key health policies for the six building blocks of the health system. It introduced policies for a fair and sustainable process of resource pooling, effective payment methods, revenue generation, and cost containment methods for health system financing. Based on the 6NPD, all Iranians must be enrolled in a basic health insurance scheme to assure universal financial protection for the entire population, rather than only for the extremely poor. The mandatory enrollment in an insurance scheme and premium collection from individuals working for an informal sector or unregistered economy , 14 requThe 6NPD introduced a means test to determine contribution based on the individuals’ financial capacity and that enrollment is not hampered by inability to pay the premium. The premium for the poor would be paid by the government. The introduction of the means test is a step forward for an equitable and sustainable financing process. Yet, it remains to determine who is poor or eligible for governmental subside. Proxy measures such as income, age, employment, being under the umbrella of an employed person, or having consistent support from another person are used in other countries . Among tThe plan introduced at least two sub-articles to control costs incurred by basic health insurance funds. For this purpose, the plan mandated defining a basic benefits package of health services. By this, policymakers wanted to only reimburse the costs of essential services rather than to generously reimburse the costs of a wide set of services. Before 6NPD passes into the law, there was a benefits package that was developed based on a little evidence base, untransparent criteria for inclusion of services, and a weak decision-making process. The revised benefits package should therefore transparently include cost-effective services while considering the conflict of interests . AnotherThe governance section of the plan supports UHC by emphasizing centralized policymaking, strategic planning, evaluation, accreditation, and supervision of healthcare planning and finance in MoHME. It proposed centralizing the management of health resources in MoHME with emphasis on prepaid arrangements. It also mandated MoHME to design a basic benefits package and to unify insurance policies and procedures. Centering the governance of the health system in MoHME provokes various arguments. The most notable is that the MoHME is the main provider of health services and policies, for instance, strategic purchasing mechanisms that will be developed through the MoHME, in a first step, affect its affiliated hospitals. This is a great conflict of interest that impedes the effective enforcement of rules and regulations imposed by MoHME. One study showed that a conflict of interests is the main barrier to strategic purchasing . Yet, thAbout strategic purchasing, there exist critical issues. A payer-provider split is a prerequisite for strategic purchasing, which is not the case in Iran . StrikinIran has taken steps to tackle the issues of UHC in the past two decades; most requirements set by the 6NPD for the governmental agencies while being aligned with UHC sound right for the current time . Howeverequality by entitling everyone to an equal set of benefits, though reducing inequity requires arrangements for additional protection for high costly diseases such as chronic diseases. For example, under a standard benefits package, patients with chronic diseases are entitled to a set of services similar to those with no chronic disease, despite the fact that, patients with chronic conditions face greater financial risk due to increased use of services and higher out-of-pocket expenditures that they incur [Equity seems to be pursued through prohibiting dual insurance coverage, standard premium calculation methods, unified insurance policies and procedure, and standard benefits package. Standard benefits package contributes to ey incur . In an aBased on the plan, MoHME also requires to equip and improve health services offshore and in oil-rich areas using the resources and capacity of the Petroleum Industry Health Organization and the Mine Industry Organization to make them socially responsible for the adverse impact of petroleum and mining operations on health. The 6NPD is establishing social responsibility for harmful operations of industries. Therefore, while the plan introduced articles for taxing the import and production of tobacco products, the law requires to extend taxing to other industries such as sugar-sweetened beverages. Taxing harmful products is at the beginning stage as yet several other harmful products are traded while taking little responsibility for likely harmful impacts on health.The 6NPD also introduced measures to improve efficiency through need-based human resource development. As the health workforce educational system of the country is mainly funded by public money, the goal is to address health gaps and the health system needs by making an efficient use of the educational system capacity. Policies proposed by the 6NPD are expected to balance the demand and supply of the health workforce by adjusting the capacity human resource development system by the job market.About transparency and accountability, a long path remains to go. Access to tobacco tax data is an example of increasing accountability and transparency for industries that do harm to health. The 6NPD could even make better use of transparency to leverage other building blocks, for example, in the governance area to reduce dual practice or to increase compliance to fee schedules.The plan also mandated developing health records for all Iranian and supported progress towards e-health. Furthermore, to control the misuse of health services, the plan proposed developing a national online data warehouse of health insurance enrollees to contain dual coverage by multiple insurance funds. It will limit unequal access to services and increase risk-sharing. Though given the capacity of health information technology (HIT) in improving efficiency and patient experience in 21st century, it was expected from 6NPD to introduce more advancements using HIT.Similar to the 6NPD, financing of health services is markedly addressed by the national health policies and health insurance arrangements in Iran, e.g., the Health Transformation Plan (HTP). Those policies aimed to reduce the proportions of healthcare expenditures  and wereThis research aimed to shed light on how the six building blocks of the Iranian health system are framed by UHC. Hence, further research is needed to display how the key objectives of UHC e.g. equity are directly or indirectly addressed, and the extent to which each UHC objective is realized. Future research may use quantitative data and research methods and longitudinal study designs to measure achievements of 6NPD in addressing health needs, effective coverage, and financial risk protection. Future studies of 6NPD may consider this evaluation using indicators that are already developed for the evaluation of 6NPD in the health sector . It is wThis study assessed the 6NPD from the UHC perspective using the contents of the plan that was enacted to a law by the parliament. The 6NPD introduced policies that partially address the objectives of UHC in terms of increasing the utilization of health services in relation to health needs and enhancing universal financial protection. Effective coverage is an area that remains untouched. The 6NPH introduced policies that help health sector financing be more sustainable, primarily through a mandatory enrolment of entire populations into the social health insurance schemes. To encourage rational use of services, the MoHME as the governing body of the health system will design a basic health benefits package to be adhered to by all basic insurance schemes. From a payment perspective, the plan mandated using strategic purchasing to increase the efficient use of resources. Other policies included unifying health insurance policies across schemes, compulsory adherence by all healthcare providers to a formal fee schedule, and prohibiting contracts that reimburse surcharges of health services on top of the formal fee schedule. And to create a supportive environment for UHC, the governance of the health sector should becentered on the MoHME.


