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m
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k
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K
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w
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s
:
An
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en
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Mo
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Sem
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co
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1.
I
NT
RO
D
UCT
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N
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h
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d
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tr
a
n
s
f
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y
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tem
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tly
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cr
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e
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ailab
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ata,
p
ar
ticu
lar
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i
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th
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f
ield
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ac
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,
p
r
o
v
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g
u
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p
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ted
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p
p
o
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t
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ities
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en
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d
ec
is
io
n
-
m
ak
in
g
an
d
h
ea
lth
o
u
tco
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es
[
1
]
.
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wev
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a
p
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is
ten
t
ch
allen
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in
co
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ata
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f
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[
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]
.
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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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6
I
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t J Pu
b
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Hea
lth
Sci
,
Vo
l.
15
,
No
.
2
,
J
u
n
e
20
26
:
5
8
3
-
5
9
2
584
R
ec
en
t
s
tu
d
ies
em
p
h
asis
e
th
at
s
tr
en
g
th
e
n
in
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d
ata
a
n
aly
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s
k
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estab
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f
ee
d
b
ac
k
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v
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t
ar
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to
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th
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f
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tin
e
d
ata
with
in
h
ea
lth
ca
r
e
f
ac
ilit
ies
[
4
]
,
[
5
]
.
Mo
r
eo
v
er
,
co
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tin
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u
s
q
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ality
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5
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[
6
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th
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Va
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as
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[
7
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B
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I
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ased
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a
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ality
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er
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ices
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n
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ata
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ir
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(
E
PI)
at
f
ir
s
t
-
lin
e
f
ac
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ies
[
8
]
.
Ho
wev
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q
u
esti
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s
r
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in
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with
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B
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.
2.
M
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2
.
1
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Fig
u
r
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Ma
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2
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8
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6
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2
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3
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.
2
.
4
.
Descript
io
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l
r
i
g
o
u
r
,
a
n
d
t
h
e
e
f
f
e
c
t
i
v
e
u
s
e
o
f
f
i
n
d
i
n
g
s
.
R
es
ea
r
c
h
q
u
e
s
t
i
o
n
: “
D
o
es
t
h
e
s
e
m
i
-
a
n
n
u
a
l
m
o
n
i
t
o
r
i
n
g
o
f
v
a
c
ci
n
a
t
io
n
a
c
t
i
v
i
ti
es
f
o
s
t
e
r
a
c
u
l
t
u
r
e
o
f
a
n
a
l
y
s
i
s
a
n
d
e
f
f
e
ct
i
v
e
u
s
e
o
f
r
e
l
i
a
b
l
e
d
a
t
a
t
o
s
u
p
p
o
r
t
d
e
c
i
s
i
o
n
-
m
a
k
i
n
g
a
t
t
h
e
o
p
e
r
a
t
io
n
a
l
l
e
v
e
l
?
”
2
.
5
.
Da
t
a
c
o
llect
io
n t
ec
hn
iqu
es,
t
o
o
ls
,
a
nd
v
a
ria
bles
F
o
u
r
m
a
i
n
t
e
c
h
n
i
q
u
e
s
w
e
r
e
u
s
ed
:
i)
D
i
r
e
c
t
o
b
s
e
r
v
at
i
o
n
:
t
h
is
c
o
v
e
r
e
d
t
h
e
p
r
e
p
a
r
a
t
i
o
n
a
n
d
i
m
p
l
e
m
e
n
t
a
t
i
o
n
o
f
s
e
l
f
-
m
o
n
i
t
o
r
i
n
g
,
d
a
t
a
v
a
l
i
d
a
t
i
o
n
,
a
n
d
i
n
t
e
r
n
a
l
a
n
d
h
e
a
l
t
h
z
o
n
e
–
l
e
v
el
d
i
s
s
e
m
i
n
a
ti
o
n
o
f
r
e
s
u
l
t
s
.
A
d
i
g
i
t
a
l
i
z
e
d
o
b
s
e
r
v
a
t
i
o
n
c
h
e
c
k
li
s
t
wa
s
u
s
e
d
to
a
s
s
e
s
s
t
h
e
e
f
f
e
c
ti
v
e
n
e
s
s
,
a
v
a
il
a
b
i
l
it
y
,
a
n
d
q
u
a
l
i
t
y
o
f
t
o
o
l
s
,
p
r
o
d
u
c
t
i
o
n
o
f
r
e
q
u
i
r
e
d
d
o
c
u
m
e
n
t
a
t
i
o
n
,
a
n
d
a
n
a
l
y
t
i
c
al
d
y
n
a
m
i
c
s
.
