Species abundance distributions over time

It has been known for 50 years that the time period over which data are collected affects the shape of empirical species abundance distributions. However, despite a recent resurgence of interest in characterizing and explaining these patterns the temporal component of species abundance distributions has been largely ignored. I argue that it is essential to take account of time, and not only because sampling duration can have a profound influence on the perceived shape of the distribution. Partitions of species abundance distributions based on temporal occurrence in the record will facilitate tests of both biological and neutral models and may lead to a better understanding of rarity. These temporal partitions also have interesting, but as yet barely explored, parallels with spatial ones such as the core-satellite division. Moreover, changes in abundance distributions across all three of Preston's temporal scales (sampling time, ecological time and evolutionary time) present rich opportunities for ecological research.     

Do the Preferences of Healthcare Provider Selection Vary among Rural and Urban Patients with Different Income and Cause Different Outcome?

BackgroundEqual access to healthcare facilities and high-level quality of care are important strategies to eliminate the disparity in outcome of care. However, the existing literature regarding how urban or rural dwelling patients with different income level select healthcare providers is insufficient. The purposes of this study were to examine whether differences of healthcare provider selection exist among urban and rural coronary artery bypass surgery (CABG) patients with different income level. If so, we further investigated the associated impact on mortality.MethodsA retrospective, multilevel study design was conducted using claims data from 2007–2011 Taiwan’s Universal Health Insurance Scheme. Healthcare providers’ performance and patients’ travelling distance to hospitals were used to define the patterns of healthcare provider selection. Baron and Kenny’s procedures for mediation effect were conducted.ResultsThere were 10,108 CABG surgeries included in this study. The results showed that urban dwelling and higher income patients were prone to receive care from better-performance providers. The travelling distances of urban dwelling patients was 15 KM shorter, especially when they received better-performance provider’s care. The results also showed that the difference of healthcare provider selection and mortality rate existed between rural and urban dwelling patients with different income levels. After the procedure of mediation effect testing, the results showed that the healthcare provider selection partially mediated the relationships between patients’ residential areas with different income levels and 30-day mortality.ConclusionPreferences of healthcare provider selection vary among rural and urban patients with different income, and such differences partially mediated the outcome of care. Health authorities should pay attention to this issue, and propose appropriate solutions to eliminate the disparity in outcome of CABG care.     

Factors Driving Inequality in Prostate Cancer Survival: A Population Based Study

Purpose

As cancer control strategies have become more successful, issues around survival have become increasingly important to researchers and policy makers. The aim of this study was to examine the role of a range of clinical and socio-demographic variables in explaining variations in survival after a prostate cancer diagnosis, paying particular attention to the role of healthcare provider(s) i.e. private versus public status.

Methods

Data were extracted from the National Cancer Registry Ireland, for patients diagnosed with prostate cancer from 1998–2009 (N = 26,183). A series of multivariate Cox and logistic regression models were used to examine the role of healthcare provider and socio-economic status (area-based deprivation) on survival, controlling for age, stage, Gleason grade, marital status and region of residence. Survival was based on all-cause mortality.

Results

Older individuals who were treated in a private care setting were more likely to have survived than those who had not, when other factors were controlled for. Differences were evident with respect to marital status, region of residence, clinical stage and Gleason grade. The effect of socio-economic status was modified by healthcare provider, such that risk of death was higher in those men of lower socio-economic status treated by public, but not private providers in the Cox models. The logistic models revealed a socio-economic gradient in risk of death overall; the gradient was larger for those treated by public providers compared to those treated by private providers when controlling for a range of other confounding factors.

Conclusion

The role of healthcare provider and socio-economic status in survival of men with prostate cancer may give rise to concerns that warrant further investigation.     

The Association of Longitudinal and Interpersonal Continuity of Care with Emergency Department Use,Hospitalization, and Mortality among Medicare Beneficiaries

Background

Continuity of medical care is widely believed to lead to better health outcomes and service utilization patterns for patients. Most continuity studies, however, have only used administrative claims to assess longitudinal continuity with a provider. As a result, little is known about how interpersonal continuity (the patient''s experience at the visit) relates to improved health outcomes and service use.

Methods

We linked claims-based longitudinal continuity and survey-based self-reported interpersonal continuity indicators for 1,219 Medicare beneficiaries who completed the National Health and Health Services Use Questionnaire. With these linked data, we prospectively evaluated the effect of both types of continuity of care indicators on emergency department use, hospitalization, and mortality over a five-year period.