Low birth weight (LBW) is a common outcome of preterm birth, which increases the risk of an infant’s morbidity and mortality. Approximately 20 million infants are born with LBW globally per year. Since a significant number of births in Pakistan take place at home, it is important to focus on the use of kangaroo mother care (KMC), the practice of skin-to-skin contact, in communities to prevent neonatal mortality and morbidity.We employed a formative research approach to understand the context of communities and facilities with regard to neonatal care and KMC practice. The broader aims were to inform the design and delivery of culturally appropriate platforms to introduce KMC in communities, and develop effective recruitment and retention strategies of KMC in rural areas of the Dadu district in the Sindh province of Pakistan.We conducted focus group discussions, in-depth interviews, and key informant interviews with families of LBW babies, community members, health care providers, and hospital administrators to identify barriers, enablers, and a knowledge base for KMC interventions.Newborn care practices in communities were found to be suboptimal. The community was generally unaware of the KMC intervention for the care of LBW babies. However, facility health care providers, the community, and family members were willing to provide KMC to improve outcomes. We found significant support from the community members and health care providers for KMC practices. Mothers were also ready to provide intermittent KMC. The administrative staff at the hospitals accepted the introduction of KMC practices for LBW babies.KMC as a method of treating LBW babies is widely accepted in the community. This formative research provides strategically valuable information that will be helpful for developing effective implementation strategies by identifying common community practices for LBW babies, along with identifying the barriers and enablers to KMC practice. The neonatal period (first 4 weeks of life) is the most vulnerable time for child survival. Approximately 2.4 million infants die within the neonatal period globally every year, with most deaths occurring in low-and middle-income countries (LMICs) ,2. The lCurrently, Pakistan’s neonatal mortality rate lies at about 44 deaths per 1000 live births . The preA newborn, particularly one born preterm or with LBW, is vulnerable and requires critical care. This challenge largely looms in LMICs where the rates of preterm and LBW babies are higher and the resources available for their care are scarce. Many health facilities are characterized by a lack of staff availability and training, along with ill-functioning equipment with nonexistent neonatal care units, which ultimately result in higher neonatal mortality ,9. FurthIn response, the kangaroo mother care (KMC) method for the care of preterm and LBW babies was developed over 30 years ago, which is practiced through continuous and long-term skin-to-skin contact between the baby and an adult . KMC is The clinical efficacy and health benefits of KMC have been established in multiple settings of developed and developing countries. However, despite the evidence of its benefits, the uptake and implementation of KMC are limited in many developing countries, including Pakistan. Therefore, we conducted a formative assessment to evaluate the barriers and enablers associated with KMC uptake among families, communities, and health services related to newborn care practices in a rural area of Pakistan. These perspectives can help to identify culturally acceptable ways of implementing KMC in the health facilities and communities of this region.taluka (subdistrict) hospital administrators. LHWs are first-line community health workers employed by the government to provide maternal newborn child health at the primary-care level and in the community. They provide an essential link between the formal health system and the community. LHVs are a trained cadre that are stationed in the facility and are responsible for conducting deliveries, recognizing high-risk pregnancies, and providing appropriate referrals. They are also trained in immediate newborn care. Mothers were selected for interviews if they had a newborn under 6 months of age and were residents of the project area. LHVs and nurses interviewed were required to have worked in the project area for at least 5 years. For FGDs, family members were required to have a baby in their household with a maximum age of 2 years. The study was conducted in three talukas  of the rural district Dadu in the Sindh province of Pakistan.A qualitative exploratory study was conducted using focus group discussions (FGDs), key informant interviews (KIIs), and in-depth interviews (IDIs). Study participants included community members , health care providers, lady health workers (LHWs), lady health visitors (LHVs), traditional birth attendants (TBAs), nurses, pediatricians, gynecologists, and The core research team comprising the principal investigator and coinvestigators developed the interview guidelines. The guidelines were developed in English and translated into the local language. The conceptual framework used for formulating the guidelines was adapted from a KMC formative study conducted in India . Findingtaluka hospitals were also asked about the potential role of health care providers in implementing KMC and suggestions for KMC implementation at the facility level.The interview guides were designed to evaluate the knowledge and perception of the community about KMC practices. They contained questions about the community’s understanding of preterm birth complications, the prevailing beliefs and traditional practices regarding newborn care in general, and care of LBW newborns in particular. Questions about existing social support systems for mothers of newborns, the willingness of mothers to provide KMC, support available to mothers practicing KMC, and the willingness of community members to become KMC champions were also included in the guides. The hospital administrators of Before pilot testing, two training sessions were conducted for the data collectors. One was facilitated by a neonatologist well-versed in KMC. This training involved orientation to the concept of KMC and demonstration of the KMC technique. Participants were educated on various wraps and methods used to hold the baby and establish skin-to-skin contact. A practice session on the KMC position was carried out using a doll. The second training was carried out in a 3-day-long workshop on formative research methods by the core study team.Following the training, pilot testing was conducted in a village with similar socioeconomic and demographic characteristics as those of the project area. Six mothers, one male community member, and one grandmother participated in the pilot. The results from the pilot were incorporated to modify the study instruments. Moreover, the KMC technique was demonstrated to nine mothers and one grandmother to evaluate the experience of securing the baby in the KMC position with the local KMC wrap.Information was collected with the help of six data collectors, including two LHVs and four social scientists with a proven qualitative research background. LHVs are typically the first point of care during the reproductive health period. They have a formal education up to grade 10 and undergo a 2-year training program that comprises 1 year of training in midwifery and 1 year in pediatrics and tropical diseases. LHVs conduct deliveries at the household and facility levels and provide immediate newborn care. The social scientists had master’s degrees in social sciences. All of the data collectors were from the same community and were fluent in the local language. Data were collected between August and November 2017.Details of qualitative assessments are provided in Verbal consent was provided by the study participants and recorded on tape. All FGDs, KIIs, and IDIs were conducted in Sindhi, the local language of the area, and were tape-recorded. The recordings were also transcribed in Sindhi. Notes of all sessions were taken by a note-taker in Sindhi.A video of KMC being practiced was shown to all participants and their reactions were observed. The video was recorded and developed by a professional firm that was outsourced. A Term of Reference was developed for this purpose. The video was 10 minutes long and was recorded in the native language. The core study team, including the principal investigator and coinvestigators, developed