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s.
K
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w
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:
C
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C
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m
u
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ity
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Dep
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Qu
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C
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Vo
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Facu
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9
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C
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titu
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[
1
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[
2
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.
T
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f
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b
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ea
lth
ca
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[
3
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.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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8
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6
F
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ervices p
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f th
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(
S
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p
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p
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t
)
217
Acc
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to
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2
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T
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C
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n
s
titu
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[
5
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6
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.
Prim
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o
f
h
o
s
p
ital o
v
er
cr
o
wd
in
g
in
T
h
ailan
d
[
7
]
-
[
9
].
I
n
2
0
2
3
,
n
ew
h
ea
lth
s
er
v
ice
s
tan
d
ar
d
s
wer
e
in
tr
o
d
u
ce
d
to
ass
is
t
in
d
ev
elo
p
in
g
an
d
ass
ess
in
g
s
er
v
ic
e
q
u
ality
f
air
ly
an
d
ef
f
icien
tly
[
1
0
]
.
Ho
wev
er
,
is
s
u
es
r
elate
d
to
s
o
cial
an
d
cu
ltu
r
al
s
tan
d
ar
d
s
r
em
ain
,
an
d
th
e
ac
tio
n
s
o
f
h
ea
lth
ca
r
e
wo
r
k
er
s
p
lay
a
b
ig
r
o
le.
T
h
u
s
,
it
is
im
p
o
r
tan
t
to
tr
ain
p
r
im
ar
y
ca
r
e
wo
r
k
er
s
,
esp
ec
ially
th
o
s
e
in
clin
ical
n
u
r
s
in
g
,
to
b
et
ter
ca
r
e
f
o
r
p
atien
ts
,
p
r
o
m
o
te
h
ea
lth
,
an
d
p
r
ev
en
t
an
d
tr
ea
t
d
is
ea
s
es
[
1
1
]
-
[1
3
].
Prim
ar
y
ca
r
e
ce
n
ter
s
also
n
ee
d
to
im
p
r
o
v
e
co
llab
o
r
atio
n
an
d
p
er
s
o
n
n
el
m
an
ag
em
en
t
[
1
4
]
,
[
1
5
].
Pro
b
lem
s
lik
e
lo
w
wo
r
k
er
m
o
tiv
atio
n
,
in
ad
eq
u
ate
m
ed
ical
s
u
p
p
lies
,
p
o
o
r
r
ef
er
r
al
s
y
s
tem
s
,
an
d
f
in
an
cial
in
s
u
f
f
icien
cy
h
av
e
ar
is
en
af
ter
th
ese
h
o
s
p
itals
wer
e
m
o
v
ed
u
n
d
er
lo
ca
l
co
n
tr
o
l,
lead
in
g
to
lo
wer
s
er
v
ice
q
u
ality
.
Giv
en
th
ese
ch
allen
g
es,
th
e
p
r
esen
t
s
tu
d
y
in
v
esti
g
ated
th
e
co
n
tr
ib
u
tin
g
f
ac
to
r
s
.
I
t
ass
ess
ed
th
e
q
u
ality
o
f
ca
r
e
p
r
o
v
id
ed
by
h
ea
lth
-
p
r
o
m
o
tin
g
h
o
s
p
itals
af
ter
th
ey
wer
e
tr
an
s
f
er
r
ed
to
lo
ca
l
m
an
ag
em
en
t
an
d
ex
p
lo
r
ed
h
o
w
p
r
o
f
ess
io
n
al
n
u
r
s
es
co
n
tr
ib
u
ted
to
m
ain
tain
in
g
h
ig
h
s
er
v
ice
s
tan
d
ar
d
s
u
n
d
er
th
e
n
ew
lead
er
s
h
ip
[
16
]
.
T
h
e
r
esear
ch
q
u
esti
o
n
s
wer
e
as
f
o
llo
ws:
i
)
W
h
at
p
r
im
ar
y
ele
m
en
ts
in
f
lu
en
ce
th
e
s
tan
d
ar
d
o
f
ca
r
e
p
r
o
v
id
ed
b
y
h
ea
lth
-
p
r
o
m
o
tin
g
h
o
s
p
itals
o
n
ce
u
n
d
er
th
e
m
an
ag
em
en
t
o
f
lo
ca
l
au
th
o
r
ities
?
ii
)
W
h
at
is
th
e
co
n
n
ec
tio
n
b
etwe
en
th
e
attitu
d
es a
n
d
ab
ilit
ies o
f
h
ea
lth
ca
r
e
wo
r
k
er
s
an
d
th
e
q
u
ality
o
f
s
er
v
ices p
r
o
v
id
ed
in
th
ese
l
o
ca
l a
r
ea
s
?
T
h
u
s
,
th
is
s
tu
d
y
s
o
u
g
h
t
to
ex
am
in
e
th
e
ef
f
ec
t
o
f
d
ec
en
tr
aliza
tio
n
o
n
th
e
o
p
er
atio
n
s
o
f
s
u
b
-
d
is
tr
ict
h
ea
lth
-
p
r
o
m
o
tin
g
h
o
s
p
itals
b
y
ev
alu
atin
g
th
ese
in
s
titu
tio
n
s
b
ased
o
n
th
eir
d
ay
-
to
-
d
ay
ac
tiv
ities
u
s
in
g
a
co
m
b
in
atio
n
o
f
ap
p
r
o
ac
h
es.
T
h
is
r
esear
c
h
ca
n
h
elp
im
p
r
o
v
e
p
o
licies
an
d
r
ea
l
-
wo
r
ld
p
r
ac
tices,
lead
in
g
to
b
etter
h
ea
lth
ca
r
e
u
n
d
er
T
h
ailan
d
’
s
n
ew
h
ea
lth
s
y
s
tem
s
tr
u
ctu
r
e.
T
h
e
r
esu
lts
ar
e
in
ten
d
ed
to
h
elp
s
h
ap
e
f
u
tu
r
e
p
o
licy
an
d
p
r
ac
tice
an
d
b
r
id
g
e
th
e
g
ap
b
etwe
en
d
ec
en
tr
aliza
tio
n
p
lan
s
’
aim
s
an
d
t
h
e
o
n
-
th
e
-
g
r
o
u
n
d
r
ea
lity
.
2.
M
E
T
H
O
D
2
.
1
.
Co
ncept
ua
l
f
r
a
m
ewo
r
k
T
h
e
s
tu
d
y
u
s
ed
th
e
Glo
b
al
Fu
n
d
-
h
ea
lth
s
y
s
tem
s
s
cien
ce
(
HSS
)
f
r
am
ewo
r
k
[
11
]
.
wh
ich
is
o
r
g
an
ized
in
to
4
p
ar
ts
,
to
ass
ess
r
elev
an
t
f
ac
to
r
s
th
at
af
f
ec
t th
e
q
u
ality
an
d
ef
f
icien
cy
o
f
h
ea
lth
ca
r
e
s
er
v
ices.
