Patient satisfaction has been identified as a major index in the assessment of quality of healthcare globally. Mothers judge the quality of perinatal care received based on their satisfaction with the services provided, thus influencing their utilization of the available health facilities. There is currently a dearth of literature on users’ satisfaction of services rendered at the primary level of care, which is the first port of call to the health system aimed at serving majority of the populace.The study was set out to investigate maternal satisfaction with perinatal care received in selected primary health centres in Ibadan.The study was a cross-sectional survey involving 66 women receiving postpartum care from five randomly selected primary health centres in Ibadan north-west local government using a 72-itemed questionnaire with p ≤ 0.05.2 = 13.306; p = 0.0001).The majority of the respondents (98.5%) perceived the perinatal care they received as high quality, and 94% and 98% were satisfied with services and facilities used for their care, respectively. Identified causes of dissatisfaction included dirty hospital environment, inadequate water supply and hospital facilities, distance of hospital location, cost of materials, time wasting, inadequate staffing and poor attitude, and verbal and physical abuse. An association exists between maternal satisfaction with quality of care and future intention for subsequent utilization (χThe overall maternal satisfaction on the perinatal care provided was perceived as very good. However, few domains of dissatisfaction were identified that would need to be addressed by healthcare professionals and policymakers to sustain and improve utilization of orthodox health care services amongst mothers, thereby contributing to achieving the third Sustainable Development Goal. Patient satisfaction can be defined as patients’ judgement on the quality and goodness of care . It mean3The quality of perinatal healthcare in most developing countries is chronically poor and grossly appalling 6. This hThe World Health Organization reported that approximately 830 women die from preventable causes related to pregnancy and childbirth every day, with 99% of all these maternal deaths occurring in developing countries . In 2013The primary target of the United Nations’ Sustainable Development Goal 3 is to reduce the global maternal mortality rate to less than 70 per 100,000 live births, with no countries having a maternal mortality rate higher than twice the global average . A majorHowever, in most developing countries, the quality of primary health care services available is very poor . The pri1Poor attitude of caregivers such as ineffective communication , neglect , unfriendliness , and financial factors , amongst others, are major factors that makes women uncomfortable . This re12The majority of people who opt for perinatal care at these primary health centres are often women within low socio-economic class who accept whatever services offered. Thus poor quality healthcare services received is often underreported and only expressed by non-usage of such a facility in subsequent times – defeating the purpose of primary health care, which is to provide quality health care for all 14.The health care system in Nigeria has received numerous negative comments both from the patients and the society . These n15There may be evidence of the success in providing more primary health centres recently against what used to be in Nigeria before, but if they are not being tailored to clients’ needs and satisfaction, they are of no use to the clients. The main focus is to meet the clients’  needs and expectations as a means of attaining objectives of improving maternal and child health and incorporating periodic patient satisfaction studies into the quality improvement plan in the service delivery in selected primary health centres.Most studies on satisfaction with quality of healthcare services has been in the higher levels of the health facilities and with broader focus, but this study is focused on assessing maternal satisfaction with perinatal care at the primary healthcare level, which is actually the first port of call to the health system and which is expected to serve majority of the populace. Satisfaction with perinatal care services may well be a pointer to general service of the entire primary health care (PHC) facility.It is against this background that the researcher set out to assess perinatal women’s satisfaction with quality of care received at selected primary health centres using selected indices of satisfaction in the primary health centres. Specific objectives included (a) to assess perception of study participants regarding quality of perinatal care received at PHC; (b) to assess level of satisfaction of study participants with perinatal nursing care received at selected primary health centres; (c) to examine the relationship between patients’ expectation and satisfaction with perinatal nursing care; (d) to examine the relationship between maternal satisfaction with perinatal care and subsequent intention of utilization of primary health centres for perinatal care; and (e) to examine factors associated with satisfaction or dissatisfaction of study participants.This study was a descriptive cross-sectional survey. It was designed to collect information on maternal satisfaction with perinatal care and its relationship with choice of place of birth for subsequent pregnancies. The survey was carried out in the 5 major primary healthcare centres in the Ibadan North-West Local Government Area, Oyo State, Nigeria. These facilities were chosen due to their location and proximity to the semi-literate and low socio-economic community in Ibadan, an urban community in south-west Nigeria. This method was considered appropriate because it gave quantitative information about the situation under study.The study included all consenting women who had received antenatal and intranatal care, and were currently receiving postpartum care, at Oniyanrin PHC, Ayeye PHC, Orieru PHC, Eleyele PHC, and Koseunti community PHC. Women who were receiving postpartum care but who did not receive antenatal and intranatal care at the same primary health centre were excluded from this study. Also, women who did not consent to participating in the study and other women who were receiving care for other medical conditions at these primary health centres were excluded.Using the Fisher’s sample size calculation formula, with consideration for attrition, a study population comprising of 66 women who consented and were receiving perinatal care and who had received antenatal and intranatal care at all the five major primary health centres in Ibadan North-West Local Government; Oniyanrin PHC, Ayeye PHC, Orieru PHC, Eleyele PHC, and Koseunti community PHC in Ibadan. New antenatal clients are registered every day of the week but with specific days for postnatal visits. Simple random sampling was used for this study.A 72-itemed researcher-developed and self-administered structured questionnaire, which was well assessed for face and content validity, was used for the study. The instrument was also ascertained for stability, consistency, and equivalence by the use of the Kuder-Richardson (KR-20) formula to determine the internal consistency reliability coefficient of the instrument. A KR-20 score of 0.7 was obtained, which indicates a high level of internal consistency reliability.An ethical approval was obtained from the UI/UCH Health Ethical Review Committee. Data was collected and processed using the Statistical Package for Social Sciences (SPSS) version 20.0. Descriptive statistics of frequency distribution tables, pie charts, and bar charts were used to describe the data.Table Table Table Table Also, 35 respondents (53.3%) stated that they always had to buy things that the hospital was supposed to supply, but 31 respondents (47%) disagreed to paying out of pocket. Fifty-three respondents (80.3%) agreed to adequate electricity and water supply in the primary health centres, whereas about 90% of the respondents indicated satisfaction with the beds and bedsheets in the wards, the toilet and bathroom, attitude of staff, and cost of drugs and other medical services. Finally, 98% (65 respondents) indicated that they were satisfied with facilities used for their care.Table In summary, 75.8% of the respondents have high likelihood of subsequent patronage of the respective PHC for perinatal care, whereas 24.2% have low likelihood for subsequent patronage of PHC for perinatal care.The research tool (questionnaire) had both quantitative and qualitative aspects. Questions 67–72 on the research tool were structured to obtain qualitative information about satisfaction with care and likelihood for subsequent utilization of facility. Respondents were required to state the most important reason for their satisfaction or dissatisfaction, and they were required to identify the problems about the hospital as well as the things they appreciate most about the hospital.On a scale of 10, respondents were required to rate the extent to which their expectations were met, and a mean score of 7 was obtained. A mean score of 8 was obtained when respondents were requested to rate the likelihood of subsequent delivery at the same PHC and a mean score of 9 was obtained when respondents were asked to rate the likelihood of recommending the PHC , a semi-urban area of Osun state in south-western Nigeria, where most of the respondents  were between 20 and 29 years of age as well .Furthermore, it was also discovered that majority of the women had a low level of education, and most of them could successfully read neither the English questionnaires nor the Yoruba questionnaires, which is their native language, despite the fact that majority of the women claimed to have secondary school education. This is in concord with a study by Nnebue, Ebenebe, Adinma, Iyoke, Obionu, and Ilika on clients’ knowledge, perception, and satisfaction with quality of maternal health care services at the primary health care level in Nnewi, Nigeria, where it was also discovered that majority of the women attending the PHC had comparatively low levels of education . The samOverall, very few respondents (6%) expressed dissatisfaction with the perinatal nursing care provided at the primary health centres. The majority of the respondents  were satisfied with services provided. The women expressed satisfaction with certain aspects of care, particularly the skills and competence with which the midwives and nurses provide care. This result is similar to previous studies on client satisfaction in Nigeria, which also reported that over 80% of clients were satisfied with services provided 21. This Majority of the respondents were generally satisfied with other aspects of care such as hospital environment, facilities, other hospital staff, process of care, and affordability of care. Findings shows that 64 respondents (97%) agreed that the hospital environment is neat and conducive, whereas 2 respondents (3%) stated otherwise. Sixty-two respondents agreed that the hospital has the facilities needed to provide care. In contrast, 45 respondents (68.2%) testified that nurses always complain of lack of instruments. This implies that nurses could have been improvising so much that most patients do not discover that the hospital actually does not have enough facilities needed to provide quality care, hence making their complain of lack of instruments seemingly incomprehensible and needless to clients. This is a very common occurrence because nurses are great ward managers and often go the extra mile to improvise for needed facilities, especially nurses practicing in rural primary health centres.Also, 35 respondents (53.3%) expressed dissatisfaction about the fact that they always have to buy things that the hospital is supposed to supply. Apparently, the power (electricity) and water supply in most PHCs is satisfactory because a majority  agreed to adequate electricity and water supply in the primary health centres, with only 13 respondents (19.7%) indicating inadequate power and water supply as a problem in the PHCs. Satisfaction with power and water supply could probably be a result of low expectations in terms of power and water supply in the country generally. About 90% of the respondents indicated satisfaction with the beds and bedsheets in the wards, the toilet and bathroom, attitude of other hospital staff, and cost of drugs and other medical services. Finally, 98% (65 respondents) indicated that they are satisfied with facilities used for their care.Results from this study revealed that the majority of the women (98.5%) perceived the perinatal nursing care they received at the primary health centres as of high quality. This result is similar to the findings of Asekun-olarinmoye, Bamidele, Egbewale, & Asekun-Olarinmoye, Ojofeitimi .It has been established in literature that the relationship between expectation and actual experience determines satisfaction 23. The rFindings from this study indicated that some women  actually received better care than they expected, while  stated that all their expectations were met. This could probably be the reason behind the report of high satisfaction obtained from this research. Also, the chi-square test of association between maternal expectation and satisfaction with perinatal care received indicated a statistically significant relationship. This result is similar to a previous study conducted by Galle, VanParys, Roelens, and Keygneart where the researchers discovered that women whose expectations were met expressed higher levels of satisfaction . Fenny, This research revealed that there is a significant association between perception of quality of care and satisfaction with care (p < 0.05). Analysis of obtained data reveals that 98.5% of women rated the care received as high quality, and a corresponding 94% of the total respondents had a high level of satisfaction with care. This result is similar to the results obtained from a research conducted by Fenny, Enemark, Asante, and Hansen, where they reported that 98% of patients attending primary health care centres were satisfied with the quality of care they received .The results of this study indicate no significant association between maternal level of education and women’s satisfaction with care. This result is in contrast with previous study conducted by Ige and Nwachuckwu on areas of dissatisfaction with primary health care services in government-owned health facilities in Igboora community, a south-western, semi-urban community in Nigeria . Ige andThis study found that there is an association between maternal satisfaction with quality of care and likelihood for subsequent utilization Figure . The stu627The attitude of healthcare providers constitutes a major aspect of interpersonal relationship and has been identified as one of the major determinants of patients’ satisfaction. However, results from this study indicate that the respondents were satisfied with the attitude of staff in terms of respect, politeness, and kindness. Majority of the respondents (95.5%) agreed that the midwives and nurses had good attitude towards the patients. Sixty respondents (90.9%) agreed that the nurses were very respectful, and 93% of the respondents agreed that midwives always showed respect to their families. This respect could probably be a reason for the perception of care as high quality and the report of good satisfaction with care provided. This result is similar to the result of a previous study by Iloh et al. in south-eastern Nigeria, where the researchers reported that 81.5% of the respondents were satisfied with the attitude of the care provider and the patient-provider relationship .Although the majority of the women perceived the quality of care as very high and satisfactory, there are certain aspects of care with which the women were not satisfied. For instance, about one-fifth of respondents  reported having been beaten at least once by a midwife at the primary health centre, and 16 respondents (24.2%) agreed to having been verbally abused at least once by a midwife during the course of receiving perinatal care in the PHC. It should be noted that on no basis should a nurse or midwife verbally or physically abuse a patient, irrespective of the situation or what the patient could have done wrong, because this is against the ethics of the nursing profession. Although it was very few, some of the respondents also reported having been shouted at by a midwife during the course of care.Other factors that respondents identified as causes of dissatisfaction include dirty hospital environment, dirty toilet, inadequate water supply, distance of hospital location, increased cost of some services , having to pay for things hospital management is supposed to supply, time wasting, inadequate hospital facilities, inadequate beds, inadequate chairs in the waiting area, inadequate staffing (midwives are not enough), poor attitude, preferential treatment, and disrespect.This result is similar to previous studies conducted on maternal satisfaction in Nigeria. Dzomeku iterated that poor attitude of caregivers such as ineffective communication , neglect , unfriendliness , and financial factors , amongst others, are major factors that make women uncomfortable . IliyasuFindings from this study further emphasises the importance of maternal satisfaction to utilization of health facility. It has been revealed that satisfaction is largely dependent on the extent to which expectations are met. It is therefore imperative to note that every woman approaching the primary health centre has some fundamental expectations about quality of care to be provided, and the extent to which these expectations are met determines the level of satisfaction and likelihood of subsequent utilization of health facility. Hence, midwives should pay attention to women’s needs and provide opportunities for them to state how they feel and be carried along with their care. All women expect to be treated with respect and be given adequate information to make informed decision as regards the care of pregnancy, the process of delivery, and care of the baby after delivery.This study has revealed that aside from competence and skilfulness of the midwives, the attitude of care providers and interpersonal relationship between the midwives and the patient constitute the basis of maternal perception of quality of care and their level of satisfaction with care. Therefore in order to maintain the high level of maternal satisfaction and continually improve the quality of care at the primary health centres, midwives should make a conscious effort to provide patient-centred, individualized care. Midwives should treat the mothers with respect; communicate effectively; provide encouragement, support, praise; and give quality health education. Midwives should advocate for a conducive environment as well as the provision of necessary facilities for quality care.Patient satisfaction has been identified as a major index in the assessment of quality of healthcare globally. Mothers judge the quality of perinatal care received based on their satisfaction with the services provided, thus influencing their utilization of the available health facilities. There is currently a dearth of literature on users’ satisfaction of services rendered at a primary level of care, which is the first port of call to the health system aimed at serving the majority of the populace – thus the need to investigate maternal satisfaction with perinatal care received in selected primary health centres in Ibadan. The cross-sectional survey involved 66 women receiving postpartum care in Ibadan North-West Local Government.Findings revealed that the majority of respondents perceived the perinatal care they received as of high quality and were satisfied with services and facilities used for their care. Identified causes of dissatisfaction included dirty hospital environment, inadequate water supply and hospital facilities, distance of hospital location, cost of materials, time wasting, inadequate staffing, poor attitude, and verbal and physical abuse. An association was found to exist between maternal satisfaction with quality of care and future intention for subsequent utilization.Though the overall maternal satisfaction on the perinatal care provided was very good, few domains of dissatisfaction identified need to be addressed by healthcare professionals and policymakers to sustain and improve utilisation of orthodox health care services amongst mothers, thereby contributing to achieving the third Sustainable Development Goal.Care should be timely with respect, devoid of any form of abuse, and targeted towards providing quality care as well as meeting the needs and expectations of the women, with caregivers displaying competence and adequate skills.Social desirability bias could have affected the quality of data collected because some respondents had difficulty in expressing dissatisfaction in the presence of others, despite the fact that the researcher has explained that their responses would be totally confidential. Also, the five primary health centres are located quite far from each other, and hence the research consumed a lot of money in terms of transportation to the research sites.There is a need to institute measures for measuring patients’ satisfaction in all public primary health centres. This will provide a basis for assessment of quality of care from users’ perspective and provide roadmap for improving quality of care.There is need for more in-depth research on the factors affecting adequate utilization of primary health centres amongst mothers in higher socio-economic class in Nigeria.In conclusion, the role of government in improving quality of care in public primary health centres cannot be over-emphasized. Government should provide adequate facilities and conducive environment for quality health care delivery. Government should make proper provision for adequate staffing and funding for the health sector.