the storyboard for the video. The conceptual model was based on the hypothesis that the adoption of KMC by mothers and by the community at large would be predominantly influenced by factors at different levels: individual and community levels, health care provider, supportive environment, social and cultural factors, and existing practices. The script was originally written in English and then translated into the local language by the study investigators well-versed in both languages. The participating performers in the video were a mixture of professional actors and community members. The principal investigator accompanied the professional crew to the filming and ensured that correct KMC techniques were captured and relevant social aspects incorporated. The inductive thematic analysis approach was used to analyze the data to determine the themes. First, the data collection team and the investigators familiarized themselves with the data. For the nonnative investigators, the data were transcribed into the English language. Next, the data were coded based on the content to describe the most interesting and important findings. The codes were then classified into common themes. Finally, the themes were reviewed and finalized based on the relevance to answering the research questions.The process of data collection and analysis is presented in New themes were also identified according to the findings from the transcripts. Since all transcripts were in Sindhi, all data analysis was also performed in Sindhi. The analyzed quotes were then translated to English for reporting.The study was approved by the Ethical Review Committee of Aga Khan University (ERC #2020-0321-8561). Informed consent was obtained from all participants before study commencement.We interviewed a total of 184 respondents, including 43 (23.3%) men and 141 (76.6%) women. The respondents included mothers, fathers, women of reproductive age, grandmothers, elderly male members of the community, community village committee members, fathers, and community and facility health care providers . The participants ranged in age from 16 to over 50 years. A total of 66 mothers participated in the study. The mean age of the mothers was 31.9 (SD 7.3) years and that of the fathers was 30.3 (SD 9.0) years.Surmo, oil, Desi Ghee, spirit, and betamethasone cream are applied to the umbilicus to prevent infections. It is a common belief that newborns are born “impure” and are covered with dirt and substances of the uterus; thus, bathing allows for purification. Once the baby is bathed and is cleared of impurities, the call to prayer can be uttered. Uttering the call to prayer (Azaan) in a baby’s ear is a sacred practice in Islam to enable starting one’s life with the name of God: “When babies come out from mothers’ bellies they are covered with impure substance and we wash them first and prepare them for Azaan because we are Muslims.” [Grandmother]Soon after birth, the newborn’s umbilical cord is cut with a blade, and chilla (baby and mother dyad rooming-in) for approximately 40 days is extensively practiced in the community. It is believed that the newborn needs the mother to protect them against evil spirits. Some families even practice keeping sharp objects under the pillow to ward off evil spirits.Baby massage is widely reported as an essential component of immediate newborn care in the community. Some other unique practices include applying the saliva of the mother to the infant’s ankles as “protection from evil spirits.” The cultural concept of kamzor), those born early (sattria), and those with LBW (ghatwazan). They were knowledgeable about the special needs of small babies; almost 70% of these respondents stated that such babies require extra care. Two-thirds of the women responded that these babies are slow, it is difficult to feed them, and they become cold very quickly, and therefore they defer the bathing practice in such babies beyond day 1 of life. Approximately half of the mothers and grandmothers stated that the kamzor babies are bathed at 2 to 3 days of age, and in the winters such babies’ first bath is delayed to 2 weeks or even more. One-third of the mothers recognized small babies as “sick and unwell” when there is less movement or if the baby is cold (kamzori):When mothers and grandmothers were enquired about the unique issues related to small babies and if they were able to differentiate small babies from normal-size babies, the majority were able to do so and characterized small babies as weak (If a baby is born ghat wazan waro (kamzor) we give the bath after 2 to 3 days.MotherDuring the winter season, LBW babies are not given a bath and if they become sick doctors tell us not to give bath to the baby till they are well and breastfeeding.Motherghatwazan) babies. Both mothers and grandmothers perceived that a small baby must be frequently breastfed. One mother explained, “I used to give my milk to my LBW baby after every 30 minutes unless he would fall asleep.”Exclusive breastfeeding is not common across the community, although the mothers and grandmothers were aware of its benefits and understood that breast milk was a nutritious diet, especially for LBW  and that it keeps babies healthy, whereas others were advised that colostrum was thick (kharr) and dirty and must be discarded: “I had a baby who was born early [sattria] and I gave him colostrum [ghantoo kheer peri khanj], the doctors say that it is good for the health of the baby.” [Mother]Regarding colostrum, we found mixed views, where some women were advised by doctors that it is equal to 100 injections  gripe water and (ghutti) for small babies to help the digestive system.In addition, infants were frequently given prelacteal feeds such as cardamom (thaand). It is perceived by the community that wrapping them in warm clothing or cotton promotes their growth and well-being. Kamzor babies are given sunbaths to keep them warm: “When we have small babies, we keep them in cotton for some time and also wrap them in blankets.” [Grandmother]LBW babies are generally wrapped in cotton wool and blankets immediately after birth up to 2 to 3 months of age owing to the fear of hypothermia  and agreed that the practice would help enhance bonding between the baby and the mother and also enhance breastfeeding. When enquired about its acceptance, the grandmothers expressed that the KMC method will likely be culturally acceptable.The majority of mothers and grandmothers were excited and intrigued while watching the video as they had never heard of or seen such practice. As the video was developed in a similar setting to the project site, they expressed happiness and felt connected to the language and the performers in the video. Many believed that KMC appeared to be an effective method as it would Yes sister [baji], it is a good way, the baby will get more and more breastmilk and will become healthy.MotherIt is free treatment; no need to spend money, we can also do it at home when we are free.FatherYes, this is a good way, a baby will have enough mother-milk, a baby will feel emotionally good, and will gain weight.GrandmotherMost mothers agreed to administer KMC for an average of 6-8 hours a day without any support from their husbands and other family members. However, they felt that continuous 24-hour KMC would not be possible. They shared their concerns of “backaches” if they were to hold the baby in this position for long hours, especially soon after delivery. They also felt “unsafe” with the baby (skin-to-skin contact) on their chest while sleeping and were concerned about “suffocating” the baby during sleep. Several mothers reported concerns about difficulties in practicing KMC in the summer when excessive heat and humidity cause a lot of perspiration and make KMC administration uncomfortable for both the baby and mother. Many grandmothers were worried that the baby will have sweat rashes. They also expressed anxiety in carrying the baby in this position with a cloth wrapped around their waist and thought that while performing household chores such as sweeping the floor, animal rearing, and washing dishes, they may drop the baby or that the baby may slip out of the wrap.suthto).However, nearly all mothers were still willing to try and practice KMC as they recognize the benefits of this method for their child’s well-being and good health  with a zipper or front buttons. The modified garment would make it more comfortable for practicing KMC.As the Dadu district has very hot summers, many mothers