−
I
n
p
u
t
Facto
r
s
:
T
h
e
in
p
u
t
f
ac
to
r
s
co
m
p
o
n
en
t
in
clu
d
es
6
p
ar
ts
ass
ess
in
g
h
o
w
h
ea
lth
ca
r
e
s
er
v
ices
ar
e
p
r
o
v
id
e
d
an
d
wh
o
p
r
o
v
id
es
th
em
.
I
t
co
v
er
s
all
th
e
r
eso
u
r
ce
s
n
ee
d
ed
f
o
r
h
ea
lth
ca
r
e
p
r
o
v
i
s
io
n
,
lik
e
b
u
ild
in
g
s
,
m
e
d
ical
to
o
ls
,
an
d
h
ea
lth
ca
r
e
p
er
s
o
n
n
el.
−
Pro
ce
s
s
es
:
T
h
e
p
r
o
ce
s
s
es
co
m
p
o
n
e
n
t
is
r
elate
d
to
th
e
s
k
ills
o
f
h
ea
lth
ca
r
e
wo
r
k
er
s
.
I
t
lo
o
k
s
at
h
o
w
h
ea
lth
ca
r
e
is
p
r
o
v
i
d
ed
th
r
o
u
g
h
p
ar
am
eter
s
lik
e
p
atien
t
t
r
ea
tm
en
t,
h
ea
lth
m
ain
te
n
an
ce
,
d
is
ea
s
e
p
r
ev
en
tio
n
,
an
d
r
ec
o
v
er
y
.
I
t r
ef
lects h
o
w
h
ea
lth
ca
r
e
wo
r
k
er
s
d
o
th
eir
j
o
b
s
.
−
Ou
tp
u
ts
:
T
h
e
o
u
tp
u
ts
co
m
p
o
n
en
t
in
clu
d
es
th
e
s
er
v
ices
p
r
o
v
id
ed
i
n
h
o
s
p
itals
an
d
th
e
co
m
m
u
n
ity
.
I
t
m
ea
s
u
r
es h
o
w
well
h
ea
lth
ca
r
e
is
p
r
o
v
id
ed
an
d
r
ec
eiv
ed
in
th
ese
s
ettin
g
s
.
−
Ou
tco
m
es
:
T
h
e
o
u
tco
m
es
co
m
p
o
n
e
n
t
u
s
es
SER
VQUA
L
a
n
d
th
e
q
u
ality
an
d
o
u
tco
m
e
f
r
am
ewo
r
k
(
QOF)
[
4
]
,
[
1
7
].
to
ch
ec
k
h
ea
lth
c
ar
e
q
u
ality
an
d
ef
f
ec
tiv
en
ess
.
SE
R
VQUA
L
ch
ec
k
s
s
er
v
ice
q
u
a
lity
in
ar
ea
s
lik
e
r
eliab
ilit
y
,
tr
u
s
t,
t
h
e
lo
o
k
o
f
t
h
e
s
er
v
ice,
ca
r
e,
an
d
r
esp
o
n
s
e
tim
es
.
QOF
ch
ec
k
s
th
e
r
esu
lts
b
ased
o
n
clea
r
s
tan
d
ar
d
s
[
1
8
]
.
Usi
n
g
b
o
th
t
h
e
Glo
b
al
Fu
n
d
-
HSS
an
d
th
e
s
e
m
o
d
els
h
el
p
s
ass
ess
b
o
th
h
o
w
h
ea
lth
ca
r
e
wo
r
k
s
an
d
h
o
w
p
atien
ts
an
d
h
ea
lth
ca
r
e
wo
r
k
e
r
s
p
er
ce
iv
e
its
q
u
ality
.
T
h
is
a
p
p
r
o
ac
h
c
o
v
er
s
s
ev
er
al
ar
ea
s
o
f
h
ea
lth
ca
r
e
an
d
h
elp
s
u
n
d
er
s
ta
n
d
h
o
w
m
o
v
in
g
h
ea
lth
ca
r
e
d
e
cisi
o
n
s
to
th
e
l
o
ca
l
lev
el
a
f
f
ec
t
s
th
e
q
u
ality
an
d
ef
f
icien
cy
o
f
s
er
v
ices.
2
.
2
.
Study
s
et
t
ing
T
h
is
m
ix
ed
-
m
eth
o
d
s
s
tu
d
y
was
co
n
d
u
cted
f
r
o
m
Ap
r
il
2
0
2
2
to
Sep
tem
b
er
2
0
2
3
at
th
e
s
u
b
-
d
is
tr
ict
h
ea
lth
-
p
r
o
m
o
tin
g
h
o
s
p
ita
l
i
n
Ma
h
asar
ak
h
am
Pr
o
v
in
ce
.
T
h
is
h
o
s
p
ital
was
ch
o
s
en
b
ec
a
u
s
e
it
ac
tiv
ely
p
r
o
v
id
es
h
ea
lth
-
p
r
o
m
o
tin
g
s
er
v
ices th
at
ar
e
n
o
w
b
ein
g
m
a
n
ag
ed
u
n
d
e
r
a
n
ew
p
r
o
v
in
cial
s
y
s
tem
in
T
h
ailan
d
.
Evaluation Warning : The document was created with Spire.PDF for Python.
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2
5
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-
8
8
0
6
I
n
t J Pu
b
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Hea
lth
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,
Vo
l.
1
5
,
No
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1
,
Ma
r
ch
20
2
6
:
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1
6
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223
218
2
.
3
.
E
t
hics
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ro
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a
l
T
h
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tu
d
y
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ec
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p
r
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l
f
r
o
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th
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Hu
m
an
R
esear
ch
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th
ics
C
o
m
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ittee
at
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h
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h
am
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er
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ity
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ap
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r
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v
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er
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5
6
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)
.
I
t
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o
llo
wed
s
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ar
d
p
r
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ce
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u
r
es,
with
r
esear
ch
er
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clea
r
l
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p
lain
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g
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s
tu
d
y
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s
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u
r
p
o
s
e,
ad
v
a
n
tag
es,
an
d
m
et
h
o
d
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,
a
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o
n
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ib
ilit
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o
f
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ar
ticip
a
n
ts
.
Data
wer
e
k
ep
t
p
r
iv
ate
an
d
u
s
ed
o
n
ly
f
o
r
r
esear
ch
p
u
r
p
o
s
es.
Par
ticip
an
ts
co
u
ld
r
ef
u
s
e
p
ar
ticip
at
io
n
o
r
with
d
r
aw
at
an
y
tim
e
with
o
u
t
n
eg
ativ
e
c
o
n
s
eq
u
en
ce
s
.
All p
ar
ticip
an
ts
p
r
o
v
id
ed
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n
f
o
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m
ed
co
n
s
en
t b
ef
o
r
e
jo
in
in
g
t
h
e
s
tu
d
y
.