Hamate hook fractures are usually caused by direct trauma while using a tennis racket or a baseball bat. We report stress fracture of the hamate hook in a water polo player without any specific trauma. We consider that the stress fracture occurred via indirect mechanisms through the flexor tendons. Strong ulnar deviation of the wrist during ball release and strong grip on a ball with outstretched fingers, which are unique to water polo, were the likely causes of the stress fracture of the hamate hook. The hamate hook is an eminence of bone at the hypothenar region and the attachment point for the flexor digiti minimi brevis, abductor digiti minimi, flexor retinaculum, and pisohamate ligament as well as a pulley for the flexor tendons. Fractures of the hamate hook are usually caused by direct trauma while playing racket sports, baseball, or golf . We repoA 17-year-old male water polo player presented with pain in the ulnar side of the right wrist for the past 3 months. He is a member of the water polo team at his high school, and his level was high enough to participate in the interscholastic water polo competition. After shooting a goal 1 week ago, his pain increased; however, there was no previous direct trauma to the right wrist. Upon an initial presentation to a private clinic, no specific injury was diagnosed, and he was then referred to our institution.Upon initial physical examination, he had tenderness on the hypothenar region and ulnar pain when moving the wrist. The grip strength of his right hand was 10 kg, contrasted with 44 kg of the left hand. Radiographs taken in the previous clinic did not show any injury . TendernOne week after the injection, he showed improved tenderness around the pisiform; however, hypothenar pain persisted when he flexed his right wrist. Furthermore, his grip weakness did not improve.To diagnose the injury, magnetic resonance imaging  of the affected region was performed. The right wrist showed intensity changes around the hamate hook, suggesting inflammation . A compuThree weeks after his initial presentation, we surgically removed the hamate hook fragment. Mild synovitis of the flexor tendon of the small finger was intraoperatively found but not at the site of injury itself. Radiograph taken after the surgery showed that the hamate hook fragment was completely removed .He was advised not to play water polo for 3 weeks after the surgery, and he did not resume practice until 4 weeks. Three months after the surgery, mild tenderness around the surgical scar was reported; however, his grip strength of the right hand improved and was measured as 44 kg. One year after the surgery, he was completely pain-free, and the grip strength of his right hand had further improved to 46 kg. He achieved the full range of motion in the wrist  and felt no pain around his right wrist at any time, including while playing water polo. The most recent Disabilities of the Arm, Shoulder and Hand score was 2.6 points.Fractures of the hamate account for 2% of all carpal fractures. The most common causes are racket sports, baseball, and golf, and the main mechanism of fracture is the direct injury to the hamate hook .Several reports have indicated fracture of the hamate hook without direct trauma to the hamate hook itself, caused by some other indirect mechanism. How Kit et al.  have repIn our case, the fracture of the hamate hook in the water polo player was difficult to detect and diagnose because he had no previous typical direct trauma to his right wrist. However, because the onset of his wrist pain was nonspecific and similar to previous reports of indirect mechanisms, we considered that this may be a case of stress fracture of the hamate hook. In such cases, MRI is useful in diagnosing the fracture.The following two indirect mechanisms led to stress fracture of the hamate hook in the water polo player. The first mechanism was the indirect forces that resulted from the strong ulnar deviation of the wrist during ball throwing. In water polo, putting snap on the ball is needed to spin the ball while throwing it. Particularly, pushing and knuckling are unique motions used to throw a ball in water polo, which cause strong ulnar deviations of the wrist at ball release, similar to the side-undercling position of rock climbers . ExtremeNo previous studies relating to stress fractures of the hamate hook in water polo players have been reported. Our patient's range of motion in the bilateral wrists at 1 year after the surgery was wider than normal but cannot be regarded as so-called general joint laxity and may lead to a greater strain on the flexor tendons.


Primary, specialist, and allied health services can assist in providing equitable access in rural and remote areas, where higher proportions of Aboriginal and Torres Strait Islander people  reside, to overcome the high rates of chronic diseases experienced by this population group. Little is currently known about the location and frequency of services and the extent to which providers believe delivery is occurring in a sustained and coordinated manner.The objective of this study will be to determine the availability, accessibility, and level of coordination of a range of community-based health care services to Aboriginal people and identify potential barriers in accessing health care services from the perspectives of the health service providers.This mixed-methods study will take place in 3 deidentified communities in New South Wales selected for their high population of Aboriginal people and geographical representation of location type . The study is designed and will be conducted in collaboration with the communities, Aboriginal Community Controlled Health Services (ACCHSs), and other local health services. Data collection will involve face-to-face and telephone interviews with participants who are health and community professionals and stakeholders. Participants will be recruited through snowball sampling and will answer structured, quantitative questions about the availability and accessibility of primary health care, specialist medical and allied health services and qualitative questions about accessing services. Quantitative data analysis will determine the frequency and accessibility of specific services across each community. Thematic and content analysis will identify issues relating to availability, accessibility, and coordination arising from the qualitative data. We will then combine the quantitative and qualitative data using a health ecosystems approach.We identified 28 stakeholder participants across the ACCHSs for recruitment through snowball sampling  for data collection. The project was funded in 2017, and enrolment was completed in 2017. Data analysis is currently under way, and the first results are expected to be submitted for publication in 2019.The study will give an indication of the scope and level of coordination of primary, specialist, and allied health services in rural communities with high Aboriginal populations from the perspectives of service providers from those communities. Identification of factors affecting the availability, accessibility, and coordination of services can assist ways of developing and implementing culturally sensitive service delivery. These findings could inform recommendations for the provision of health services for Aboriginal people in rural and remote settings. The study will also contribute to the broader literature of rural and remote health service provision.DERR1-10.2196/11471 Access to coordinated and timely specialist care improves health outcomes for people with complex health needs . During Approximately one-third of the Australian population lives outside the eight major cities, roughly 7.7 million people . HoweverTackling chronic diseases requires a multidisciplinary approach , with reThe unique social and cultural needs of Aboriginal Australians should be carefully considered in the provision of care to ensure culturally competent service delivery . The NatThe primary aim of this study is to determine the availability and accessibility of primary health care, specialist medical, and allied health services to Aboriginal people living in three rural or remote towns in NSW and their current level of coordination from the perspectives of service providers in those communities.Our study design will utilize a mixed-methods approach to give a broader, more comprehensive perspective to answer the aims of the study and combine the strengths of quantitative and qualitative approaches. We will use both inductive and deductive approaches, using initial deductive reasoning driven by the examination of the aims of the study in combination with generating findings that emerge from observations from the data. The study will take place in 3 communities  across NSW with higher than average populations of Aboriginal people . These tWe will conduct the study in collaboration with ACCHSs and other service providers including hospitals, general practice clinics, pharmacies, and community health centers. Stakeholder participants will be staff recruited from local health districts and primary health networks, ACCHSs, pharmacies, early childhood centers, general practices, Aboriginal working parties, schools, local councils, and the private health sector. By interviewing representatives from multiple service providers in each community, we will be able to triangulate the data to ensure that we capture a comprehensive picture of service providers’ perspectives.While we selected the three communities for the study based on their demographic characteristics and their established relationships with the researchers, a snowball sampling recruitment process will be used to recruit individual participants. We asked partner ACCHSs to provide information on all relevant service providers in their community for recruitment. Subsequently, the research team contacted each of these organizations to invite them to participate in the study. Where consent was granted by the organization to approach their staff members to participate in the study, the organization subsequently introduced the study to their staff and facilitated recruitment by providing contact details of potential participants. While snowball sampling does not provide a known sampling population size, it gives a more effective means of accessing vulnerable and isolated population groups, such as rural populations and professionals  working with Aboriginal communities, for mixed-methods research .We will deidentify each location to ensure confidentiality and privacy for the participants, which may facilitate more honest and