stated that providing KMC during the daytime may be difficult, but they could hold the baby in the KMC position during the evening and at night. Several mothers suggested that this challenge could be overcome if they were provided with a loose robe  provide support to the woman within a household setting. Several respondents, including grandmothers, expressed that the period of chilla would facilitate KMC practice.Dai [TBA] comes to wash my clothes and my baby’s clothes and massage my body for some days.MotherDuring chilla, days woman is taken care of, she is provided food and she does not do anything but rest till 21 days.GrandmotherAdi, we rest for 21 days and can do this [KMC] during that time.Mothertaluka facility) administrators to understand their knowledge and perception of KMC practice for LBW babies. One of the hospital administrators who was from the local community and was a public health expert was aware of the KMC intervention and its benefits. He was of the view that KMC practices can be introduced in the local setting and that the video on KMC would serve well for the uptake. The remaining administrators were unaware of KMC: “The main benefits of KMC include exclusive breastfeeding and prevention of hypothermia.” [Administrator]We interviewed three hospital  with a wide neck  and open front that would make the baby and the mother more comfortable and allow for longer hours in maintaining the KMC position.When asked “how they felt” with the baby in direct skin-to-skin contact on the chest, the common response was “I feel happy and peaceful, my baby is on my chest and protected.” However, there were concerns of tightness on wearing a shirt over the wrap. Some suggestions were shared, including the availability of a loose robe , mothers were asked to lie down and incline on the bed, walk and perform some simple household chores, and share their feelings and experience. Overall, the mothers were comfortable and felt good.The enablers and barriers promoting and limiting KMC uptake in communities identified through this formative research are summarized in EnablersFamily members are willing to provide KMC to low birth weight (LBW) babies.“chilla” period, where the baby and mother dyad room-in and the family members ensure that the mother is rested, provided good nutrition, and her daily chore responsibilities are taken over by close family members.There exists a caring social support system within the family for a woman giving birth, particularly during the Community elders are willing to create support groups to facilitate KMC.Health care providers understand the benefits of KMC and are willing to support mothers in practicing it.Since families take advice from health care providers on health-related matters, it is beneficial for these providers to support, promote, and advise on KMC.There is support from religious leaders for the practice as it facilitates breastfeeding and mother and baby attachment.The use of diapers is a usual practice in the community that would facilitate keeping the baby dry and in a KMC position for long hours.The mother is willing to provide intermittent KMC with a maximum of 2 hours at a time in KMC position.Multigravida women are happy to provide support and counseling to young mothers and show interest to demonstrate and administer KMC to the baby.BarriersThere is no additional community or traditional birth attendant support to provide KMC.The community and health care providers generally are not aware of KMC practice and its benefits.There is practically no facility in the district where KMC is presently being practiced.taluka hospitals.Health care providers are scarce, especially pediatricians and obstetricians that can provide comprehensive maternal and newborn care at Immediate bathing practices due to social and cultural beliefs may delay the initiation of KMC and could predispose babies to hypothermia.KMC is difficult to practice during the day in the summer months due to extreme weather conditions.Women are not confident in moving about and carrying out household chores with the baby in the KMC position and fear that the baby may slip out of the wrap. This was considered a significant challenge by the community.Keeping the baby in KMC position during the night while sleeping is considered dangerous for the baby.Early recruitment of newborns for KMC from the facility would be difficult as the families are typically discharged within a few hours of delivery.There is reluctance to practice 24-hour continuous KMC.No one had heard of the animal kangaroo or knew how it held its baby.Implementation of KMC in Pakistan has remained elusive until recently, unlike other LMICs where national guidelines for the practice were published as early as 2014 . Most stdupatta/chaddar that the women adorn for modesty) to secure the baby in the KMC position. Our findings are similar to those of a study carried out by Mazumder et al [We found an overall willingness to practice KMC and implement the practice of skin-to-skin contact with the use of a local wrap , and providing suboptimal thermal care -33. Someka doud) by the health care providers in clinics and facilities. Similar findings have been reported in qualitative studies from India, Bangladesh, and Indonesia regarding the use of formula feeds [We found mixed perceptions and practices on colostrum, as some women discarded the colostrum due to its thickness and dirty color, while others fed their babies colostrum knowing its impact on immunity and health. The overall opinion of the community was that breastmilk is nutritious and should be offered, even though exclusive breastfeeding practice is uncommon in the community, even for LBW babies. Several mothers were prescribed formula milk  in Pakistan. This is a 30-45–day–long period where the mother and baby dyad room-in and rest to recover from delivery exhaustion and to encourage breastfeeding and bonding. In Pakistan, this period could be beneficial for mothers in providing KMC to neonates as close family members and friends carry out household chores for the mother [We found that the postpartum period could be utilized to provide KMC to an LBW baby. e mother .A multicountry analysis on bottlenecks for KMC implementation in 12 countries in Africa and Asia as part of the Every Newborn Action Plan progress concluded that a weak health workforce was a significant bottleneck in 9 of the 12 countries . AccordiMost of the research in this field has solely focused on accounts by mothers practicing KMC, since cultural gender roles prevent fathers’ involvement in KMC . Before dhoronis, similar to the TBAs in Pakistan. Dhoronis play a significant role during childbirth, from delivering the baby to assisting mothers with caring for the baby and doing household chores, and in facilitating KMC to the newborn [TBAs also play an important role in the birth of a child. KMC was supported in communities in Bangladesh through the role of  newborn . The rol. The tradition of chilla can serve as an ideal window of opportunity to implement KMC with counseling and supervision in our setting.To implement KMC in the future, communities at large must be educated on safe care practices for LBW babies with a special focus on exclusive breastfeeding, bathing, and the benefits of skin-to-skin contact . Family taluka hospitals is required to institute KMC at the facility level.During the demonstration and practice of KMC wrapping by mothers, we recognized the necessity of close liaison, supervision, and a strong support system within the community. The potential of local KMC champions could be explored for offering a source of continuous support to the mothers. A special focus from the mobilization team is also needed to ward off apprehensions about the KMC wrap among mothers and grandmothers, and the safety it poses for newborns. From local dressing patterns, it is inferred that some modification in the form of loose shirts with broad necklines and open fronts may be required. Moreover, establishing newborn inpatient care services at the The practice of KMC is widely accepted in communities given that it aligns with culturally suited enablers. Families and community elders, including male members, are willing to assist, encourage, and facilitate KMC. Although the adoption of KMC can be facilitated, it would require assistance and counseling from health care providers and community health workers. The government needs to invest in improving newborn care services at hospitals to encourage facility-based KMC.