2
.
4
.
P
o
pu
la
t
io
n a
nd
Sa
m
ple
T
h
e
s
tu
d
y
in
clu
d
ed
5
0
0
p
r
o
f
e
s
s
io
n
al
h
ea
lth
ca
r
e
wo
r
k
er
s
,
with
th
e
s
am
p
le
s
ize
ca
lcu
lated
u
s
in
g
th
e
Dan
iel
an
d
C
r
o
s
s
f
o
r
m
u
la
[
1
9
].
=
NP
(
1
−
)
1
−
/
2
2
2
(
−
1
)
+
(
1
−
)
1
−
/
2
2
=
5
,
2
4
7
X
0
.
179
(
1
−
0
.
1
7
9
)
1
.
96
2
0
.
0472
2
(
5
,
247
−
1
)
+
0
.
179
(
1
−
0
.
179
)
1
.
96
2
=
500
Her
e,
n
r
ep
r
esen
ts
th
e
s
am
p
le
s
ize,
N
is
th
e
p
o
p
u
latio
n
s
ize,
p
is
th
e
p
r
o
p
o
r
tio
n
,
1
−
/
2
2
eq
u
als
1
.
9
6
,
an
d
d
is
th
e
m
ar
g
in
o
f
er
r
o
r
.
E
lig
ib
le
p
ar
ticip
an
ts
wer
e
h
e
alth
ca
r
e
wo
r
k
er
s
wh
o
h
ad
at
least
6
m
o
n
t
h
s
o
f
ex
p
e
r
i
en
ce
at
h
ea
lth
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0
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atien
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r
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les f
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er
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T
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ac
to
r
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g
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to
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m
ain
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ac
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,
p
r
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s
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p
r
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esp
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f
th
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tu
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2
.
5
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Resea
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ins
t
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T
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ct
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n
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it
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s
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OF
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[
1
7
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P
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D
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[
1
3
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.
P
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1
1
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B
es
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s
f
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l
a
[
1
8
].
2
.
6
.
Q
ua
lit
y
v
er
if
ic
a
t
io
n o
f
r
esea
rc
h ins
t
rum
ent
s
T
h
r
ee
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x
p
er
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ce
d
p
r
o
f
ess
io
n
als
ass
es
s
ed
th
e
v
alid
ity
o
f
th
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r
esear
ch
t
o
o
ls
b
ased
o
n
th
ei
r
co
n
te
n
t,
with
m
o
d
if
icatio
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s
im
p
lem
en
t
ed
ac
co
r
d
in
g
to
th
eir
s
u
g
g
esti
o
n
s
.
T
h
e
v
alid
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p
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ce
s
s
in
v
o
lv
e
d
co
m
p
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tin
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e
I
n
d
ex
o
f
item
o
b
jectiv
e
c
o
n
g
r
u
en
ce
[1
9
]
.
f
o
r
th
e
6
s
ec
tio
n
s
o
f
th
e
h
ea
lth
wo
r
k
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r
s
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q
u
esti
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wh
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p
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o
d
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ce
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th
e
f
o
llo
win
g
s
co
r
es: 0
.
8
9
,
0
.
8
7
,
0
.
9
2
,
0
.
8
8
,
0
.
9
1
,
0
.
8
5
,
an
d
0
.
9
4
,
r
esp
ec
tiv
ely
.
2
.
7
.
Da
t
a
c
o
llect
io
n
−
Pre
p
ar
atio
n
s
tag
e
:
T
h
e
r
esear
ch
er
b
u
ilt
a
g
o
o
d
r
elatio
n
s
h
ip
with
th
e
p
ar
ticip
an
ts
b
y
in
tr
o
d
u
cin
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th
em
s
elv
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d
ex
p
lain
in
g
th
e
aim
an
d
d
etails
o
f
th
e
q
u
esti
o
n
n
air
e.
T
h
e
r
esear
ch
e
r
also
ar
r
an
g
ed
s
p
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if
ic
tim
es a
n
d
lo
ca
tio
n
s
f
o
r
d
ata
co
llectio
n
.
−
Data
co
llectio
n
s
tag
e
:
T
h
e
r
esear
ch
er
g
ath
e
r
ed
th
e
d
ata
in
p
r
iv
ate,
m
ak
in
g
s
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e
t
o
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o
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y
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o
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b
ias,
an
d
ac
ted
co
n
s
is
ten
tly
to
h
ig
h
l
ig
h
t
th
e
v
alu
e
o
f
th
e
in
f
o
r
m
ati
o
n
co
llected
,
en
s
u
r
in
g
th
at
n
o
t
h
in
g
im
p
o
r
tan
t
was m
is
s
ed
.
2
.
8
.
Da
t
a
a
na
ly
s
is
Descr
ip
tiv
e
s
tatis
tics
wer
e
u
s
ed
to
s
u
m
m
ar
ize
th
e
p
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o
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ata
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f
th
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s
am
p
le.
A
p
air
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t
-
test
was
ap
p
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to
ass
ess
th
e
ef
f
ec
t
o
f
th
e
in
ter
v
en
tio
n
b
ef
o
r
e
an
d
af
ter
its
im
p
lem
en
tatio
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.
T
o
co
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Ad
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8
8
0
6
F
a
cto
r
s
a
ffectin
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h
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lth
-
p
r
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mo
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g
s
ervices p
r
o
visi
o
n
o
f th
e
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u
b
-
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lth
…
(
S
ir
ima
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a
s
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p
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)
219
an
aly
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is
was
ca
r
r
ied
o
u
t
to
ex
am
in
e
th
e
f
ac
t
o
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s
in
f
lu
en
cin
g
th
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q
u
ality
-
of
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.
All
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tatis
tical
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aly
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es we
r
e
co
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u
cted
u
s
in
g
SP
SS
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io
n
2
3
.
0
,
en
s
u
r
in
g
u
n
if
o
r
m
ity
an
d
d
ep
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ab
ilit
y
.
Qu
alitativ
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d
ata
an
aly
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is
was
co
n
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u
cted
ac
co
r
d
in
g
to
th
e
g
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id
elin
es
s
et
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y
Stre
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-
Sp
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an
d
C
ar
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ter
.
T
h
e
p
r
o
ce
s
s
in
v
o
lv
ed
th
e
f
o
llo
win
g
s
tep
s
:
First,
th
e
r
esear
ch
er
ex
am
in
ed
ea
ch
lin
e
o
f
th
e
tr
an
s
cr
ib
ed
in
ter
v
iews
to
g
ain
a
g
en
er
al
u
n
d
er
s
tan
d
in
g
o
f
th
e
p
ar
ticip
an
ts
’
th
o
u
g
h
ts
,
em
o
tio
n
s
,
an
d
ex
p
er
ien
ce
s
,
k
ee
p
in
g
th
e
r
esear
ch
o
b
jectiv
es
in
m
in
d
.