Results

Patient-reported continuity was associated with reduced emergency department use, preventable hospitalization, and mortality. Most of the claims-based measures, including those most frequently used to assess continuity, were not associated with reduced utilization or mortality.

Conclusion

Our results indicate that the patient- and claims-based indicators of continuity have very different effects on these important health outcomes, suggesting that reform efforts must include the patient-provider experience when evaluating health care quality.     

Safety analysis over time: seven major changes to adverse event investigation

Background

Every safety-critical industry devotes considerable time and resource to investigating and analysing accidents, incidents and near misses. The systematic analysis of incidents has greatly expanded our understanding of both the causes and prevention of harm. These methods have been widely employed in healthcare over the last 20 years but are now subject to critique and reassessment. In this paper, we reconsider the purpose and value of incident analysis and methods appropriate to the healthcare of today.

Main text

The primary need for a revised vision of incident analysis is that healthcare itself is changing dramatically. People are living longer, often with multiple co-morbidities which are managed over very long timescales. Our vision of safety analysis needs to expand concomitantly to embrace much longer timescales. Rather than think only in terms of the prevention of specific incidents, we need to consider the balance of benefit, harm and risks over long time periods encompassing the social and psychological impact of healthcare as well as physical effects.We argued for major changes in our approach to the analysis of safety events: assume that patients and families will be partners in investigation and where possible engage them fully from the beginning, examine much longer time periods and assess contributory factors at different time points in the patient journey, be more proportionate and strategic in analysing safety issues, seek to understand success and recovery as well as failure, consider the workability of clinical processes as well as deviations from them and develop a much more structured and wide-ranging approach to recommendations.

Conclusions

Previous methods of incident analysis were simply adopted and disseminated with little research into the concepts, methods, reliability and outcomes of such analyses. There is a need for significant research and investment in the development of new methods. These changes are profound and will require major adjustments in both practical and cultural terms and research to explore and evaluate the most effective approaches.

     

Does Ownership Matter? An Overview of Systematic Reviews of the Performance of Private For-Profit,Private Not-For-Profit and Public Healthcare Providers

Introduction

Ownership of healthcare providers has been considered as one factor that might influence their health and healthcare related performance. The aim of this article was to provide an overview of what is known about the effects on economic, administrative and health related outcomes of different types of ownership of healthcare providers -namely public, private non-for-profit (PNFP) and private for-profit (PFP)- based on the findings of systematic reviews (SR).

Methods and Findings

An overview of systematic reviews was performed. Different databases were searched in order to select SRs according to an explicit comprehensive criterion. Included SRs were assessed to determine their methodological quality. Of the 5918 references reviewed, fifteen SR were included, but six of them were rated as having major limitations, so they weren''t incorporated in the analyses. According to the nine analyzed SR, ownership does seem to have an effect on health and healthcare related outcomes. In the comparison of PFP and PNFP providers, significant differences in terms of mortality of patients and payments to facilities have been found, both being higher in PFP facilities. In terms of quality and economic indicators such as efficiency, there are no concluding results. When comparing PNFP and public providers, as well as for PFP and public providers, no clear differences were found.

Conclusion

PFP providers seem to have worst results than their PNFP counterparts, but there are still important evidence gaps in the literature that needs to be covered, including the comparison between public and both PFP and PNFP providers. More research is needed in low and middle income countries to understand the impact on and development of healthcare delivery systems.     

Analysis of NVMe over fabrics with SCinet DTN-as-a-Service

Supporting transfers of science big data over Wide Area Networks (WANs) with Data Transfer Nodes (DTNs) requires optimizing multiple parameters within the underlying infrastructure. New solutions for such data movement require new paradigms and technologies, such as NVMe over Fabrics, which provides high-performance data movement with direct remote NVMe device access over traditional fabrics. However, recent NVMe over Fabrics studies have been limited to local storage fabrics. To support increasing demands for the large volume of science data movement during Supercomputing (SC) conferences, we proposed a SCinet DTN-as-a-Service framework orchestrating the desired optimization to meet users, applications, and providers’ requirements. Furthermore, we extend the SCinet DTN-as-a-Service framework to incorporate new techniques, solve optimization issues in data-intensive science and evaluate NVMe over Fabrics with multiple WAN testbeds to examine its performance and discover new opportunities for optimization.