Studies have usually addressed the utilization of either medical or dental services, and less is known about how medical and dentist visits are associated. As oral health is linked to systemic health, knowledge on care coordination between dental and medical services is important to gain understanding of the overall functioning of health care. Register data on 25–64-year-old residents of the city of Oulu, Finland, were used for the years 2017–2018 . Logit models were estimated to analyze the probability of dentist visits, according to the number of medical visits in total and by three separate health care sectors. The majority, 61%, had visited both a medical professional and a dentist. All sectors combined, as few as one to two visits increased the odds of dentist visits . When separated by medical professionals’ health care sectors, for one to two visits, the strongest association was found with public  and private sector . For occupational health service visits, the odds increased only after six or more visits. The results support the idea of integrated medical and dental care. However, the result may also arise from individual health behavior where health-conscious persons seek both medical and dental care independently. Utilization of health care has been shown to have a strong social gradient. Irrespective of need of care, those with higher socioeconomic status are more likely to utilize medical and dental services ,2,3,4,5.In most countries, health care is provided separately through public and private sector schemes. Studies have shown that persons from a higher socioeconomic background utilize disproportionately more private sector care ,5,13,14,The setting that we studied in this paper, the Finnish health care system, is unique in the sense that it is organized in three co-existing sectors: a public sector, occupational health services (OHS), and a private sector . MedicalPublic health care consists of universal coverage for all Finnish residents. Public primary care is organized by municipal health centers, while specialized health care is organized by larger hospital districts. Specialized health care may be accessed through primary care, with nurses and physicians acting as gatekeepers. The funding is based on taxes and small co-payments for the treatment .OHS provides health care services for the working population. In Finland, all employers are obliged to arrange at least preventive care for their employees. However, the range of care covered in OHS can vary between employers, and primary care level coverage is commonly included . OHS is The private health care sector is a market-based fee-for-service system, although part of the fees is also covered by the National Health Insurance (NHI) scheme. In 2018, the average fees per visit for physicians and dentists were 106 and 155 euros, respectively [Previous studies have focused on either the sectoral utilization of medical services ,2,4 and Our study population consisted of working age residents in the city of Oulu, Finland, during the 2017–2018 period. Oulu is the fifth largest city in Finland, with approximately 200,000 residents in 2018. Oulu does not differ from the general Finnish population in any systematic way in terms of demographic, socioeconomic, or health care utilization related factors . The popData on outpatient medical and dental care visits were gathered from several different registers for the 2017–2018 period. We chose a two-year period since it is common to have regular dental checks only every other year. Using data from two consecutive years allows us to examine more closely those who rarely utilize health care. Also, private dental care is reimbursed by the NHI scheme only every other year.First, data on public outpatient medical care and dental care utilization were obtained from the register of the city of Oulu. For outpatient medical care, we restricted the data to care given by physicians and nurses. For brevity, we use the term “medical” to cover the care given by both physicians and nurses. For dental care, we restricted the data to care given by dentists. This register included visits with appointment and on-call duty visits. In addition, we included information on visits with appointment and on-call duty visits to outpatient specialized health care. That information was derived from the Care Register of Health Care, which is maintained by the Finnish Institute for Health and Welfare.Second, we gathered data on OHS utilization from the four largest OHS providers in Oulu . Together they cover around 92% of all OHS visits in Oulu .Third, the information on private sector medical and dental care utilization was derived from the registers of the Social Insurance Institution of Finland. These data included all visits and procedures that were reimbursed by the NHI scheme.We included only visits that were active face-to-face visits . In the registers, one visit may include several inconsistently recorded events, and it was not possible to measure reliably the number of separate visits during one day with the same service provider. Thus, we approximated the number of visits as the number of separate contact days with each health care provider during the two-year period.Information on personal gross taxable income, added together for the two years from 2017 to 2018, was collected from the Finnish Tax Administration. To take into account any nonlinearities, we grouped income into five categories, from highest to lowest, by quintiles.As a proxy for chronic morbidities, we used the number of entitlements to special reimbursement for medicine expenses. This information was gathered from the register of the Social Insurance Institution of Finland. To become entitled for the special reimbursement, a patient needs to apply for it and has to have a medical certificate from a physician. Once an affirmative decision has been given, a patient is entitled to a higher NHI reimbursement rate for medicine expenses. Information on these entitlements is often used as a register-based measure of chronic disease .In this study, we were interested in the overall probability of dentist visits. Thus, we grouped visits to public and private dentists in order to form a binary variable of having any dentist visits during the two-year period. For medical visits, we grouped the number of visits during the two-year period into five categories: 0, 1–2, 3–5, 6–10, and over 10 visits. We calculated the total number of visits and their number by health care sector. This enabled us to study whether, with respect to dentist visits, there were any differences between health care sectors or nonlinearities in the number of medical visits.First, we calculated the proportion of residents that had visited a dentist, a medical professional, or both during the two-year period from 2017 to 2018. Further, we calculated the proportion of residents that had a dentist visit with respect to the number of medical visits in each sector.Second, to adjust the probability of having dentist visits for socioeconomic, demographic, and health related factors, we estimated a logit model by maximum likelihood . The covTo further describe the distribution of medical visits in different health care sectors during the two-year period, This study examined the association between medical visits and dental attendance during a two-year period from 2017 to 2018, using register data from the city of Oulu, the fifth largest city in Finland. The strength of the association was evaluated separately for public, OHS, and private medical visits. Crude descriptive methods and logistic regressions were used in the analysis.The majority of residents, 91%, had at least one medical visit and most of the visits were made to the public or OHS sector. Almost two thirds had at least one dentist visit during the examined two-year period. Only 5% had neither medical nor dentist visits, and 61% had both medical and dentist visits. The fraction of patients that had a dentist visit consistently increased with the number of medical visits. While the increase was more pronounced with respect to private sector medical visits, one must bear in mind that the proportion of residents with a high number of private visits was notably lower compared to other sectors. The results of our logistic regression analysis revealed a similar result. The odds of a dentist visit increased with the number of medical visits. The association was strongest for private medical visits and lowest for OHS medical visits.The association of medical visits in different sectors with dental care attendance has not been studied before. However, the general result that medical service utilization is associated with increased probability of dental attendance is in line with the scarce literature ,23,24. OIn contrast, as few as one to two medical visits were enough to cause a clear increase in the odds of dental attendance compared to those with no medical visits. This may be indicative of the same phenomena we discussed above; those having at least some medical visits are overall more inclined to look after their health. However, persons with only a few medical visits are likely to be relatively healthier and their dentist visits may often be related to routine checkups and preventive measures. Conversely, as the number of medical visits increases, the person is likely to be less healthy and the treatment of the underlying disease may include both physician and dental care. Those who had a large number of medical visits may be more likely to suffer from chronic conditions such as diabetes. In these types of cases, it is likely that treatment requires the regular involvement of both physicians and dentists ,32,33.It is also possible that the association between medical and dentist visits is stronger within sectors than across sectors  medical professionals lead to public (private) dentist visits). This could partly explain the weaker association between OHS medical visits and the odds of having a dentist visit, as it is atypical for the OHS scheme to cover dental care. Further studies are needed to examine within-sector health care utilization. Another reason could be that the ease of access and free of charge visits lower the barriers to visit OHS physicians for less serious conditions. Also, employers may often require proof of sickness from their employees even for common minor diseases, such as flus, which then increase the number of OHS medical visits. These types of visits are unlikely to be strongly associated with dental care attendance.Furthermore, lower socioeconomic status has been associated with poorer health ,36,37,38The strength of this study is the detailed register data gathered and merged from several different administrative registers that offer a comprehensive view of both medical and dental visits in all of the main health care schemes in Finland. The advantage of using register-based data is the reliability in terms of negligible missing information and no selection into the data. By contrast, survey-based data may often suffer from response bias. Loss of data from dentist and medical visits and incomplete recall of past visits can be a major problem in studies that rely on survey data. In this study, we credibly observed visits to both medical care and dental care that reveal the real magnitudes of visits across the heath care sectors. With the demographic, socioeconomic, and morbidity information drawn from the registers, we were able to adjust for the common confounders known to be associated with health care utilization ,2,3,4,5.One drawback in the data was the lack of information on the reasons behind the visits and the diagnoses associated with the visits. Without such information, little can be inferred about the health of the patient or the intensity of the treatment given. Thus, it could not be determined to what extent decisions were driven by a person’s own health behavior as opposed to underlying diseases. More research on the association between health and joint-utilization of medical and dental services is needed.This study produced new information on how medical visits in different health care sectors are associated with the probability of dental attendance. Research on this topic is scarce as the literature has focused on studying the sociodemographic determinants of dental attendance. The more medical visits a person had during the two-year study period, the higher was the probability to have visited a dentist. Particularly, a high number of visits in the private and public sectors was strongly associated with dental attendance.Our results suggest that medical visits may actively promote dental attendance. Also, our results could partly be explained by personal health behavior or by a greater overall need of comprehensive medical intervention that requires both medical and dental services. Future work needs to be undertaken to disentangle the importance of these factors in dental care utilization.