Nex
t,
m
ea
n
in
g
u
n
its
wer
e
id
en
tifie
d
,
wh
ich
wer
e
k
ey
wo
r
d
s
,
s
en
ten
ce
s
,
o
r
p
ar
ts
o
f
th
e
in
ter
v
iews
th
at
r
ef
lecte
d
p
ar
ticip
an
ts
’
p
er
s
p
ec
tiv
es
o
n
th
e
q
u
ality
o
f
p
r
im
ar
y
ca
r
e
s
er
v
ices.
T
h
ese
u
n
its
wer
e
th
en
s
im
p
lifie
d
,
ass
ig
n
ed
co
d
es,
an
d
g
r
o
u
p
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in
to
r
elate
d
s
u
b
-
th
em
es
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d
b
r
o
ad
er
th
em
es.
Fin
ally
,
th
e
s
u
b
-
th
em
es
wer
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co
n
n
ec
ted
to
f
o
r
m
co
m
p
r
eh
en
s
iv
e
th
em
es
th
at
clea
r
ly
illu
s
tr
ate
th
e
p
ar
ticip
an
ts
’
ex
p
er
ien
ce
s
with
p
r
im
ar
y
ca
r
e
s
er
v
ices.
2
.
9
.
E
ns
uring
t
rus
t
wo
rt
hin
e
s
s
L
in
co
ln
en
s
u
r
ed
th
e
d
ata
wer
e
tr
u
s
two
r
th
y
u
s
in
g
s
ev
er
al
m
eth
o
d
s
[
2
0
]
.
E
x
p
er
ts
an
d
p
ar
ti
cip
an
ts
p
r
o
v
id
ed
f
ee
d
b
ac
k
to
en
s
u
r
e
th
at
th
e
d
ata
co
v
er
ed
en
o
u
g
h
to
p
ics an
d
was su
f
f
icien
tly
d
etailed
an
d
r
ich
,
wh
ich
h
elp
ed
co
n
f
ir
m
d
ata
cr
ed
ib
ilit
y
.
T
o
en
s
u
r
e
r
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,
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r
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iewe
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ef
lectio
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tes
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g
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p
d
is
cu
s
s
io
n
tr
an
s
cr
ip
ts
in
d
ep
en
d
en
tly
an
d
th
en
wo
r
k
ed
with
o
th
er
r
esear
ch
er
s
an
d
ex
p
er
ts
in
th
e
co
m
m
u
n
ity
to
ex
am
in
e
th
e
f
in
d
in
g
s
.
T
o
en
s
u
r
e
th
e
r
esu
lts
co
u
ld
b
e
ap
p
lied
to
o
th
er
s
itu
atio
n
s
,
a
v
ar
ied
g
r
o
u
p
o
f
p
eo
p
le
was
ch
o
s
en
,
in
clu
d
in
g
in
d
iv
id
u
als
o
f
d
if
f
er
en
t
ag
es,
g
en
d
er
s
,
an
d
b
ac
k
g
r
o
u
n
d
s
.
T
h
e
d
ata’
s
r
elev
an
ce
to
s
im
ilar
s
itu
atio
n
s
was
also
en
s
u
r
ed
.
C
o
n
f
ir
m
ab
ilit
y
was
m
ain
tain
ed
th
r
o
u
g
h
o
u
t
th
e
s
tu
d
y
b
y
u
s
in
g
d
if
f
er
en
t
d
ata
s
o
u
r
ce
s
s
u
ch
as
au
d
io
r
ec
o
r
d
in
g
s
,
f
ield
n
o
tes,
an
d
p
er
s
o
n
al
r
ef
lectio
n
jo
u
r
n
als.
T
h
ese
s
o
u
r
ce
s
wer
e
an
aly
ze
d
u
s
in
g
NViv
o
1
0
2
2
[2
1
]
.
to
en
s
u
r
e
co
n
s
is
ten
t d
ata
r
ef
er
en
cin
g
an
d
v
alid
atio
n
.
3.
RE
SU
L
T
S AN
D
D
I
SCU
SS
I
O
N
3
.
1
.
O
v
er
v
iew
o
f
s
er
v
ices
pro
v
ided
a
t
s
ub
-
dis
t
rict
hea
lt
h
-
pro
m
o
t
ing
ho
s
pita
ls
m
a
na
g
ed
by
pro
v
incia
l
a
dm
ini
s
t
ra
t
iv
e
o
rg
a
niza
t
io
ns
As
r
eq
u
ir
e
d
b
y
th
e
Prim
ar
y
Hea
lth
Sy
s
tem
Act
o
f
2
0
2
0
,
m
o
s
t m
ed
iu
m
-
s
ized
h
o
s
p
itals
in
Hea
lth
Ar
ea
7
(
5
9
.
8
2
%)
wer
e
class
if
ied
as
p
r
im
ar
y
ca
r
e
u
n
its
(
PC
Us)
b
ef
o
r
e
th
ey
wer
e
tr
an
s
f
er
r
ed
to
th
e
p
r
o
v
in
cial
ad
m
in
is
tr
ativ
e
s
tr
u
ctu
r
e,
wh
ile
4
0
.
1
8
%
wer
e
ca
teg
o
r
ized
as
non
-
p
r
im
ar
y
ca
r
e
u
n
its
(
NPC
Us).
T
h
ese
h
o
s
p
itals
in
itially
h
ad
a
h
ig
h
-
p
er
f
o
r
m
an
ce
s
co
r
e
o
f
8
8
.
5
3
%,
b
u
t
th
is
s
co
r
e
d
ec
r
ea
s
ed
to
8
2
.
4
3
%
f
o
llo
win
g
th
e
tr
an
s
f
er
.
On
av
er
ag
e,
th
ese
h
o
s
p
itals
s
er
v
e
ap
p
r
o
x
im
at
ely
4
1
1
5
in
d
iv
id
u
als
(
with
a
s
tan
d
ar
d
d
ev
iatio
n
[
SD]
o
f
3
4
0
5
.
0
5
)
,
m
ain
ly
in
ar
ea
s
with
p
o
p
u
latio
n
s
r
an
g
in
g
f
r
o
m
3
0
0
0
to
8
0
0
0
p
eo
p
le
(
6
0
.
6
9
%),
an
d
n
o
m
o
r
e
th
an
1
0
0
0
h
o
u
s
eh
o
ld
s
(
6
3
.
1
1
%).
T
h
ese
h
o
s
p
it
als
co
v
er
h
ea
lth
in
s
u
r
an
ce
(
6
7
.
5
0
%),
civ
il
s
er
v
an
t
b
en
ef
its
(
7
0
.
8
0
%),
an
d
s
o
cial
s
ec
u
r
ity
(
4
4
.
8
0
%)
.