     

Identifying Elements of Patient-Centered Care in Underserved Populations: A Qualitative Study of Patient Perspectives

Patient-centered care is an important goal in the delivery of healthcare. However, many patients do not engage in preventive medical care. In this pilot study, we conducted twenty in depth, semi-structured qualitative interviews at the University of Illinois at Chicago Health Sciences campus in a four month time frame. Many patients were underserved and underinsured, and we wanted to understand their experiences in the healthcare system. Using content analysis, several themes emerged from the interview data. Participants discussed the need for empathy and rapport with their providers. They identified provider behaviors that fostered a positive clinical relationship, including step-by step explanations of procedures, attention to body language and clinic atmosphere, and appropriate time management. Participants identified cost as the most common barrier to engaging in preventive care and discussed children and social support as motivating factors. A long-term relationship with a provider was an important motivator for preventive care, suggesting that the therapeutic alliance was essential to many patients. Conversely, many participants discussed a sense of dehumanization in the healthcare system, reporting that their life circumstances were overlooked, or that they were judged based on insurance status or ethnicity. We discuss implications for provider training and healthcare delivery, including the importance of patient-centered medical homes.     

The pattern of disease in the post-infection era: national trends.

Information that can be used to assess trends in the health of the population is limited to the results of irregular surveys of nutritional status and 'I.Q.', to data obtained from the notification of infectious diseases, congenital malformations, blindness and other selected defects, and to mortality rates. The last have been recorded since 1841 and provide the most detailed and useful information, although they are often difficult to interpret because of changes in the nomenclature, classification, methods of diagnosis, and efficacy of treatment of disease states. In the last 40 years, mortality rates have shown progressive reductions at all ages which have continued past the time when improvements in the prevention and treatment of infectious disease might be expected to have produced their principal benefits. Notable differences have emerged between the sexes, the rates continuing to decline in women but remaining more or less stable for a period in middle-aged men. This difference can be attributed to sex differences in life-style, so that until recently the trends in women are likely to have been the better indicators of the effect of toxic agents in the environment. The available data are inadequate to assess possible effects such as alterations in behaviour, but are of some help in regard to teratogenicity and carcinogenicity.     

Postpartum women’s perception of antenatal breastfeeding education: a descriptive survey

Mexico has shown a worrisome decrease in breastfeeding indicators, especially in the lowest socioeconomic level. Improving breastfeeding protection, promotion, and support services through workforce development is a key area of intervention. The objective of this study is to assess the influence on breastfeeding knowledge and abilities of a semi-virtual training for primary healthcare providers assisting beneficiaries of PROSPERA in Mexico, which is one of the largest conditional cash-transfer programs in the world. Two independent cross-sectional samples of healthcare providers were drawn at baseline and post-intervention in three states of Mexico. Baseline data were collected among primary physicians, registered nurses and nurse technicians (i.e. unit of analysis) on July 2016 (n = 529) and post-training between March and April 2017 (n = 211). A 19-item telephone questionnaire assessed providers’ general knowledge about breastfeeding, breastfeeding benefits and clinical aspects of breastfeeding, clinical ability to solve problems and abilities to overcome breastfeeding challenges. The effects of the training were assessed through a propensity score matching (PSM) stratified by types of providers (i.e. physicians, registered nurses, nurse technicians). The PSM analysis showed significant improvements among all providers in the general knowledge about breastfeeding (around 20 percentage points [pp]) and knowledge about breastfeeding benefits (approximately 50 pp). In addition, physicians improved their knowledge about clinical aspects of breastfeeding (7 pp), while registered nurses improved in their ability to solve breastfeeding problems (14 pp) and in helping mothers overcome breastfeeding challenges (12 pp). Promoting a breastfeeding enabling environment in Mexico to improve breastfeeding rates will require improving the knowledge and skills of healthcare providers. While a semi-virtual training showed large improvements in knowledge, developing skills among providers may require a more intensive approach.     