The purpose of this study is to estimate the economic cost of burnout in the veterinary profession and highlight the financial reasons why the industry should address the burnout crisis from an organizational perspective. Using data from 5,786 associate veterinarians in private practice, information was obtained using employment information related to compensation, work hours, hour preferences, and job turnover. Burnout was measured using the Professional Quality of Life Scale and used to calculate conditional probabilities on turnover and reduced working hours due to burnout. Lost revenue from each outcome (turnover and reduced working hours) was then used to calculate the economic costs to the veterinary services industry. The attributable cost of burnout of veterinarians to the US industry is between $1 and 2 billion annually in lost revenue, though there is a large amount of uncertainty. The cost is dependent on whether veterinary technicians are included in the analysis. The highest economic cost per veterinarian is among food animal practitioners, while the lowest is among equine. This study demonstrates that there are significant economic costs due to burnout among veterinarians and veterinary technicians. We suggest pursuing organizational interventions as these have shown the most impact in decreasing burnout and increasing satisfaction among human health physicians. Burnout is a prominent problem in many healthcare professions –4 and noBurnout in physicians is largely driven by excessive workloads, imbalance between job demands and skills, a lack of autonomy, and prolonged work stress , 14. WhiFrom an economic perspective, higher rates of burnout affect both sides of the market—lower consumer and producer (veterinarian) welfare. While there is a lack of research in the veterinary profession, it would not be out of place to state that burnout also affects a veterinarian's ability to attend to patients effectively and efficiently, which lowers an individual's earning potential, as well as the clinic's profitability , 21, 22.via turnover and reduced working hours  Aptify membership database was used to obtain the number of veterinarians in the United States. This database is used in the calculations and simulations later in the methods to get industry level estimates. We use this database as most (~95%) US associate veterinarians are AVMA members and allows us to look at practice-type specific numbers. Numbers from the US Bureau of Labor statistics includes all non-clinical veterinarians and is not detailed enough to break about practice-type information. Several data sources were also used to compute calculations for the burnout calculator and described below.Data used to calculate burnout prevalence, turnover, and reduced work hours came from the 2016 to 2020 AVMA Census of Veterinarians surveys, administered annually in the late winter and spring by the Survey Research Laboratory of the University of Illinois at Chicago (2016–2019) and the Florida Agricultural Market Research Centre at the University of Florida, Food and Resource Economics Department. Response rates were 11.8% for 2016 , 17.5% for 2017 , 18.9% for 2018 , 19.5% for 2019 , and 22.0% for 2020 . This survey was designed to gather information about the economics of veterinary practice and veterinary compensation asking veterinarians questions related to veterinary education, employment, compensation, debt, wellbeing, and demographics.Burnout prevalence was measured using the Professional Quality of Life Scale (ProQOL) version 5 tool  and was Note that an alternative to the ProQOL scale is the Maslach Burnout Inventory (MBI) . The difWe directly observe turnover from survey respondents and also accounted for anyone who retired earlier than expected. Specifically, we observe those that have been working for their current employer for a year or less and if they had previously had a job. To estimate the intention to reduce clinical hours, veterinarians who desired to work fewer hours for less compensation were used. Reduced work hour intention was anyone who signaled that they desired to work fewer hours for less pay. Combining this information with each individual's rate of burnout allows for us to observe the conditional probability of reducing work hours (or turnover) based on burnout scores. Unfortunately, the actual reduction in hours is not observed through the survey, but this is also an issue in the physician study conducted by Han et al. . Thus, oAnnual compensation numbers came from the 2016 to 2020 AVMA Census of Veterinarians where respondents indicated their compensation at the end of a given year. The replacement cost is derived from several research findings aggregated by the Center for American Progress in which employment positions that require higher education and specific training have higher replacement costs . The Socvia turnover and reduced working hours. These two outcomes are chosen as they are organizational in nature, meaning they directly affect the businesses' profitability because they reduce clinical capacity. As previously mentioned, these two outcomes of burnout lead to reduced revenue generation for a veterinary clinic/hospital which is how the monetary cost is calculated. In this study, we simulate a hypothetical population of associate veterinarians  that represent the current population of veterinarians participating in clinical practice. The particular focus of this study is on associates practicing in companion, equine, food, and mixed animal practices. As of 2020, the US population of associate veterinarians working in one of these four practice types was 68,532–55,952 in companion animal; 4,151 in equine; 4,291 in food animal; and 4,138 in mixed animal. The populations were used to simulate the overall costs of burnout to the veterinary service industry.Following the cost-consequence approach of Han et al. , the attFor the case of turnover, we directly observe associate veterinarian turnover as part of the 2020 questionnaire. Again, we observe those that have been working for their current employer for a year or less and if they had previously had a job. This eliminates recent graduates of veterinary medicine programs. We also observe those that retired from clinical practice early. Since we eliminate practice owners from the analysis this would not include those that sold a practice and chose to retire early. Since we directly observe turnover and burnout, we directly calculate the cost of burnout attributable to turnover for an individual as:cT is the replacement cost associated with turnover , and P(T = 1|B = 1) represents the conditional probability of turnover, T, given that the associate is experiencing burnout, as measured by the ProQOL tool. To simulate this for the industry, this cost is multiplied by the number of associate veterinarians overall or for the specific practice type. The cost of turnover is calculated from two specific components: replacement cost and lost income contribution due to position vacancy of an average of 40 days. Replacement cost is calculated as 66% of annual salary—we present both the mean and median from the data for transparency. Lost income contribution is the average net revenue contribution  multiplied by the average vacancy period as percent of the year.where The attributable cost of burnout due to reduced working hours is not directly captured in the survey data. Instead, we observe the intention to reduce working hours. As such, the calculation is expressed differently to account for the signaling of wanting to reduce work hours. Again, we follow the methodology set forth by Han et al.  and formCRH is the cost of reduced working hours, P(B = 1) is the probability that the individual is experiencing burnout, P(RH = 1) is the probability that the individual is signaling a desire to reduce work hours, and P(RH = 1|B = 1)−P(RH = 1|B = 0) represents the difference in signaled intent for reduced working hours when burnout is present and absent, respectively  for many of the inputs. While this approach provides a singular answer, there is much variability given uncertainty