candid responses, and to protect the privacy of the communities. All participants will go through an informed consent process and sign consent forms prior to data collection. We will collect the data over a 2-week period in each community using both face-to-face and telephone interviews. Each community supported the undertaking of data collection in this timeframe and considered it to be appropriate for answering the aims of the study and that it would not place an undue burden on the community. We will invite the participants to undertake a structured, quantitative interview about the primary health care, specialist medical and allied health services in their community and give them the opportunity to provide longer, open-ended  answers for each question. The quantitative component will allow the participants to indicate the specific services  available in these communities, by providing a response of “yes,” “no,” or “unsure.” Participants will be asked to identify where  these services are offered. We will also ask the participants about the frequency of service delivery, measured through a 9-point scale from “always” to “never” . The qualitative component will collect information about the participant’s experiences, beliefs, and expectations about accessing health services in their community. Participants will also be asked open-ended questions about the barriers and enablers to health care services for Aboriginal people in their respective locations.One of the authors and a project manager, who are experienced in conducting interviews for qualitative research in Aboriginal communities, will conduct the interviews. All interviews will be audio recorded and transcribed by a transcription service. Quantitative data will be collected using REDCap (REDCap Software), a secure electronic data capture tool hosted at The George Institute for Global Health .We will analyze the data to provide an informative analysis of service providers’ perceptions of the provision of health care services to these communities. A research student who was not involved in the data collection will conduct the initial data analyses, with subsequent data interpretation by the study investigators and the advisory group.Descriptive statistical analysis will be used for all quantitative data to determine the frequency of specific services, across the three communities and combined, to determine their availability. We anticipate that data on services will be defined and categorized by service type , service delivery type , and delivery organization . In each community, we will compare participant reports of the type and frequency of health services available. We will tabulate services readily identified by all participants as well as those where there is uncertainty or dispute. Similarly, the reported frequency of services will be compared across participants in each community to determine knowledge about services available at a community level.All qualitative data will undergo thematic and content analysis using both inductive and deductive approaches . This anQuantitative analyses will be performed using SPSS 19.0 (IBM Corp) and qualitative analyses using NVivo 10 .The AHMRC of NSW gave ethical approval for this study (1173/16). A requirement of ethical approval was the establishment of an advisory group to advise the research team. The advisory committee comprised representatives from ACCHSs and mainstream  health organizations. This committee met twice at the development and start-up of the study and will meet again once data collection is complete. The study addresses the AHMRC and National Health and Medical Research Council principles and guidelines for Aboriginal and Torres Strait Islander research . We willWe identified 28 stakeholder participants across the ACCHSs for recruitment through snowball sampling  in Phase 1 for data collection in Phase 2. The project was funded in 2017, and enrolment was completed in 2017. Data analysis is currently underway, and the first results are expected to be submitted for publication in 2019.This study will use quantitative and qualitative data to provide unique insight into the lived experiences of service providers in 3 rural communities with high Aboriginal populations in NSW. Further, this study provides insights into the availability and frequency of primary, specialist, and allied health services in those communities. Combining the quantitative and qualitative data will provide a comprehensive way to identify issues and enablers from a systems perspective and make explicit how all the parts of the health system might interact, support, and influence outcomes . The resThe provision of health care services to Australians is a multifaceted undertaking that is often influenced by a range of factors, particularly social, cultural, political, and geographical factors. When this provision exists outside major cities, the challenges and expenses faced by health care providers are significantly increased . The proThe strengths of this study are its collaborative development and delivery, with the key stakeholders involved in health service delivery to Aboriginal Australians including community-controlled health services. Another strength is the application of the novel ecosystems approach that enables a broader lens on the interactions between individuals, issues, and system ,20. Limi


Invasion of the superior vena cava (SVC) by thoracic tumors and occurrence of SVC syndrome are often encountered in clinical practice; but the prognosis in these cases is poor. Replacement of the SVC with autologous pericardial tissue is rarely performed. In this study, we sought to investigate the postoperative outcomes of this rare procedure.We performed a retrospective analysis of six patients who underwent SVC replacement using autologous pericardial tissue between October 2010 and November 2016. We collected data on the patients’ pathological features, operative characteristics, postoperative outcomes, and survival.All six patients were male with an average age of 52 years . Three of the patients had lung cancer, one had stage III thymoma, and two had germinoma. Four of the six patients had mild or moderate superior vena cava compression and no corresponding clinical symptoms. The other two patients had severe compression and obvious symptoms of SVC syndrome, with the typical swelling of the face, eyelids, and upper extremities. All six patients underwent complete tumor resection, with two of the lung cancer patients undergoing right lobectomy and one undergoing right pneumonectomy. With respect to the postoperative outcomes, one patient died, whereas the others did not develop any major complications. At the end of the follow-up period, five of the patients were alive and none of the patients had developed thrombosis in the grafts.Our findings indicated that SVC replacement with autologous pericardium is technically feasible and safe, with few postoperative complications and favorable long-term effects. Although it has some limitations, this method appears to be useful in achieving SVC reconstruction of moderate size. SVC replacement with autologous pericardium appears to have the potential for widespread clinical use. Locally advanced lung or mediastinal tumors sometimes invade the superior vena cava (SVC), and surgery for such invasive lesions is still controversial because of the poor prognosis , 2. LocaSurgical treatment for the management of lung cancer or mediastinal malignancy invading the SVC involves the replacement of the SVC. The use of autologous tissue, particularly the pericardium, is less common and challenging in a clinical setting, especially when performed by surgeons who lack relevant experience . Cases oAlthough successful SVC replacement with an autologous pericardium has been reported in a few cases, the application of this technique in actual practice still remains limited. In this study, we examine in detail the process of pericardial replacement of the SVC and summarize the advantages and long-term results of this procedure.This investigation was designed as a retrospective study of the data of patients who underwent SVC replacement with an autologous pericardium at the Jiangxi Cancer Hospital, between October 2010 and November 2016. Three of these patients had lung cancer, one had thymoma, and two had germinomas. We analyzed the data of the patients to evaluate their clinical characteristics, pathological features, type of surgery, postoperative outcomes, and long-term survival rates. In addition, we assessed their imaging findings; representative images obtained from 2 of the 6 patients are presented in Fig. In the patient who underwent SVC reconstruction for a thymoma, we performed a median sternotomy with an incision in the right first intercostal space. For the three lung cancer patients, a right posterolateral incision was taken on the fifth intercostal space. The arteries, veins, and bronchi of the lungs were prepared routinely, and the lung tissues were removed. The azygos vein was ligated and severed, with proximal and distal clamping of the SVC. We then resected the tumor-invaded portion of the SVC. Depending on the extent of the SVC resected, an appropriate length of the pericardium was obtained, from the precordial region. A 5-0 prolene suture line was used for the continuous eversion suturing of the two edges of the pericardium to form a tubular pericardium Fig. . The innTwo of the enrolled patients underwent surgery for germinoma. In these patients, we performed median sternotomy in combination with an incision in the right first intercostal space. Further, the distal and proximal ends of the azygos vein and right brachiocephalic vein were clamped and then severed. The graft obtained was flushed with heparin saline, and proximal ligation of the right brachiocephalic veins and distal ligation of the azygos vein were performed. By using a 5-0 prolene suture line, the distal end of the right brachiocephalic vein was anastomosed with the proximal end of the azygous vein by serial sutures. Then, the two veins were declamped, and the blood flow in the anastomosis was checked to ensure that it was smooth and that there was no bleeding. A portion of the pericardium was resected from the precordial region, according to the required size, and the two edges of the pericardium were approximated to form a tubular pericardium by continuous eversion suture using a 5-0 prolene line. The inner and outer surfaces of the pericardial tube were repeatedly washed with 1:1000 heparin saline. The left brachiocephalic vein was blocked and cut-off, followed by flushing