Comparing trends in cancer rates across overlapping regions

Monitoring and comparing trends in cancer rates across geographic regions or over different time periods have been major tasks of the National Cancer Institute's (NCI) Surveillance, Epidemiology, and End Results (SEER) Program as it profiles healthcare quality as well as decides healthcare resource allocations within a spatial-temporal framework. A fundamental difficulty, however, arises when such comparisons have to be made for regions or time intervals that overlap, for example, comparing the change in trends of mortality rates in a local area (e.g., the mortality rate of breast cancer in California) with a more global level (i.e., the national mortality rate of breast cancer). In view of sparsity of available methodologies, this article develops a simple corrected Z-test that accounts for such overlapping. The performance of the proposed test over the two-sample "pooled"t-test that assumes independence across comparison groups is assessed via the Pitman asymptotic relative efficiency as well as Monte Carlo simulations and applications to the SEER cancer data. The proposed test will be important for the SEER * STAT software, maintained by the NCI, for the analysis of the SEER data.     

Increasing pre-term and low-birth-weight rates over time and their impact on infant mortality in south-east Brazil

This study investigates the possible effects of pre-term births and low birth weight on infant mortality rates (IMRs) over a 15-year period in Ribeir?o Preto, Brazil, based on surveys carried out in 1978/79 and 1994. The 1978/79 survey included 6750 births over a 12-month period and the 1994 survey 2846 births over a 4-month period. Infant deaths were retrieved monthly from the city register. Infant mortality rate decreased from 36.6 to 16.9 deaths per 1000 over 15 years. The decrease in IMR was larger in the 2500-2999 g group than in any other group. The observed falls in IMR were attributable to decreases in birth-weight-specific mortality rates. Likewise, there was a general decrease in IMR in mild, moderate and severe pre-term births. The incidence rate ratio of infant mortality between surveys was 0.46 (95% CI 0.34-0.63); it increased to 0.57 (95% CI 0.35-0.75) when adjusted for birth weight and other factors in the model and rose to 0.69 (95% CI 0.49-0.97) when adjusted for length of gestation and other variables. The increase in pre-term births and low birth weight may have had, at most, a marginal effect on the IMR. Progress in the care of newborns may have decreased the mortality risk, but even mild pre-term birth still has an impact on infant mortality. There is room for further improvement in IMR by tackling the high rates of pre-term birth.     

Detecting invertebrate ecosystem service providers in orchards: traditional methods versus barcoding of environmental DNA in soil

1. The objective of this study was to assess barcoding of environmental DNA as a method for monitoring invertebrate ecosystem service providers in soil samples.
2. We selected 26 invertebrate ecosystem service providers that occur in New Zealand kiwifruit or apple orchards and produced mitochondrial cytochrome c oxidase gene subunit I (cytochrome oxidase I) and/or 28S ribosomal DNA sequences for each. Specific barcode primers were designed for each invertebrate ecosystem service provider and tested, along with generic barcoding cytochrome oxidase I primers, for their ability to detect DNA from invertebrate ecosystem service providers that had been added to sterilized and unsterilized soil samples.
3. Although the specific primers accurately detected the invertebrate ecosystem service providers in more than 96% of the samples, the generic cytochrome oxidase I primers detected only 37% of the invertebrate ecosystem service providers added to the sterilized samples and 2.5% in the unsterilized samples.
4. In a field test, we compared metabarcoding with traditional invertebrate trapping methods to detect the invertebrate ecosystem service providers in 10 kiwifruit and 10 apple orchards. All invertebrate ecosystem service providers were collected in traps in at least one orchard, but very few were identified by metabarcoding of soil environmental DNA.
5. Although the specific primers can be used as a tool for monitoring invertebrate ecosystem service providers in soil samples, methodological improvements are needed before metabarcoding of soil environmental DNA can be used to monitor these taxa.

     

Long-term stability of the hawkmoth fauna (Lepidoptera,Sphingidae) in a protected area of Brazilian Atlantic Rain Forest

Hawkmoths are an important component of tropical ecosystems, with significant roles as herbivores and pollinators. These moths can be used as indicators in biodiversity assessments because they can be easily sampled and identified. However, hawkmoths have seldom been surveyed over the long term for this purpose, especially in the Neotropical region. Considering that long-term datasets are of indisputable importance for understanding and monitoring temporal changes in biodiversity, this study assessed long-term changes in the hawkmoth fauna in a protected Atlantic Rain Forest area over a period of 64 years. We used historical and recent empirical datasets to ask whether faunal-diversity patterns and species composition have changed over time. We used individual- and sample-based rarefaction and extrapolation curves based on Hill number (diversity order of q = 0) to compare species richness, and the probability version of the abundance-based Chao-Jaccard index to assess beta diversity over time. To assess changes in faunal composition, we conducted a nonmetric multidimensional scaling analysis and performed an analysis of similarities to test whether the community composition has changed. Our results clearly showed long-term stability of the hawkmoth community over the 64 years, despite the growing human-induced landscape changes that occurred in the region surrounding the study area during the last 6 decades. This study emphasizes the importance of large remnants of Atlantic Forest for long-term maintenance of both functional diversity and ecosystem functioning.     