around the inputs and the natural variability in the sample data. As such, a multivariate sensitivity analysis is performed to allow all inputs to vary and provide a range of possible outcomes. This presents a distribution of economic cost estimates and highlights the most probabilistic range of outcomes.We used the @Risk version 8 program. This program allows inputs to vary along all possible values given a distributional assumption. The iterative process randomly pulls a value from the distributional range and simulates the outcome. This allows for a distribution of outcomes. Moreover, this approach allows for identification of the “most likely” range of outcomes so as to increase confidence in our estimates. However, it is important to note that the simulation is sensitive to the inputs and distributional assumptions. Since the probabilistic inputs on rates of burnout, turnover, and reduced working hours are calculated from data on veterinarians we can provide a robust, data informed approach to conducting the sensitivity analysis—we can use the data to inform the range and distribution of the inputs. For the inputs from secondary data sources, ranges are based on the reporting of the inputs and margins of error of 5%. Distributions are chosen to be either uniform or triangular distributions to represent relevant uncertainty about the input. All input ranges and distributional assumptions are reported in Using the median values and the entirety of the associate clinical profession, it is estimated that the economic cost of burnout due to turnover and reduced working hours is ~$997 million in lost revenue. The cost of turnover is almost twice as much as the cost of lost productivity from reduced working hours. In particular, the median cost of turnover per veterinarian is about $104,000 while the cost of reduced clinical hours at the average preferred reduction in working hours is about $56,000. Using mean values for turnover costs , the industry level cost attributable to burnout is $1.075 billion as compared to $997 million.To better understand the nuances of burnout cost across the industry, the same calculations are performed for each of four practice areas: companion animal, equine, food animal, and mixed animal. As seen in For veterinary technicians, the median industry cost of burnout attributable to turnover is about $933 million. The cost of turnover per veterinary technician, which is the only cost accounted for due to data limitations, is ~$59,000. The largest component of turnover cost for veterinary technicians is the loss of potential income given their absence, which is about $35,000. The replacement cost for veterinary technicians is estimated to be about $24,000. Adding the economic cost of burnout of veterinarians to that of veterinary technicians brings the total cost of burnout to a total of about $1.930 billion.The multivariate sensitivity analysis, Overall, this study adds to the growing literature on the effects of burnout within veterinary medicine and healthcare as a whole. The results suggests that the economic cost of burnout is large. Burnout among individuals within the veterinary industry has long been a concern, and this study provides tangible, economic reasons to induce actions aimed at reducing the prevalence of the problem.As in Han et al. , these bWhile we conduct a multivariate sensitivity analysis, these estimates may not be reflective of individual clinics/hospitals. However, this calculator can be used to look at individual clinic/hospital costs given that the necessary information is being tracked. To aid in this process, we provide an editable version of the burnout calculator in the online Our study has several limitations that should be noted. As previously mentioned, there are several other direct and indirect effects of burnout that have economic impacts on firms and the industry. While we provide a robust sensitivity analysis, our estimates are likely a lower bound estimate. This means the actual economic cost of burnout is much greater. Another limitation is our reliance on survey data to extract salary and revenue amounts. There is always a degree of sampling and measurement error in these estimates that are unavoidable. Measurement error may also exist in the measure of burnout for veterinary medicine used for this study  . A thirdIt is imperative that the discussion of burnout include organizational interventions to address burnout. While there should always be a notion of individual self-care to combat burnout, clinics and hospitals also have a responsibility to reduce and prevent the causes of burnout. According to the AVMA , 40% of Human health physicians have been using organizational interventions to address burnout for several years. The interventions that have shown the most progress in reducing burnout and increasing work satisfaction focus on improving communication, optimizing workflow, and pursuing projects that target individual concerns . Some inShanafelt et al.  showed tPerhaps just as important as improving communication and workflow, another study found that good organizational leadership reduced burnout and stress among staff . In factFuture work should focus on organizational interventions to the burnout problem. These solutions should be tailored to each individual practice, but the general ideas of quality leadership, improving workflow, feedback mechanisms, and increased utilization of current, non-veterinarian staff are all factors that can be implemented in the short-term. These short-term changes could have long-term impacts to reduce turnover and improve burnout for the entire profession. In essence, it is up to everyone  to decrease the barriers for a more satisfactory work experience and address this wellbeing crisis.msalois@avma.org.The data analyzed in this study is subject to the following licenses/restrictions: data is proprietary and owned by the American Veterinary Medical Association. Requests to access these datasets should be directed to Dr. Matthew Salois, CN and CH were responsible for data analysis and interpretation, drafting of the manuscript, and approval of the submitted manuscript. MS, CN, and CH were responsible for the conception of the study and manuscript writing and revisions. CH was responsible for acquisition of data and manuscript revision. All authors contributed to the article and approved the submitted version.This study was jointly funded by the American Veterinary Medical Association and Cornell University with support from Zoetis.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


This research examines the moderating role of gender on the adoption of online payment systems (OPS). It also explores the impact of using OPS on the performance of SMEs in an emerging economy, using the Technology Acceptance Model (TAM) and Resource-Based View (RBV). The results indicate that male SME owners (entrepreneurs) are more likely to focus on perceived usefulness, whereas female SME entrepreneurs are more likely to focus on perceived ease of use while adopting OPS, according to data obtained from 302 SMEs in Bangladesh through face-to-face surveys. The results also report that the use of OPS has a considerable positive effect on SMEs' performance. The study's findings will add to the scarce research on the impact of using OPS on business performance in the context of SMEs in emerging economies, in addition to enhancing the OPS adoption literature from a gendered lens. In the last few years, the rapid diffusion of the internet has played a major role in individual and business practises , let alone the implications of such adoption. Using this as a backdrop, this study examines the adoption of OPS and its impact on company performance in Bangladeshi SMEs.Majority of the existing literature focuses on the factors that impact the adoption of OPS  in emerging economies? Second, does the use of OPS impact SME performance in emerging economies?The remainder of the paper is organised as follows. In the section “Literature Review and Research Framework,” I review existing literature to aggregate different independent, dependent, and