of the section with heparin saline. One end of the pericardial tube was anastomosed to the distal end of the left brachiocephalic vein using a 5-0 consecutive prolene suture line. The SVC was then clipped and severed at a distance of ≥ 2 cm from the base of the tumor. The other end of the pericardial tube was anastomosed to the proximal end of the SVC, taking care to avoid any torsion. Finally, the lumen of the prepared tube was repeatedly washed with heparin saline, after checking for any trapped gas and kinking. The blockage of the SVC was then released, and the pericardial tube filling was checked to ensure that there was no bleeding from the anastomosis. The procedure of this reconstruction process is shown in Fig. After the operation, patients were administered short-term intravenous anticoagulants . Routine thoracic spiral computed tomography (CT) and 3D reconstruction was performed for all patients, to assess the patency of the graft after surgery. Procedure-related mortality was defined as death occurring within 30 days of the surgery or within the first 30 days of the initial postoperative hospitalization period. Survival was defined as the time from surgery to death or the last follow-up.In our study, 2 of the 6 patients had developed manifestations of SVC syndrome before surgery, with the typical swelling of the face, eyelids, and upper extremities. After the surgery, symptoms had significantly reduced  was administered before the clamping of the SVC. In five of the six cases, SVC reconstruction was performed using the SVC clamp technique; the average duration of SVC clamping in these cases was 77 min. In the remaining case, clamping was performed for 20 min combined with a venovenous shunt creation. The average operative time was 420 min, and the average volume of blood loss during the operation was 1050 mL. The amount of intraoperative blood transfusion required for the patients was different for different patients. Complete resection was performed for all patients with no instances of intraoperative death. The operative data for the six patients is shown in Table The average length of hospital stay for five of our patients was 25 days. The average duration of postoperative anticoagulation was 10 days . Postoperative thoracic spiral computed tomography (CT) with 3D reconstruction was performed in all cases, and uninterrupted flow and adequate filling of the SVC were noted in all cases  Gore-Tex® synthetic prostheses and heterologous (bovine) custom-made pericardial prostheses –18. AutoWith respect to the use of the bovine pericardial tissue, the main advantages are the lack of limitation in the length of the graft and lower risk of pericardial infection and thrombosis as compared to PTFE. However, Ciccone et al.  recommenOne of the most important advantages of SVC reconstruction using an autologous pericardium is the material. Since this is an autologous tissue, the risk of antigenicity of other materials and rejection are completely eliminated. Furthermore, soon after implantation, the graft is re-epithelized with autogenous epithelial cells in humans, and it is associated with a low risk of infection, reduced platelet deposition, and less thrombogenicity on the flow surface. Thus, patients treated with this method do not require long-term, postoperative anticoagulant therapy.The optimal duration for short-term anticoagulant therapy has not yet been established . In our In this paper, we describe, in detail, two surgical procedures for SVC replacement with an autologous pericardium. These procedures were useful in successfully creating unobstructed SVC grafts, without any serious postoperative complications. One of our patients was scheduled for right pneumonectomy and carinal reconstruction, which led to death during hospitalization. Spaggiari et al. suggest that pneumonectomy with complete resection of the SVC and reconstruction increases the risk of mortality in patients . It mustThis study has a few limitations. The sample size is too small and larger-scale studies are necessary. Further, in the case of the pericardium, there is a limit to the size that can be utilized. This is a drawback of the replacement surgery. Nevertheless, the main purpose of this study was to propose an innovative surgical technique process, and this surgical technique has some obvious advantages and value.To conclude, we found that the use of other methods for SVC replacement could lead to serious postoperative complications, such as severe rejection. The choice of autologous pericardium would preclude some of these serious complications. We found that among the 6 patients included in this study, 5 had relatively few postoperative complications, which implies that there is still some predictability in the safety of the surgery. This study at least proves that it is feasible to use the autologous pericardium for the operation, and only interception of the pericardium makes it complex. There is a degree of predictability in terms of safety and efficacy with this method, and the replacement of the SVC with autologous pericardium seems to have broad clinical application potential.


The growing multi-hazard environment to which millions of people in the world are exposed highlights the importance of making sure that populations are increasingly better prepared. The objective of this study was to report the levels of preparedness of a community exposed to two natural hazards and identify the primary sociodemographic characteristics of groups with different preparedness levels. A survey was conducted on 476 participants from two localities of the Atacama Region in the north of Chile during the spring of 2015. Their level of preparedness at home and work was assessed to face two types of natural hazards: earthquakes and floods.The findings show that participants are significantly better prepared to face earthquakes than floods, which sends a serious warning to local authorities, given that floods have caused the greatest human and material losses in the region’s recent history of natural disasters. Men claimed to be more prepared than women to face floods, something that the authors attribute to the particular characteristics of the main employment sectors for men and women in the region. The potential contribution of large companies on preparedness levels of communities in the areas in which they operate is discussed. The sociodemographic profile of individuals with the highest levels of preparedness in an environment with multiple natural hazards are people between 30 and 59 years of age, living with their partner and school-age children. The implications of the results pertaining to institutions responsible for developing disaster risk reduction plans, policies and programs in a multi-hazard environment are discussed. An increase in the magnitude, frequency and geographic distribution of natural disasters has been recently demonstrated, particularly for those related to climate change [A World Bank report that assessed the main natural disaster hotspots in the world  found the change  and cause change . These sThe combination of human and economic losses, together with reconstruction costs, makes natural disasters both a humanitarian and an economic problem . BetweenThere are no countries or communities that are currently immune to the impact of natural disasters. It is, however, possible to reduce the effects of these events through management strategies focused on risk reduction . CitizenChile, located in the Pacific Ring of Fire, is one of the countries that is most exposed to earthquakes/tsunamis and volcanic eruptions on the planet. Among the OECD member countries, Chile is the most exposed to natural hazards, where 54% of its population and 12.9% of its total surface area are exposed to three or more hazards . As suchThe complexity of territories and social structures expose communities to various hazards, both natural and man-made. Against this backdrop, the leading institutions responsible for disaster risk reduction worldwide indicate the importance of nations being able to assess, recognize and integrate the various hazards in their territories in their planning, in order to prepare the population to effectively mitigate the damages associated with these multiple hazards .Although addressing a multi-hazard environment requires significant economic and political efforts, several studies have indicated that the multi-hazard approach has major benefits for the design of effective disaster risk reduction policies , 13. A mThe main recommendations for multi-hazard environments include strengthening risk assessment within territories, informing the population of these risks to raise awareness, and establishing multi-disciplinary and multi-sectoral efforts to develop integrated public policies .In recent decades, numerous studies have been focused on assessing individuals’ levels of preparedness for natural hazards, and the factors that promote the adoption of preparedness measures –17. In tOne of the most common ways to study natural disaster preparedness levels is by characterizing these measures within the places where individuals spend most of their time, such as their homes (with their families) and their workplaces –23. ThesResearchers have proposed several models to explain the decision to take action and implement preparedness actions, with a particular emphasis on the role that social cognitive processes . TraditiResearchers have mostly focused on understanding family preparedness when characterizing the preparedness levels of the population , 27. FamDespite the fact that research on natural disaster preparedness has primarily focused on family preparedness, the study of workplace preparedness is emerging as a relevant focus for research, given the role that organizations play in local economies, the lives of the people they employ and even recovery following natural disasters , 32.As in the case of family preparedness, workplace preparedness involves planning activities, such as speaking with employees about the impact and importance of preparing the company for natural hazards, having an emergency plan in place, alternative energy supplies for the company’s operation following a natural disaster, insurance for this type of events, and the presence of an emergency kit in the company, among many others , 31, 33.One factor that is most closely related to workplace preparedness is company size , 31, 33.gender to the adoption of preparedness measures conclude that women prepare more than men [married people or those who live with their partner show higher levels of preparedness