T
h
ey
also
s
u
p
p
o
r
t
4
-
8
v
illag
es
(
5
7
.
4
0
%)
.
Ou
r
r
esear
ch
s
h
o
ws th
at
th
e
r
o
les an
d
s
k
ills
o
f
h
ea
lth
wo
r
k
er
s
h
av
e
ch
an
g
ed
af
ter
th
e
tr
an
s
f
er
.
T
h
e
h
ig
h
est
lev
el
o
f
co
m
p
eten
ce
was
n
o
ted
in
h
ea
lth
p
r
o
m
o
t
io
n
,
with
an
av
er
ag
e
o
f
5
.
2
5
(
SD
=
0
.
6
2
)
.
I
n
co
n
tr
ast,
th
e
lo
west
lev
el
o
f
co
m
p
eten
ce
was in
d
ev
elo
p
in
g
p
r
im
ar
y
n
u
r
s
in
g
q
u
ality
,
with
an
av
er
ag
e
s
co
r
e
o
f
4
.
2
6
(
SD
=
1
.
6
1
)
.
Sco
r
es
f
o
r
s
p
ec
if
ic
task
s
,
lik
e
tak
in
g
p
atien
t
h
is
to
r
ies an
d
ass
ess
m
en
ts
,
r
em
ain
ed
co
n
s
is
ten
t a
t 3
.
4
1
(
SD =
1
.
5
8
)
an
d
4
.
4
1
(
SD =
1
.
5
3
)
,
r
esp
ec
tiv
ely
.
3
.
2
.
F
a
ct
o
rs
influencing
t
he
deliv
er
y
o
f
s
er
v
ices
a
t
s
ub
-
dis
t
rict
hea
lt
h
-
pro
m
o
t
ing
ho
s
pita
ls
t
ha
t
ha
v
e
been
t
ra
ns
f
er
re
d t
o
pro
v
incia
l a
dm
ini
s
t
ra
t
iv
e
bo
dies
T
h
e
s
t
u
d
y
e
x
a
m
i
n
e
d
t
h
e
q
u
a
l
i
t
y
o
f
s
e
r
v
i
c
e
s
p
r
o
v
i
d
e
d
i
n
p
r
i
m
a
r
y
c
a
r
e
s
e
t
t
i
n
g
s
.
I
t
e
v
a
l
u
a
t
e
d
t
h
e
d
e
l
i
v
e
r
y
o
f
s
e
r
v
i
c
e
s
a
c
r
o
s
s
6
k
e
y
a
r
e
a
s
:
m
e
d
i
c
a
l
t
r
e
a
t
m
e
n
t
,
h
e
a
l
t
h
p
r
o
m
o
t
i
o
n
,
d
i
s
e
a
s
e
p
r
e
v
e
n
t
i
o
n
a
n
d
c
o
n
t
r
o
l
,
r
e
h
a
b
i
l
i
t
a
t
i
o
n
,
e
m
e
r
g
e
n
c
y
c
a
r
e
,
a
n
d
p
a
l
l
i
a
t
i
v
e
c
a
r
e
:
i
)
A
f
t
e
r
t
h
e
t
r
a
n
s
f
e
r
,
t
h
e
g
r
o
u
p
t
h
a
t
m
o
v
e
d
e
n
t
i
r
e
l
y
r
e
c
e
i
v
e
d
t
h
e
h
i
g
h
e
s
t
a
v
e
r
a
g
e
s
c
o
r
e
s
,
p
a
r
t
i
c
u
l
a
r
l
y
i
n
t
h
e
t
a
n
g
i
b
l
e
a
s
p
e
c
t
s
o
f
s
e
r
v
i
c
e
.
T
h
e
i
r
s
c
o
r
e
s
w
e
r
e
3
.
6
2
f
o
r
t
a
n
g
i
b
i
l
i
t
y
,
4
.
3
8
f
o
r
r
e
l
i
a
b
i
l
i
t
y
,
4
.
1
7
f
o
r
r
e
s
p
o
n
s
i
v
e
n
e
s
s
,
4
.
3
6
f
o
r
a
s
s
u
r
a
n
c
e
,
a
n
d
4
.
5
6
f
o
r
e
m
p
a
t
h
y
;
ii
)
A
f
t
e
r
t
h
e
t
r
a
n
s
f
e
r
,
t
h
e
r
e
w
a
s
a
n
o
t
i
c
e
a
b
l
e
d
i
f
f
e
r
e
n
c
e
b
e
t
w
e
e
n
e
x
p
e
c
t
a
t
i
o
n
s
a
n
d
r
e
a
l
e
x
p
e
r
i
e
n
c
e
.
I
n
g
e
n
e
r
a
l
,
e
x
p
e
c
t
a
t
i
o
n
s
w
e
r
e
h
i
g
h
e
r
t
h
a
n
t
h
e
r
e
al
s
e
r
v
i
c
e
e
x
p
e
r
i
e
n
c
e
s
a
c
r
o
s
s
a
l
l
a
r
e
a
s
.
T
h
i
s
d
i
f
f
e
r
e
n
c
e
w
a
s
f
o
u
n
d
t
o
b
e
s
t
a
t
i
s
t
i
c
a
l
l
y
s
i
g
n
i
f
i
c
a
n
t
a
t
t
h
e
0
.
0
5
l
e
v
e
l
.
T
h
e
g
a
p
b
e
t
w
e
e
n
e
x
p
e
c
t
a
t
i
o
n
s
a
n
d
r
e
a
l
i
t
y
w
a
s
m
o
s
t
a
p
p
a
r
e
n
t
i
n
t
h
e
g
r
o
u
p
w
h
e
r
e
1
0
0
%
o
f
t
h
e
t
r
a
n
s
f
e
r
t
o
o
k
p
l
a
c
e
,
a
s
s
i
g
n
i
f
i
c
a
n
t
d
i
f
f
e
r
e
n
c
e
s
w
e
r
e
o
b
s
e
r
v
e
d
i
n
a
l
l
a
r
e
a
s
.
O
n
t
h
e
o
t
h
e
r
h
a
n
d
,
g
r
o
u
p
s
w
i
t
h
l
e
s
s
t
h
a
n
5
0
%
t
r
a
n
s
f
e
r
a
l
s
o
h
a
d
h
i
g
h
e
r
e
x
p
e
c
t
a
t
i
o
n
s
c
o
m
p
a
r
e
d
t
o
t
h
e
i
r
a
c
t
u
a
l
e
x
p
e
r
i
e
n
c
e
s
.