Stability in temperate reef communities over a decadal time scale despite concurrent ocean warming

Despite increasing scientific and public concerns on the potential impacts of global ocean warming on marine biodiversity, very few empirical data on community-level responses to rising water temperatures are available other than for coral reefs. This study describes changes in temperate subtidal reef communities over decadal and regional scales in a location that has undergone considerable warming in recent decades and is forecast to be a 'hotspot' for future warming.
Plant and animal communities at 136 rocky reef sites around Tasmania (south-east Australia) were censused between 1992 and 1995, and again in 2006 and 2007. Despite evidence of major ecological changes before the period of study, reef communities appeared to remain relatively stable over the past decade. Multivariate analyses and univariate metrics of biotic communities revealed few changes with time, although some species-level responses could be interpreted as symptomatic of ocean warming. These included fishes detected in Tasmania only in recent surveys and several species with warmer water affinities that appeared to extend their distributions further south. The most statistically significant changes observed in species abundances, however, were not related to their biogeographical affinities. The majority of species with changing abundance possessed lower to mid-range abundances rather than being common, raising questions for biodiversity monitoring and management. We suggest that our study encompassed a relatively stable period following more abrupt change, and that community responses to ocean warming may follow nonlinear, step-like trajectories.     

Impact of NHS walk-in centres on the workload of other local healthcare providers: time series analysis

ObjectivesTo assess the impact of NHS walk-in centres on the workload of local accident and emergency departments, general practices, and out of hours services.DesignTime series analysis in walk-in centre sites with no-treatment control series in matched sites.SettingWalk-in centres and matched control towns without walk-in centres in England.Participants20 accident and emergency departments, 40 general practices, and 14 out of hours services within 3 km of a walk-in centre or the centre of a control town.ResultsA reduction in consultations at emergency departments (–175 (95% confidence interval –387 to 36) consultations per department per month) and general practices (–19.8 (−53.3 to 13.8) consultations per 1000 patients per month) close to walk-in centres became apparent, although these reductions were not statistically significant. Walk-in centres did not have any impact on consultations on out of hours services.ConclusionIt will be necessary to assess the impact of walk-in centres in a larger number of sites and over a prolonged period, to determine whether they reduce the demand on other local NHS providers.

What is already known on this topic

One of the objectives for NHS walk-in centres was to reduce demand on other NHS services, particularly general practitioners'' services and accident and emergency departmentsStudies of walk-in centres in North America have indicated that such centres do not reduce demand on other healthcare servicesStudies of minor injuries units in the United Kingdom (which have some similarities with walk-in centres) indicate that these units substitute mainly for consultations in accident and emergency departments

What this study adds

The data imply that walk-in centres may moderate the increasing demand on general practice and reduce the number of consultations in accident and emergency departmentsThe high level of background variability in consultation rates means that any impact of a walk-in centre is not statistically significantTo draw robust conclusions about the impact of walk-in centres on other health providers will require study of a large number of sites over an extended period of time     

Evaluating municipal solid waste management performance in regions with strong seasonal variability

The evaluation of municipal solid waste (MSW) services using management systems (ISO 9001, ISO 14001, and OHSAS 18001) is important for improving the quality of such services. In this study, we prioritize and select performance indicators (PIs) for MSW service evaluation and organize them in a Balanced Scorecard (BSC) tool. The tool is applied for the period 2008–2011 to the public administration organization responsible for waste management in Loulé Municipality, Portugal, a region characterized by strong tourist seasonality. MSW management priorities are well established through EU directives and the application of PIs should allow service objectives to be quantified, including reducing the production of waste, increasing the quantity of recyclables, improving clients’ satisfaction with the service, improving workers’ motivation, decreasing the quantities of waste in landfills, and reducing service costs. The results indicate that the use of indicators and BSC tool can assess the strategic objectives of the organization and monitor its performance over time. The overall BSC assessment ratings were 51.7%, 66.1%, and 70.1% for 2009, 2010, and 2011, respectively, indicating an improvement in overall service performance over time. The results demonstrate that monitoring seasonal variations of PIs in tourist regions is important since these variations can help to explain annual changes in the factors affecting waste services management, their impacts on overall service quality, and the best time for measures to be applied. Based on this case study, the BSC can effectively contribute to improvements in the quality and cost of MSW services in areas characterized by strong seasonal variations in population and waste.     