than those who do not [Several of the studies that link than men , 34, espthan men . Similaro do not , 36, 37.age of subjects is also a predictor for the adoption of preparedness measures. While some studies conclude that older people adopt more preparedness measures, with one of the main reasons being previous exposure to and/or experience with natural disasters [The isasters , 38. In isasters , 39.presence of children under 18 years of age in the household is associated to higher levels of preparedness [The aredness , 40, 41.aredness  suggestsaredness  indicateThe research focused on the inhabitants of Copiapó and Tierra Amarilla municipalities see  in the A2, equivalent to 9.94% of the country’s total  and another to measure workplace preparedness (3 items). The items on both sub-scales were adapted from previous studies [ studies , 28, 29.Sociodemographic characteristics. The participants were asked about various sociodemographic characteristics, including their age, gender, marital status, work activity, and whether children under 18 years of age live in their household.The understanding of the questionnaire was assessed and validated through a focus group directed by the research team. The sample was designed through simple random sampling, based on population forecasts for the Atacama Region developed by the National Statistics Institute of Chile in 2015. The first stage considered the random selection of geographic clusters (housing blocks) by block code. Then, households were selected using the Kish table and systematic sampling. Finally, people were selected on the basis of a quota system . The survey took place between November and December 2015 with a statistically representative sample in the Copiapó and Tierra Amarilla municipalities. A group of interviewers contacted voluntary participants, who had to complete a paper questionnaire face to face at their homes (receiving no compensation of any form). Finally, a total of 476 people successfully completed the survey. The average age of the sample was 49 years , and 66.9% of the participants were women. All procedures were approved by the Ethics Committee of the University Andres Bello.Regarding participants’ work activity, 37.2% declared that they were employed, 35.5% were homemakers, 4.6% were studying, and 11.8% were retired. Of the total number of participants who declared that they were employed (179 participants), 45% were women. While the main employment sectors for women were services  and commerce, for men, the main sectors were large and medium-scale mining, transport (mainly related to mining) and construction.internal consistency analysis was performed on the full sample (n = 476). The internal consistency of each sub-scale was assessed through two measures: Cronbach's alpha and corrected item-total correlation. For the first measure, values above 0.7 suggest highly consistent scales [First, a descriptive analysis of the data was carried out to assess the existence of coding errors and lost data. Then, an t scales . For thet scales . Item-toTo characterize the profile of participants with higher (or lower) levels of preparedness, difference in means analyses (using post-hoc Tukey tests) and a Factorial ANOVA were carried out.household preparedness range from 0 to 2, and for workplace preparedness range from 0 to 3. The sub-scales complied with all of the predefined requirements, and as such no items were eliminated. The α-Cronbach values for the household and workplace preparedness sub-scales for earthquakes and floods were above 0.8, and can be considered to be highly consistent , regardless of their age, gender, marital status, and work activity. This result is an important warning sign for local and regulatory authorities, given that the recent history of natural disasters in the region reveals that floods have caused the greatest human and material losses.household preparedness by marital status and age group showed statistically significant differences (p < 0.1). In the former case, participants who were married or living with their partner declared higher levels of household preparedness than single, separated or widowed participants. In the latter case, subjects 60 years of age and above declared the lowest levels of household preparedness among the different age groups. In general, subjects between 30 and 59 years of age declared the highest levels of household preparedness to face both earthquakes and floods.Similarly, for both earthquakes and floods, it can be observed that the level of household preparedness for floods, women declared a lower level of preparedness compared to men.In the case of household preparedness, a factorial ANOVA was carried out using sociodemographic characteristics as independent variables, and household preparedness as the dependent variable. The first columns in household preparedness for earthquakes , which explained 23.2% of the variance. The results suggest that the groups defined for the Work Activity variable have significantly different levels of household preparedness (p < 0.10). Similarly, the effects of two-way interactions  and  also showed significantly different levels of household preparedness for earthquakes. Three-way interactions  and  were statistically significant for household preparedness for earthquakes.To characterize the sociodemographic profile of subjects with higher (or lower) levels of declared household preparedness for earthquakes are between 30 and 59 years of age, married or living with their partner, and working or studying. On the other hand, the subjects with the lowest levels of household preparedness for earthquakes are those below 30 years old or above 60 years old, retired and single, separated or widowed. With regard to the three-way interactions, no clear trends were observed that enable to infer an evident profile.household preparedness for floods , which explained 19.6% of the variance. The only groups which show significantly different levels of household preparedness for floods were those defined by the Gender variable. Meanwhile, the three-way interactions  and (ChildrenAge x AgeGroup x WorkActivity) were statistically significant for household preparedness for floods.The columns on the right-hand side of household preparedness for floods. On the other hand, the subjects who declared the lowest level of preparedness are women above 60 years of age who are single, separated, divorced or widowed. About the three-way interactions, no clear trends that suggest an evident profile may be inferred.Based on the results shown in workplace preparedness for earthquakes and floods, according to the sociodemographic characteristics of the sample (n = 179 participants who declared that they were employed). The results indicate that participants are significantly better prepared at work to face an earthquake than a flood (p < 0.001), regardless of their age, gender, and marital status.p < 0.10); that is, participants who are married or living with their partner declared higher levels of workplace preparedness.Both for earthquakes and floods, the MaritalStatus variable showed statistically significant differences . The results indicate that the effects of the two-way interactions between the AgeGroup and Children variables show significantly different levels of workplace preparedness for earthquakes.The first columns of workplace preparedness for earthquakes are married or living with their partners, between 45 and 59 years of age, and have school-age children in their household. On the other hand, the participants with the lowest levels of workplace preparedness for earthquakes are those who are single , above 60 years of age, and do not have school-age children living in the household.workplace preparedness for floods as the dependent variable. This model explained 17.7% of the variance . The results show that the groups defined by the Gender and MaritalStatus variables have significantly different levels of workplace preparedness (p < 0.10). Likewise, the two-way interaction effects of the Gender and MaritalStatus variables show significantly different levels of workplace preparedness for floods. workplace preparedness for floods is men who are married or living with their partner, the profile of those with the lowest level is women who are single, separated, divorced or widowed.The columns on the right-hand side of household and workplace preparedness of people living in an area exposed to multiple natural hazards and identify those groups of people with different preparedness levels.The objective of this study was to assess the level of We conclude that significant differences exist in the preparedness levels declared by participants depending on the type of hazard analyzed. In fact, participants declared that they were significantly more prepared (both at home and at work) to face an earthquake than a flood, regardless of their age, gender, marital status and work activity. These results are an important warning sign for regulators and authorities, given that the recent history of natural disasters in the study area reveals that floods have caused the greatest human and material losses. Additionally, the influence of climate change is expected to produce an increase in weather phenomena, which would increase the frequency of extreme hydrometeorological events in the northern of Chile.Among the reasons that may explain the above results is the fact that, historically, the country and the study area have placed greater emphasis on preparedness measures for earthquakes than for floods. In recent years, Chile has been affected by major earthquakes, with one of the most destructive one taking place on February 27, 2010 in the south of the country. This event caused great alarm and concern among citizens and government authorities, not only due to the destructive effects of the event, but also the shortcomings uncovered regarding the level of preparedness and coordination of government institutions responsible for disaster risk reduction. This situation received widespread media coverage, and was the subject of intense political debate which lasted for several years , 57.In addition to the above, the scientific community has indicated that the recent earthquakes that have occurred in the north of the country provide evidence that there are still subduction zones which have not been activated in almost 150 years . As suchworkplace preparedness for earthquakes, which could have its roots in the presence of large mining companies in the region. In fact, the mining industry has for decades constituted the main source of development in the