H
o
w
e
v
e
r
,
s
i
g
n
i
f
i
c
a
n
t
d
i
f
f
e
r
e
n
c
e
s
w
e
r
e
o
n
l
y
f
o
u
n
d
r
e
g
a
r
d
i
n
g
w
h
e
t
h
e
r
t
h
e
s
e
r
v
i
c
e
p
r
o
v
i
d
e
d
w
a
s
f
a
i
r
a
n
d
f
r
e
e
f
r
o
m
d
i
s
c
r
i
m
i
n
a
t
i
o
n
,
w
i
t
h
n
o
m
a
j
o
r
d
i
f
f
e
r
e
n
c
e
s
o
b
s
e
r
v
e
d
i
n
t
e
r
m
s
o
f
b
e
i
n
g
a
t
t
e
n
t
i
v
e
a
n
d
r
e
s
p
e
c
t
f
u
l
;
a
n
d
iii
)
S
t
a
f
f
a
t
t
i
t
u
d
e
s
b
e
f
o
r
e
a
n
d
a
f
t
e
r
t
h
e
t
r
a
n
s
f
e
r
s
h
o
w
e
d
s
o
m
e
c
h
a
n
g
e
s
.
I
n
2
0
2
3
,
t
h
e
a
v
e
r
a
g
e
a
t
t
i
t
u
d
e
s
c
o
r
e
f
o
r
t
h
e
s
e
r
v
i
c
e
t
e
a
m
w
a
s
3
.
5
6
(
S
D
=
0
.
7
8
)
.
T
h
e
h
i
g
h
e
s
t
s
c
o
r
e
w
a
s
r
e
l
a
t
e
d
t
o
p
a
t
i
e
n
t
a
n
d
p
u
b
l
i
c
b
e
n
e
f
i
t
a
t
4
.
5
4
(
S
D
=
0
.
6
5
)
.
I
n
2
0
2
3
,
t
h
e
a
v
e
r
a
g
e
a
t
t
i
t
u
d
e
s
c
o
r
e
s
l
i
g
h
t
l
y
i
m
p
r
o
v
e
d
t
o
3
.
5
2
(
S
D
=
0
.
7
5
)
.
T
h
e
h
i
g
h
e
s
t
s
c
o
r
e
f
o
r
p
a
t
i
e
n
t
a
n
d
p
u
b
l
i
c
b
e
n
e
f
i
t
r
e
m
a
i
n
e
d
a
t
4
.
6
5
(
S
D
=
0
.
5
7
)
.
A
n
i
m
p
r
o
v
e
m
e
n
t
i
n
c
o
l
l
e
a
g
u
e
r
e
l
a
t
i
o
n
s
h
i
p
s
w
a
s
n
o
t
e
d
,
w
i
t
h
t
h
e
s
c
o
r
e
r
e
a
c
h
i
n
g
5
.
0
3
(
S
D
=
0
.
6
9
)
.
T
h
e
l
o
w
e
s
t
s
c
o
r
e
i
n
b
o
t
h
y
e
a
r
s
w
a
s
r
e
l
a
t
e
d
t
o
p
e
r
c
e
i
v
e
d
a
d
e
q
u
a
t
e
c
o
m
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4.
DIS
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jectiv
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T
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Pro
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Ad
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Or
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izatio
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tates
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h
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p
o
licies
an
d
s
er
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ice
s
tan
d
ar
d
s
[
3
]
,
[
4
]
,
an
d
h
av
e
p
lay
ed
a
m
ajo
r
r
o
le
in
im
p
r
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o
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tco
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es.
T
h
is
h
ig
h
lig
h
ts
th
e
im
p
o
r
tan
ce
o
f
f
air
n
ess
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d
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T
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r
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in
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Per
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p
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em
en
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co
m
m
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h
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s
er
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Evaluation Warning : The document was created with Spire.PDF for Python.
I
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2252
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8
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6
F
a
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(
S
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s
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a
p
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221
T
h
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d
y
also
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ev
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m
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ac
to
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s
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d
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f
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in
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ce
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Peo
p
le
also
h
ad
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r
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d
if
f
icu
lty
tak
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ca
r
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f
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s
elv
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d
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o
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etim
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eh
av
ed
in
ap
p
r
o
p
r
iately
wh
ile
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ec
eiv
in
g
ass
is
tan
ce
[
6
]
.
T
h
ese
r
esu
lts
ar
e
co
m
p
ar
ab
le
to
th
e
f
in
d
in
g
s
o
f
Peer
ap
an
an
d
Pas
u
n
o
n
[
2
2
]
.
W
h
o
ass
ess
ed
th
e
ch
allen
g
es
in
s
er
v
ice
d
eliv
er
y
at
a
s
u
b
-
d
is
tr
ict
h
ea
lth
-
p
r
o
m
o
tin
g
h
o
s
p
ital
s
itu
ated
in
Uttar
ad
it
Pro
v
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ce
.
T
h
eir
s
tu
d
y
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en
tifie
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s
ev
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al
is
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u
ch
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ities
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T
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if
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er
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ices,
s
im
p
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in
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p
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s
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d
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ar
in
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in
f
o
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m
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with
th
e
p
u
b
lic,
an
d
en
h
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cin
g
th
e
s
k
ills
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f
ca
r
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s
,
alo
n
g
with
co
m
m
u
n
ity
co
llab
o
r
atio
n
[
2
2
].
4
.
2
.
H
e
a
l
t
h
w
o
r
k
e
r
s
'
p
r
a
c
t
i
c
e
s
T
h
e
s
tu
d
y
f
o
u
n
d
th
at
m
o
s
t
p
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p
le
(
9
7
.
5
0
%
an
d
8
9
.
7
5
%)
h
ad
h
ig
h
ex
p
ec
tatio
n
s
an
d
th
o
u
g
h
t
th
e
s
er
v
ice
was
good.
T
h
e
r
elev
an
t
f
ac
to
r
s
wer
e
r
elate
d
to
ea
s
e
o
f
o
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tain
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elp
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r
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ality
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p
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m
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tin
g
h
o
s
p
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af
ter
th
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tr
an
s
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.
T
h
e
h
ig
h
est
av
er
ag
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s
co
r
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was
in
h
ea
lth
p
r
o
m
o
tio
n
at
4
.
3
5
(
SD
=
0
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5
9
)
,
wh
ile
th
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r
e
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d
ev
elo
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n
g
p
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im
ar
y
n
u
r
s
in
g
q
u
ality
at
3
.
6
7
(
SD =
0
.
8
6
)
.
T
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e
s
tu
d
y
h
ig
h
lig
h
ts
th
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co
m
p
lex
ities
o
f
h
o
w
h
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wo
r
k
er
s
in
ter
ac
t
with
p
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p
le’
s
b
elief
s
,
in
f
o
r
m
atio
n
n
ee
d
s
[
1
8
]
,
an
d
p
r
ac
tical
an
d
lo
g
is
tical
ch
allen
g
es,
s
u
ch
as
o
b
tain
in
g
s
u
p
p
lies
an
d
m
ee
tin
g
clien
t
n
ee
d
s
.