moderator variables used in different papers to build my research model. The research strategy, data collection, measurements, and analysis method used for the study are explained in the section “Research Methodology.” The results are presented in the section “Results.” My research findings, implications for future research, and limitations of my study are provided in the section “Discussion and Conclusion.”The TAM's central idea is that a person's attitude toward technology is influenced by both perceived usefulness (PU) and perceived ease of use (PEU). Technology usage is determined by a person's behavioural intention (BI) to use it, which differs from the notion of reasoned action in that it is considered as being mediated by the person's attitudes toward utilising it  Davis, . To get H1: Entrepreneurs' perceived ease of use (PEU) positively influences their behavioural intention (BI) of adopting the online payment systems in their SMEs.Men are thought to adopt and use technology more extensively than women, who are considered passive consumers; yet, the number of women customers using e-payment systems has increased dramatically recently  toward entrepreneurs' adoption of the online payment systems in their SMEs.The degree to which a person believes that employing a certain technology would improve their performance is described as perceived usefulness  positively influences their behavioural intention (BI) of adopting the online payment systems in their SMEs.H4: Gender moderates perceived usefulness (PU) toward entrepreneurs' adoption of the online payment systems in their SMEs.Ong and Lai  note varAs per the above discoveries, I suggest the following hypothesis:H5: Entrepreneurs' behavioural intention (BI) of adopting the online payment systems positively influences their use of the online payment systems in their SMEs.This paper is grounded in the Resource-based View (RBV hereafter) because RBV has emerged as a very popular theory for explaining firm performance over the last three decades Newbert, . As per Because competitive advantages are difficult to quantify   and the other 50% from Khulna city . The surveyed SMEs were chosen randomly from the databases of relevant Chambers of Commerce and Industries of two different cities of Bangladesh. These cities have major socio-economic and infrastructure contrasts, and they exhibit rural-urban dynamism, which is relevant to Bangladesh's entrepreneurial eco-system. Agriculture, retailing, crafts, readymade garments, knitwear, infrastructure, healthcare, media, etc., are among the industries represented. I also took around 50% of the samples of female-owned firms and the other 50% male-owned firms. Three hundred and two face-to-face surveys with the key informant person (founder of the SMEs) in each SME were conducted from August to October 2018.A semi-structured questionnaire containing both closed and open-ended questions was used to collect data. In June of 2018, 350 SMEs were contacted, and the foundersIndustry/Sector Categorisation of the collected data is provided in The associated graphs related to Industry/Sector Categorisation are given in The list of variables used in this research is given in It is mentionable here that the female was coded as 0 and the male as 1 for the measurement of gender (moderator).Data has been analysed by applying STATA using Bivariate Analysis (Pearson Correlation Coefficient) and Multiple Hierarchical Regression Analyses. This research is divided into two sections. While the first section examines online payment system adoption via the perspective of TAM, the second part uses RBV to investigate the impact of such adoption (use) on performance. Thus, utilising structural equation modelling (for TAM-related hypotheses) and hierarchical regression analysis, the following hypotheses are investigated in the context of SMEs in Bangladesh in order to serve the research's goals (for RBV related hypothesis). Please see The results of hypotheses testing are provided below see .The above table shows that Gender moderated relationships of PEU and PU to behavioural intention lead to the use of the online payment system (OPS) at the SMEs in Bangladesh see . In PEU According to the findings of the hierarchical regression, there is a significant positive association between the use of online payment systems and the performance of SMEs. Moreover, hierarchical regression has been used in analysing the moderating impact of gender on OPS use and SME performance relationship see .All control and independent variables are significantly correlated with the dependent variable, with the exception of location, and there is no multicollinearity (checked by Pearson correlation coefficient and VIF tests).This study was meant to explore the moderating role of gender on the relationship between the online payment system and SME performance in Bangladesh. The research findings support that both Perceived ease of use and Perceived usefulness of OPS has a positive influence on the adoption of OPS in SMEs in Bangladesh. It was also found that the adoption of OPS has a positive influence on the use of OPS in SMEs in Bangladesh. Moreover, it was found that the use of OPS impacts SME performance positively in Bangladesh. Prior research findings  to achieve economic growth. Bangladesh is an emerging economy with a large number of SMEs. Bangladesh's government is devoted to utilising ICT's capacity to aid the country's economic growth and to establishing “Digital Bangladesh.” To this end, Bangladesh's government should revise its ICT policy and continue and enhance measures such as eliminating all taxes on computer hardware, providing interest-free loans to ICT (software) companies, and launching pro-ICT initiatives, grants, incentives, and motivational programmes to encourage the use of ICT in various sectors of the economy.The development of human resources, particularly women inside SMEs, is a critical component in achieving the goal of a “Digital Bangladesh.” This can be done through lowering training costs, which can be done through a variety of policy instruments. To develop internal knowledge and skills at the firm level, public policies should provide incentives for businesses to invest in their employees' training and specialisation.Acknowledging certain limitations, the study suggests numerous directions for future research. First and foremost, the research was quantitative. As a result, future researchers may choose to use qualitative research methodologies to uncover more in-depth discoveries that will add to the body of knowledge.Though OPS is important to conduct transactions in this pandemic-ridden world, this paper did not relate the implication of the study to the pandemic. This paper looks at the research question in a pre-pandemic period as the data has been collected at that time. OPS in the pandemic ridden world can definitely be the area of research in some future papers.The data for this study was collected from Bangladeshi SMEs. To obtain more robust research results, future researchers may utilise a cross-country sample technique.These studies have explored the impact of Perceived ease of use and Perceived usefulness of TAM. However, other elements of the TAM model were not considered in the study. For instance, technology affordability, trust, privacy, and security are associated with technology adoption. The reason for this is this study was conducted in the context of Bangladesh, and a few studies  in the different business sectors. In this way, more light can be shed on which business sectors the OPS has more positive impacts on firms' performances and which sectors gender plays a more important role.The raw data supporting the conclusions of this article will be made available by the authors upon request.The studies involving human participants were reviewed and approved by Essex University. The patients/participants provided their written informed consent to participate in this study.The author confirms being the sole contributor of this work and has approved it for publication.The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.