region, in which large mining companies have played an important role in local economies. The presence of large mining companies represents one of the greatest opportunities for the development and implementation of preparedness programs in the face of hazards, given that, as they have large numbers of employees, their emergency risk reduction and response processes are more formalized.Our results also show high levels of declared Although the history of earthquakes in Chile have led both public and private-sector organizations to develop increasingly effective citizen and institutional preparedness strategies, the floods that occurred in 2015 demonstrated that the Atacama Region also reveal the need to improve preparedness strategies, programs and plans to face extreme hydrometeorological events. It is therefore recommended that institutions responsible for disaster risk reduction in the region design preparedness plans and programs that recognize and integrate the different hazards present in the region, given that the prioritization of preparedness strategies for one hazard may increase vulnerability to others.family and workplace preparedness and in line with previous studies [Regarding the sociodemographic variables which are related to the  studies , 38, it  studies . On the  studies .Being married or living with a partner was significantly related to higher levels of preparedness within the household. Previous studies have concluded that the presence of a significant other generates greater concern among subjects, and therefore greater willingness to prepare for potential natural disasters . RegardiFinally, our results suggest that the level of preparedness for floods significantly differs depending on the subject’s gender: in general, men declare that they are more prepared for floods than women, contrary to what was expected. The authors attribute this result to the fact that the majority of men in the sample who are employed work in the large and medium-scale mining sector, while almost all women work in the services and commerce sectors. As mentioned throughout this study, the mining sector is the main source of employment and development in the region, characterized by the presence of large mining companies who provide direct employment to more than 15% of workers in the region, 92% of which are men . Due to The above highlights the potential importance of large companies in the areas where they operate, not only because of their impact on local economies, but also due to their potential influence on communities’ degree of preparedness for natural disasters. Therefore, the presence of large companies in the region is a relevant and important factor to be considered by government authorities when designing disaster risk reduction programs. Families with some members working in large mining companies may improve their levels of family preparedness for natural disasters to the extent in which these members bring information and experience from work regarding emergency risk reduction and response processes home with them.family and workplace preparedness to face potential natural disasters in multi-hazard environments. One of the greatest influencers on the motivation to prepare for natural disasters is the presence of significant others in the household. In general, adults between 30 to 59 years of age who live with their partners and have school-age children in the household constitute the sociodemographic profile of subjects with the highest declared levels of preparedness to face potential natural disasters. On the other hand, adults below 30 years of age or above 60 years old who are single, separated or widowed, and do not have school-age children living in the household represent the profile of subjects with the lowest declared levels of preparedness to face a potential natural disaster. Groups that are less prepared should be target of interventions in order to raise awareness and motivate them to adopt preparedness actions.Based on the results obtained, we conclude that sociodemographic variables such as age, marital status, gender and the presence of school-age children in the household characterize the profile of subjects with greater (or lower) levels of Also, our findings reveal the need to continue investigating how people perceive/adopt the recommendations provided by local authorities , so to be able to evaluate which factors facilitate (or discourage) the adoption of preparedness actions. As some studies indicate, the preparedness actions are not always carried out by the individuals in the same way that authorities recommended it . TherefoFinally, the institutions responsible for developing local disaster risk reduction plans and programs must appropriately characterize their target audiences if they expect to obtain more effective and efficient results. We hope that the results and conclusions reported in this study become a useful input to achieve this.There are certain limitations to this study. The number of participants in the study was small, as it was made up of a representative sample of solely the Copiapó and Tierra Amarilla municipalities in the Atacama Region. Therefore, studies must be carried out in other cities in the country in order to capture the different events that they experience, as well as geographic and cultural differences.The level of preparedness was assessed for participants solely through a single measure and using the self-reporting method. Even though dichotomous questions assess the perceived level of preparedness and do not allow to evaluate their objective level (or if they comprehend the emergency plan of their workplace or city), these questions provide an estimate of the basic actions of preparedness recommended by leading International Agencies, which should be done by individuals to face natural hazards. Although this method is extensively used in the literature, it does limit greater understanding of preparedness behavior.S1 Dataset(XLSX)Click here for additional data file.


In an era of unprecedented physician burnout and disconnection, there is growing recognition of the importance of integrating the study of humanities in medicine. Emerging research has underscored the importance of reflective writing and creativity in bolstering physician resilience. The publication “Murmurs Magazine,” therefore, should be of great interest to medical educators. This publication was developed and continues to be managed by medical students as a forum for creative expression and reflection. The less constrained expressions of medical students writing for their peers breaks barriers of isolation, silence, and disconnection.4 They see themselves in the writing of fellow students, they take pleasure in the shared experiences that are conveyed, and they acknowledge being part of a broader community of like-minded future physicians and healers. The student journal, “Murmurs,” honors these perspectives by nurturing a forum for open expression and reflection.Daily practice within clinical settings can be stressful and emotionally demanding, particularly for young medical students at the beginning of their careers. The literary journal as a medium offers medical students a space for the unbridled expression and processing of experiences which can flow freely from the writer’s pen (or computer) directly to the reader. Such creations are not subject to formal grading or assessment and thus are more likely to emerge from the heart. This may be one reason why reflective writing has been shown to benefit student health and wellbeing.“Murmurs” was started in 2012 as a student driven, bilingual literary magazine at the University of Ottawa. While it continues to be a student led project, the publication has continued to expand, attracting submissions from medical trainees, clinicians, and patients from across North America. In 2016 the publication developed a partnership with Shanghai Jiao Tong University School of Medicine leading to the creation of a multilingual publication. In 2018, facilitated by a new French language editor position, the magazine also extended its bilingual reach to numerous Quebec medical schools that had not previously offered submissions.The magazine publishes a wide range of genres including poetry, fiction, personal narratives, comics, photography, and art. All submissions are peer-reviewed by a team of peer-editors. Acting as peer-editors, they are well poised to select pieces that speak to the medical student experience. Pieces are selected on artistic merit and resonance with the theme selected for each issue. Every year, the magazine has a theme to inspire contributions. A majority consensus is reached by the editorial team prior to including a piece. The editors are often skilled in the visual arts, as well as writing, and bring a passion for creative expression to the crafting of Murmurs Magazine.As a medical profession, there is increasing awareness of the importance of reflection to the empathic delivery of healthcare. “Murmurs” provides an opportunity for its contributors, readers and editors alike to grapple with their moments of greatest vulnerability, strength and human connection. This has led to the growing support of “Murmurs” by both students and educators, as a unique vehicle shaping the experience of medical students in Canada.Notwithstanding the qualitative significance of the magazine in the eyes of medical students and educators, the publication has a number of limitations. While the magazine publishes submissions in English and French, the majority of contributions are in English and translation is not provided. This makes it more difficult to engage our francophone students. Like other medical student led journals, there is a range in the quality of the contributions varying by year and genre, although the editorial team makes it a point to select the highest quality works possible for each publication. While the focus of the magazine centers on expanding the voice of medical trainees, attracting submissions from allied health professionals would add to the diversity of expression and quality of publication.The publication possesses a number of strengths, most notably the genuineness of the contributions. The honest content of the contributions provides readers with a window into the lived experience of medical students. Within the pages of “Murmurs,” medical educators will likely find the wide range of themes enlightening, promoting a richer understanding of the dynamic lives of medical trainees. We strongly recommend that medical educators explore this insightful and reflective publication.