Pre
v
io
u
s
s
tu
d
ies
h
elp
ed
d
ev
elo
p
way
s
to
o
v
er
co
m
e
ac
ce
s
s
is
s
u
es
b
y
s
tu
d
y
in
g
f
ac
to
r
s
th
at
s
u
p
p
o
r
t
h
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lth
wo
r
k
er
s
in
m
ee
tin
g
in
d
iv
id
u
al
p
atien
t
n
ee
d
s
.
Hea
lth
wo
r
k
er
s
’
ab
ilit
ies
ar
e
v
er
y
im
p
o
r
tan
t,
s
o
im
p
r
o
v
in
g
th
e
g
r
o
wth
o
f
h
ea
lth
wo
r
k
er
s
in
th
e
p
r
im
ar
y
ca
r
e
s
y
s
tem
is
ess
en
tial
f
o
r
estab
lis
h
in
g
s
tan
d
ar
d
s
an
d
im
p
r
o
v
in
g
th
e
s
k
ills
o
f
n
u
r
s
es.
T
h
is
h
elp
s
en
s
u
r
e
th
at
h
ea
lth
ca
r
e
is
o
f
h
ig
h
q
u
ality
an
d
d
eliv
er
ed
ef
f
icien
tly
.
Sp
ec
if
ically
,
ca
r
in
g
f
o
r
p
atien
ts
with
m
u
ltip
le
h
ea
lth
p
r
o
b
lem
s
r
eq
u
ir
es tar
g
eted
ed
u
ca
tio
n
.
B
ased
o
n
th
e
wo
r
k
o
f
L
awso
n
et
a
l
.
[2
3
]
.
We
s
u
g
g
est
u
s
in
g
an
in
ter
n
atio
n
al
f
r
am
ewo
r
k
f
o
r
tr
ain
in
g
o
n
m
u
ltip
le
h
ea
lth
p
r
o
b
lem
s
.
T
h
is
f
r
am
ewo
r
k
in
clu
d
es
u
p
d
ated
clin
ical
g
u
id
elin
es,
lear
n
in
g
th
r
o
u
g
h
r
ea
l
-
life
s
ce
n
ar
io
s
,
an
d
team
wo
r
k
with
d
if
f
er
en
t
p
r
o
f
ess
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o
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tailo
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ed
to
f
it
th
e
n
ee
d
s
o
f
n
u
r
s
es
wh
o
ca
r
e
f
o
r
p
eo
p
le
with
m
u
ltip
le
h
ea
lth
p
r
o
b
lem
s
.
T
h
is
m
eth
o
d
alig
n
s
with
th
e
ty
p
ical
ex
p
er
ien
ce
s
an
d
ev
er
y
d
ay
r
eq
u
ir
em
en
ts
o
f
s
er
v
ice
u
s
er
s
an
d
d
ir
ec
tly
ad
d
r
ess
es
th
e
s
h
o
r
tco
m
in
g
s
in
ex
is
tin
g
tr
ain
in
g
f
o
r
h
an
d
li
n
g
m
u
ltip
le
h
ea
lth
is
s
u
es,
wh
ich
co
u
ld
im
p
r
o
v
e
p
atien
t o
u
tco
m
es a
n
d
m
ak
e
h
ea
lth
ca
r
e
m
o
r
e
ef
f
icien
t [
1
5
]
,
[
16
]
,
[
2
4
].
4
.
3
.
Q
u
a
l
i
t
y
o
f
c
a
r
e
T
h
e
s
tu
d
y
ex
am
in
ed
th
e
s
itu
atio
n
in
p
r
im
ar
y
ca
r
e
u
n
its
p
r
io
r
to
an
d
f
o
llo
win
g
th
e
tr
an
s
f
er
,
ass
ess
in
g
th
e
q
u
ality
o
f
s
er
v
ice
b
ased
o
n
th
e
SERVQUAL
an
d
QOF
cr
iter
ia.
W
e
n
o
ticed
a
m
ajo
r
d
r
o
p
in
h
ea
lth
r
esu
lts
af
ter
th
e
co
m
p
lete
tr
an
s
f
er
o
f
s
er
v
ices,
with
s
ta
tis
tically
s
ig
n
if
ican
t c
h
an
g
es a
t a
p
-
v
alu
e
o
f
0
.
0
5
.
Ou
r
an
aly
s
is
,
d
etailed
in
T
ab
le
2
,
co
v
er
ed
im
p
o
r
tan
t
h
ea
lth
m
ea
s
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r
es
s
u
ch
as
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s
cr
ee
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in
g
f
o
r
T
h
ai
p
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p
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3
0
to
7
0
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r
s
,
f
ir
s
t
an
ten
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r
e
v
is
its
f
o
r
p
r
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t
wo
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en
with
in
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f
ir
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t
1
2
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k
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o
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p
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eg
n
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,
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d
ce
r
v
ical
ca
n
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s
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a
5
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y
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o
r
wo
m
en
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ag
es o
f
3
0
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d
6
0
y
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r
s
.
T
h
e
f
in
d
in
g
s
s
h
o
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s
ig
n
if
ican
t
s
tatis
tical
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if
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er
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in
at
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r
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s
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h
ig
h
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g
h
o
w
th
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f
ec
tiv
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h
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ca
r
e
d
e
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v
ar
ied
d
ep
en
d
in
g
o
n
th
e
lev
el
o
f
s
er
v
ice
tr
an
s
f
er
.
T
h
is
f
in
d
in
g
alig
n
s
with
p
r
ev
io
u
s
r
esear
ch
,
wh
ich
em
p
h
asizes
th
at
f
ac
to
r
s
s
u
ch
as
p
eo
p
le’
s
b
elief
s
an
d
attitu
d
es,
h
o
w
th
ey
r
ec
eiv
e
an
d
p
r
o
ce
s
s
in
f
o
r
m
atio
n
,
an
d
p
r
ac
tical
an
d
lo
g
is
tical
ch
allen
g
es
g
r
ea
tly
in
f
lu
en
ce
th
e
ab
ilit
y
o
f
s
k
illed
h
ea
lth
ca
r
e
wo
r
k
er
s
to
p
r
o
v
id
e
ess
en
tial
ca
r
e.
Desp
ite
th
ese
in
s
ig
h
ts
,
r
ep
o
r
ts
f
r
o
m
s
er
v
ice
p
r
o
v
id
er
s
r
eg
ar
d
in
g
th
ese
f
ac
to
r
s
r
em
ain
ed
u
n
clea
r
.
T
h
e
r
esu
lt in
[2
4
]
-
[2
6
]
d
em
o
n
s
tr
ated
th
at
th
e
attitu
d
es o
f
h
ea
lth
ca
r
e
wo
r
k
er
s
ca
n
b
e
a
m
ajo
r
o
b
s
tacle
.