ii)
S
e
m
i
-
s
t
r
u
c
t
u
r
e
d
i
n
t
e
r
v
i
e
ws
:
c
o
n
d
u
c
t
e
d
u
s
i
n
g
a
d
a
p
t
e
d
i
n
t
e
r
v
i
ew
g
u
i
d
e
s
a
n
d
a
u
d
i
o
r
e
c
o
r
d
e
r
s
,
t
h
e
s
e
a
i
m
e
d
to
d
o
c
u
m
e
n
t
p
e
r
c
e
p
t
i
o
n
s
,
p
r
a
c
ti
c
es
,
a
n
d
c
h
a
l
l
e
n
g
e
s
r
e
l
at
e
d
t
o
m
o
n
i
t
o
r
i
n
g
.
iii)
D
o
c
u
m
e
n
t
r
e
v
i
e
w:
t
h
is
i
n
c
l
u
d
e
d
e
x
a
m
i
n
a
t
i
o
n
o
f
P
R
Ps
,
a
tt
en
d
a
n
c
e
s
h
e
e
ts
,
m
o
n
i
t
o
r
i
n
g
r
ep
o
r
t
s
,
a
n
d
o
t
h
e
r
d
o
c
u
m
e
n
t
s
p
r
o
d
u
c
e
d
w
i
t
h
i
n
t
h
e
p
r
e
v
i
o
u
s
t
w
o
y
e
a
r
s
.
i
v
)
K
e
y
v
a
r
i
a
b
l
es
c
o
l
l
ec
t
e
d
:
A
v
a
i
la
b
i
l
i
t
y
o
f
p
r
e
p
a
r
a
t
o
r
y
d
o
c
u
m
en
t
s
;
c
o
n
d
u
c
t
o
f
m
o
n
i
t
o
r
i
n
g
s
es
s
i
o
n
s
;
p
r
es
e
n
c
e
a
n
d
q
u
a
l
i
t
y
o
f
r
e
q
u
i
r
e
d
t
o
o
l
s
;
c
a
l
c
u
l
a
ti
o
n
a
n
d
v
e
r
i
f
i
c
a
t
i
o
n
o
f
k
e
y
i
n
d
i
c
a
t
o
r
s
;
i
d
e
n
t
i
f
ic
a
t
i
o
n
o
f
b
o
t
t
l
e
n
e
c
k
s
;
d
e
v
e
l
o
p
m
e
n
t
o
r
u
p
d
a
t
i
n
g
o
f
t
h
e
m
i
c
r
o
-
p
l
a
n
;
e
x
is
t
e
n
c
e
o
f
f
o
l
l
o
w
-
u
p
m
e
c
h
a
n
i
s
m
s
.
2
.
6
.
I
nd
ica
t
o
rs a
nd
a
s
s
ess
m
ent
cr
it
er
ia
P
e
r
f
o
r
m
a
n
c
e
w
as
a
s
s
es
s
e
d
u
s
i
n
g
t
h
e
f
o
l
l
o
w
i
n
g
c
o
m
p
o
n
e
n
t
s
:
i)
M
o
n
i
t
o
r
i
n
g
p
r
o
c
e
s
s
a
n
d
q
u
a
l
i
t
y
-
E
f
f
ec
tiv
en
ess
: c
o
m
p
letio
n
o
f
s
ess
io
n
s
an
d
av
ailab
ilit
y
o
f
m
o
n
ito
r
in
g
r
ep
o
r
ts
.
-
Par
ticip
atio
n
:
h
ig
h
(
all
ex
p
ec
t
ed
ac
to
r
s
p
r
esen
t)
;
m
o
d
er
ate
(
at
least
o
n
e
r
ep
r
esen
tativ
e
p
er
ca
teg
o
r
y
)
;
lo
w
(
o
th
er
s
itu
atio
n
s
)
.
-
C
o
n
ten
t
r
elev
an
ce
:
an
aly
s
is
o
f
in
d
icato
r
s
;
id
en
tific
atio
n
o
f
b
o
ttlen
ec
k
s
;
PR
P
d
ev
elo
p
ed
;
f
o
llo
w
-
u
p
m
ec
h
an
is
m
s
in
p
lace
.
Hig
h
r
elev
an
ce
:
≥
5
cr
iter
ia;
m
o
d
er
ate:
≥
3
; lo
w:
<
3
.
ii)
Q
u
a
l
i
t
y
a
n
d
u
s
e
o
f
PR
Ps
-
Av
ailab
ilit
y
/d
is
p
lay
o
f
th
e
PR
P.