Creating coordination and concerted action between sectors of modern healthcare is an inherent challenge, and decision makers in search for solutions tend replicate new models across countries and settings. An example of this is the translation of the North West London integrated care pilot into a large-scale trial that took place in the Danish Municipality of Odense from 2013–2016. This article highlights the findings from our evaluation of the ill-fated project and discusses lessons learned.We examined implementation and short-term outcome in a multi-method evaluation based on qualitative interviews, direct observation, electronic surveys and quantitative analysis of change in service use and costs, using patient level data and a matched control group.Despite an ambitious setup, ample financing, a shared governance structure and a well-functioning project organisation, implementation failed at the clinical level. Also, service use and costs for included patients increased significantly, without yielding the intended results. Primary explanations relate to an overly optimistic timeframe and a failure to take professionals’ wishes, daily practices and values into account. The results underline the importance of basing future attempts at integrated care on thorough studies of the perception of actual needs and timing, including rigorous pilot testing on a smaller scale, before attempting large-scale implementation. This ‘integrated care case’ is based on the findings of a mixed methods evaluation of a large-scale integrated care model developed and tested in the Municipality of Odense from June 2013 to February 2016 [As summarized in Table 2On the local level, the project brought together organisations from secondary, primary and community health and social sectors in an effort to increase both horizontal and vertical integration. The targeted patient groups were patients on sick leave due to stress, anxiety or depression and 70+ year-old patients with chronic illnesses. For both groups, the project aimed to improve health outcomes by creating better access to more integrated care outside hospital and by enabling effective cooperation between professionals across organisations. As primary endpoints, the project sought to reduce the duration of sick leave and retain employment for patients diagnosed with stress, anxiety or depression, and to reduce emergency admissions for the elderly chronic patients. Moreover, an overall success criterion was that the care model would produce better results at reduced or similar costs.As in the London pilot, the Odense project was rooted in three core-principles:A shared and aligned governance structure across sectors that includes contractual obligations to collaborate, in order to integrate and coordinate care across the participating provider organisations.Improved capacity for relational coordination through implementation of a shared care platform, identification of high-risk patients and participation in cross-sectoral, multidisciplinary groups at the local level.Increased patient involvement and proactive patient programmes that focus on creating a fast, individual and coherent treatment and care for participating patients. As a special service, patients could be offered ten consultations with a psychologist free of charge and without a waiting list.The project involved a university hospital, the community health, social and mental care service providers in the Municipality of Odense and the 116 general practitioners in the Municipality of Odense.As illustrated in Figure The project was prepared from June 2013 to August 2014, and the trial period ran from August 2014 to February 2016. Participation was mandatory for the community and hospital provider organisations, and costs related to development where covered while costs related to clinical tasks were financed internally. Participation was voluntary for general practitioners, and all their costs related to the project covered. Thirty-three general practitioners covering approximately 56,000 enlisted patients participated in the intervention related to psychiatric patients, while 26 covering approximately 44,000 enlisted patients joined the intervention related to elderly patients. Based on these figures, the general practitioners were expected to represent approximately 1,000 patients on sick leave and 780 elderly medical patients during the 18-month trial period.In order to enhance relational coordination, cross-sectoral multidisciplinary teams and meetings were a pivotal point in the project. Nine teams were created, and, as presented in Table Each team would meet for three hours every other month, and representatives from the supporting project management facilitated the meetings. Each meeting revolved around reviews of four to six particularly complex or illustrative patient cases. The purpose was to create collective learning and to identify ways of improving the quality of the patient path. The teams were mandated to change their own daily practices based on the meetings, but not to change stratification or other project participation requirements. Ideas for change related to project requirements were gathered by the project management and presented to the administrative steering group. Once a year, each team would meet to evaluate team meetings of the preceding year, and once a year all of the teams would meet for a one-day learning seminar.A mixed methods evaluation examined implementation, experienced results and short-term outcomes of the Odense project based on the data sources in Table Box 1:A mixture of observation, interviews and surveys were used to examine involved professionals’ and patients’ perspectives on the project. Interviews were recorded and transcribed in full. To ensure room for new themes to emerge, transcriptions and observation notes were first coded openly by two members of the evaluation team. Subsequently, the identified themes were coded vertically across the collected data and clustered around the initial research questions, presented in Interviews and surveys explored the evaluation themes below. Themes were based on the project’s core-principles, dialogue with the project owners and the results from a pilot study conducted by researchers from the University of Southern Denmark :The project’s relevance according to participating staff.Project organisation, support for implementation and usability of the integrated care platform.Multidisciplinary group’s impact on collaboration and capacity for relational coordination.Experienced results and suggestions for future improvement.The coding process did not result in any essential new analytical themes, but subcategories, such as motivation for participation, difficulties in finding relevant patients, barriers related to lack of time and disagreement/uncertainty of inclusion criteria, emerged.The survey data focused on the same themes as the interviews, and the collected data were analysed using Survey Exact and Microsoft Excel. Ethical approvals were granted by The Danish Data Protection Agency.The effect evaluation used propensity-score-matching  to matchIn June 2013, to support the many development tasks in the project the partners behind the Odense trial hired a project-team consisting of three consultants and a project director. On the governance-level, agreements concerning information sharing across sectors and contractual agreements regarding economy and patient programmes across participating provider organisations were made. On the operational level, key-professionals and IT providers worked on algorithms for identification of relevant patients, agreeing on and testing criteria for inclusion and the design of a new information-sharing platform.At this stage, there was a high level of commitment to the project at the managerial level and among the clinicians involved in the working groups. The broad spectrum of health and social workers also supported the vision and principles of integrated care promoted via the project. However, a qualitative pilot evaluation  raised sUncertainty and disagreement regarding stratification tools, inclusion criteria and routines for including patients.Widespread concerns regarding the functionality and the risk of double documentation in relation to the shared care platform.It was clear that these objections constituted potential threats to the planned large-scale implementation. However, the project moved on without the supporting tools and routines being tested in a daily clinical setting. This was partly due to the time constraints that stemmed from the limited span of time in which the partnership had permission to share data across sectors and partly due to a ‘we have to lay the tracks as we move along’ approach in the project organisation. Therefore, the partnership decided on a strategy to improve solutions as part of the ongoing process and to allocate extra resources to implementation support, training and on-location support of the involved professionals.At the end of the trial period, our interviews and surveys showed that a clear majority of the participating professionals positively acknowledged the efforts to support implementation. However, it was also clear that many (pilot) challenges remained unsolved throughout the trial, which increasingly led to uncertainty, lacking motivation and outright resistance among participating professionals. Therefore, it became an important part of our evaluation to seek explanations for the lack of implementation, as presented below.and relevant patients turned out to be a major problem throughout the trial, and in the last months inclusion had almost stopped completely. Local activity data – presented in Table Inclusion of enough patients The ensuing lack of patients severely damaged the implementation process in the provider organisations, as the participating professionals met too few patients to become properly acquainted with the project’s care-plan and patient programmes. The lack of patients also led to a great deal of frustration among the other participants, who wondered why the general practitioners – whose participation was voluntary, supported by contractual agreements and ample financing – failed to live up to their responsibilities in the project. A central explanation of these problems was that many general practitioners  actively disagreed with the projects inclusion criteria and focus, as explained below.In relation to patients diagnosed with stress, anxiety and depression, the general practitioners had wished for an intervention that targeted a) an increasing number of students suffering from stress and anxiety and b) socially deprived individuals and families with mental illness. The combination of unmet expectations and inclusion criteria conceived to be imprecise, led to the erroneous inclusion of 174 students in the first months of the trial  were out of touch with their daily routines and preferences.Due to the decentralized nature of the Danish practice sector, mechanisms for holding general practitioners accountable were weak and left as a responsibility for the local project management.Therefore, one way of seeing the failed implementation is that the decision makers behind the integrated care project in Odense failed to consider the local context when they introduced an English model into a Danish setting. A particularly important element in this regard, concerns transferring the care model from an English primary care system – organised around clinical commissioning groups and group practices with practice management and clinical support staff – to a Danish system mainly organised around individual practices with 1–2 practitioners, no management and little clinical support staff. The following unsuccessful struggle to implement agreed upon tasks in general practice also illustrates the importance of assessing the organizational capabilities and motivations of involved parties, before engaging in large-scale implementation .In the wisdom of hindsight, it can further be argued that it was unwise to copy the Integrated Care Pilot from North West London before it was properly evaluated, as the English evaluations had in fact identified a number of the same challenges that faced the Odense project 8. Thus, The Odense case serves as an important reminder of the need to match large-scale interventions addressing collaboration and corporation with the actual organisation and issues at stake for involved professionals. In concurrence with recent literature 13, we alRecognizing that planning and implementing large-scale interventions takes time and requires time spent on creating a shared understanding of challenges and possible solutions.Finding opportunities to learn from others, but at the same time remember assess how or if new or imported interventions work in their local context.Basing the process of change on rigorous pilot testing in a small, but realistic setting, before implementing on a larger scale.The Odense case also points to the importance of understanding and negotiating the sometimes immense political pressure for improvements and quick fixes , which a