A
f
t
e
r
r
e
v
i
e
w
i
n
g
t
h
e
f
i
n
d
i
n
g
s
a
n
d
r
e
l
a
t
e
d
c
h
a
l
l
e
n
g
e
s
,
a
s
w
e
l
l
a
s
t
h
e
i
r
e
f
f
e
c
t
o
n
t
h
e
c
o
m
p
l
e
x
a
n
d
s
e
r
i
o
u
s
p
r
o
c
e
s
s
o
f
s
e
e
k
i
n
g
h
e
a
l
t
h
c
a
r
e
,
i
t
a
p
p
e
a
r
s
t
h
a
t
f
u
t
u
r
e
i
n
i
t
i
a
t
i
v
e
s
a
i
m
e
d
a
t
i
m
p
r
o
v
i
n
g
s
e
r
v
i
c
e
q
u
a
l
i
t
y
s
h
o
u
l
d
c
o
n
c
e
n
t
r
a
t
e
o
n
r
e
c
o
g
n
i
z
i
n
g
a
n
d
f
u
l
f
i
l
l
i
n
g
t
h
e
b
e
l
i
e
f
s
a
n
d
n
e
e
d
s
o
f
i
n
d
i
v
i
d
u
a
l
s
w
h
o
a
r
e
r
e
c
e
i
v
i
n
g
c
a
r
e
,
a
l
o
n
g
w
i
t
h
f
i
n
d
i
n
g
e
f
f
e
c
t
i
v
e
s
o
l
u
t
i
o
n
s
t
o
g
u
a
r
a
n
t
e
e
t
h
a
t
a
l
l
p
e
o
p
l
e
c
a
n
a
c
c
e
s
s
h
i
g
h
-
q
u
a
l
i
t
y
h
e
a
l
t
h
c
a
r
e
[2
7
]
,
[
2
8
]
.
W
e
r
ec
o
g
n
ize
ce
r
tain
lim
itatio
n
s
in
o
u
r
s
tu
d
y
th
at
s
h
o
u
ld
b
e
co
n
s
id
er
ed
wh
en
in
ter
p
r
etin
g
th
e
r
esu
lts
.
First,
th
e
s
tu
d
y
r
elied
o
n
o
b
s
er
v
atio
n
s
,
wh
ich
m
ig
h
t
in
tr
o
d
u
ce
s
elec
tio
n
b
ias
an
d
m
ak
e
it
d
if
f
icu
lt
to
clea
r
ly
lin
k
s
er
v
ice
tr
an
s
f
er
with
ch
an
g
es
in
h
ea
lth
o
u
tco
m
es.
Seco
n
d
,
wh
ile
we
co
n
s
id
er
ed
s
ev
er
al
f
ac
t
o
r
s
,
o
th
er
in
f
lu
en
ce
s
th
at
wer
e
eith
er
n
o
t
m
ea
s
u
r
ed
o
r
m
ea
s
u
r
ed
in
ac
cu
r
ately
m
ig
h
t
im
p
ac
t
th
e
f
in
d
in
g
s
.
Ad
d
itio
n
ally
,
th
e
u
n
iq
u
e
co
n
tex
ts
an
d
s
tr
u
ctu
r
es
o
f
th
e
h
ea
lth
s
er
v
ices
in
v
o
lv
ed
m
ak
e
it
h
ar
d
to
ap
p
ly
th
ese
r
esu
lts
to
o
th
er
h
ea
lth
s
y
s
tem
s
.
T
h
e
u
s
e
o
f
s
elf
-
r
ep
o
r
ted
d
ata
f
o
r
s
o
m
e
h
ea
lth
in
d
icato
r
s
m
ay
also
lead
to
b
iased
r
esp
o
n
s
es,
wh
ich
co
u
ld
af
f
ec
t
th
e
r
eliab
ilit
y
o
f
th
e
m
ea
s
u
r
em
en
ts
.
L
astl
y
,
ev
en
th
o
u
g
h
th
e
r
esu
lts
wer
e
s
tatis
tically
s
ig
n
if
ican
t,
th
is
d
o
es
n
o
t
au
to
m
atica
lly
m
ea
n
th
ey
h
av
e
clin
ical
m
e
an
in
g
.
Fu
r
th
er
s
tu
d
ies
ar
e
r
eq
u
ir
ed
to
f
u
lly
d
eter
m
in
e
h
o
w
th
ese
r
esu
lts
ac
tu
ally
p
lay
o
u
t in
r
eg
u
lar
h
ea
lth
ca
r
e
en
v
ir
o
n
m
en
ts
[
29
]
-
[3
1
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
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6
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223
222
L
im
itatio
n
s
o
f
th
e
s
tu
d
y
:
T
h
is
s
tu
d
y
h
as
ce
r
tain
lim
itatio
n
s
.
First,
b
ein
g
a
cr
o
s
s
-
s
ec
tio
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s
tu
d
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,
it
was
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p
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ib
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eter
m
in
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tim
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elate
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ip
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in
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e
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ticip
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id
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als
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o
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s
.
Desp
ite
th
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s
,
o
u
r
s
tu
d
y
’
s
s
tr
en
g
th
s
lie
in
its
lar
g
e
s
am
p
le
s
ize
an
d
co
n
tr
o
l f
o
r
a
b
r
o
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r
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f
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elp
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ca
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tu
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ies
at
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if
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t
lev
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o
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an
s
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er
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co
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ld
also
p
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v
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im
p
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r
tan
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in
f
o
r
m
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.
I
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ices
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th
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o
f
o
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atio
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s
.
Ad
d
itio
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ally
,
r
esear
ch
o
n
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e
ex
p
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ien
ce
s
an
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v
iews
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f
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o
th
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p
le
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r
o
v
id
in
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d
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ec
eiv
in
g
s
er
v
ices
an
d
th
e
cir
cu
m
s
tan
ce
s
p
r
io
r
to
an
d
f
o
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win
g
tr
an
s
f
er
s
ca
n
o
f
f
er
m
o
r
e
in
s
ig
h
t
in
to
th
e
ch
allen
g
es
an
d
o
p
p
o
r
tu
n
ities
ass
o
ciate
d
with
th
ese
p
o
licy
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ju
s
tm
en
ts
.
I
n
s
u
m
m
ar
y
,
th
e
g
o
al
o
f
tr
an
s
f
er
r
in
g
h
ea
lth
s
er
v
ice
m
an
ag
em
en
t
to
p
r
o
v
in
cial
ad
m
in
is
tr
ativ
e
au
th
o
r
ities
is
ty
p
ically
to
im
p
r
o
v
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aise
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to
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ltu
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e,
an
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is
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in
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.
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o
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s
.
RE
F
E
R
E
NC
E
S
[
1
]
T
.
J
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b
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[
2
]
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[
3
]
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.
[
4
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[
5
]
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.
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[
6
]
D
.
C
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[
7
]
J
.
T
h
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t
,
P
.
;
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h
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[
8
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[
9
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1
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1
4
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