Attempted tests of the surrogacy value of the ED environmental diversity measures highlight the need for corroboration assessment of surrogacy hypotheses

A recent paper in this journal (Hortal et al., 2009) claimed to have evaluated the ED biodiversity surrogates methods of Faith and Walker, 1994, Faith and Walker, 1996, and to have provided evidence for poor performance of the continuous ED method. In fact, their study neither used nor evaluated the continuous ED method. Here, I document their misrepresentation. I then discuss some constructive lessons emerging from their study and other recent studies that have attempted tests of ED surrogacy value. The need to consider the actual degree of support that observed evidence provides for a hypothesis about surrogacy raises general issues for evaluations of indicators’ performance, and suggests a greater role for corroboration assessments. Guidelines for achieving this cover three aspects of surrogates testing: experimental design of tests, ongoing corroboration assessment of evidence produced by tests, and accumulation of lessons learned from multiple test studies over time.     

Achievement and social mobility: Relationships among IQ score,education, and occupation in two generations

This research tests the hypothesis that change over time in women’s status leads to improvements in their children’s health. Specifically, we examine whether change in resources and empowerment in mother’s roles as biological mothers, caregivers, and providers and social contexts that promote the rights and representation of and investment in women are associated with better nutritional status and survival of young children. Analysis is based on a broad sample of countries (n = 28), with data at two or more points in time to enable examination of change. Key indicators of child health show improvement in the last 13 years in developing nations. Much of this improvement—90 percent of the increase in nutritional status and 47 percent of the reduction in mortality—is associated with improving status of women. Increased maternal education, control over reproduction, freedom from violence, access to health care, legislation and enforcement of women’s rights, greater political representation, equality in the education system, and lower maternal mortality are improving children’s health. These results imply that further advancement of women’s position in society would be beneficial.     

Diarrheal Illness and Healthcare Seeking Behavior among a Population at High Risk for Diarrhea in Dhaka,Bangladesh

Diarrhea remains one of the major causes of death in Bangladesh. We studied diarrheal disease risk and healthcare seeking behavior among populations at high risk for diarrhea in Dhaka, Bangladesh. Data were obtained from a cross-sectional survey conducted during April and September 2010. The prevalence of diarrhea was calculated by age-group and sex. A generalized estimating equation with logit link function was used to predict diarrheal disease risk and seeking care from a professional healthcare provider. Of 316,766 individuals, 10% were young children (<5 years). The prevalence of diarrhea was 16 per 1000 persons among all ages; young children accounted for 44 per 1000 persons. Prevalence of diarrhea was significantly higher (p=.003) among younger males (<15 years) compared to that among younger females. In contrast, prevalence of diarrhea was significantly higher (p<.0001) among older females (≥15 years) compared to that among older males. An increased risk for diarrhea was observed in young children, males, and those staying in rented houses, lower family members in the house, using non-sanitary toilets, living in the area for short times, living in a community with less educated persons, living in a community with less use of safe water source for drinking, or living close to the hospital. About 80% of those with diarrhea sought care initially from a non-professional healthcare provider. Choice of the professional healthcare provider was driven by age of the patient, educational status of the household head, and hygienic practices by the household. The study reaffirms that young children are at greater risk for diarrhea. Like other developing countries most people in this impoverished setting of Dhaka are less likely to seek care from a professional healthcare provider than from a non-professional healthcare provider, which could be attributed to a higher number of diarrheal deaths among young children in Bangladesh. Dissemination of information on health education, increasing the supply of skilled healthcare providers, and low-cost and quality healthcare services may encourage more people to seek care from professional healthcare providers, thus may help reduce child mortality in the country. Further studies are warranted to validate the results.