-
PR
P
q
u
ality
,
ass
es
s
ed
th
r
o
u
g
h
:
ca
u
s
al
an
aly
s
is
(
A)
,
in
n
o
v
atio
n
o
f
p
r
o
p
o
s
ed
ac
tio
n
s
(
B
)
,
an
d
r
ea
lis
m
/f
ea
s
ib
ilit
y
(
C
)
.
Hig
h
q
u
ality
: A
,
B
,
C
>
8
0
%;
lo
w:
<
5
0
%; ac
ce
p
tab
le:
in
ter
m
ed
iate
v
alu
es.
-
I
m
p
lem
en
tatio
n
le
v
el
o
f
P
R
P a
ctio
n
s
: 8
0
% =
h
ig
h
;
5
0
–
8
0
%
=
m
o
d
er
ate;
<
5
0
% =
lo
w.
2
.
7
.
Da
t
a
m
a
na
g
e
m
ent
a
nd
a
na
ly
s
is
M
e
t
h
o
d
o
l
o
g
i
c
a
l
r
i
g
o
u
r
wa
s
e
n
s
u
r
e
d
t
h
r
o
u
g
h
d
i
g
i
t
a
li
s
at
i
o
n
o
f
d
a
t
a
c
o
ll
e
c
t
i
o
n
t
o
o
l
s
,
d
ai
l
y
c
r
o
s
s
-
c
h
e
c
k
s
b
y
s
u
p
e
r
v
i
s
o
r
s
,
a
n
d
s
y
s
t
e
m
a
t
i
c
v
e
r
i
f
i
c
a
t
i
o
n
o
f
c
o
n
s
i
s
t
e
n
c
y
a
c
r
o
s
s
s
o
u
r
c
e
s
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
15
,
No
.
2
,
J
u
n
e
20
26
:
5
8
3
-
5
9
2
586
-
Qu
an
titativ
e
an
aly
s
is
:
p
er
f
o
r
m
ed
u
s
in
g
E
x
ce
l
an
d
Stata
1
5
to
g
en
e
r
ate
d
escr
ip
tiv
e
s
tatis
tic
s
an
d
in
ter
an
n
u
al
c
o
m
p
ar
is
o
n
s
.
-
Qu
alitativ
e
an
aly
s
is
:
m
an
u
al
u
s
in
g
th
em
atic
an
aly
s
is
,
with
co
d
in
g
f
o
llo
win
g
a
n
in
d
u
ctiv
e
an
d
d
ed
u
ctiv
e
ap
p
r
o
ac
h
;
th
em
es
wer
e
id
en
t
if
ied
th
r
o
u
g
h
iter
ativ
e
r
ea
d
i
n
g
an
d
tr
ian
g
u
lated
ac
r
o
s
s
s
o
u
r
ce
s
to
en
s
u
r
e
r
ig
o
u
r
.
2
.
8
.
E
t
hica
l c
o
ns
idera
t
io
ns
T
h
e
s
t
u
d
y
a
d
h
e
r
e
d
t
o
e
t
h
i
c
a
l
p
r
i
n
c
i
p
l
es
f
o
r
h
e
al
t
h
r
es
e
a
r
ch
.
T
h
e
p
r
o
t
o
c
o
l
wa
s
a
p
p
r
o
v
e
d
b
y
t
h
e
i
n
s
t
it
u
t
i
o
n
a
l
c
o
m
m
i
t
te
e
o
f
s
c
ie
n
t
i
s
t
s
a
n
d
r
e
s
e
a
r
c
h
e
t
h
i
cs
e
x
p
e
r
t
s
at
I
R
S
P
.
A
d
m
i
n
is
t
r
at
i
v
e
a
u
t
h
o
r
i
s
at
i
o
n
s
w
e
r
e
o
b
t
a
i
n
e
d
f
r
o
m
t
h
e
M
i
n
is
t
r
y
o
f
H
e
a
lt
h
a
n
d
p
a
r
t
i
c
i
p
at
i
n
g
h
e
al
th
z
o
n
e
s
.
I
n
f
o
r
m
e
d
c
o
n
s
e
n
t
w
as
o
b
t
ai
n
e
d
f
r
o
m
a
ll
p
a
r
t
i
c
i
p
a
n
ts
.
A
n
o
n
y
m
i
t
y
a
n
d
co
n
f
i
d
e
n
t
i
a
l
i
t
y
w
e
r
e
e
n
s
u
r
e
d
t
h
r
o
u
g
h
d
e
-
i
d
e
n
t
i
f
i
c
a
t
i
o
n
a
n
d
s
ec
u
r
e
d
a
t
a
s
t
o
r
a
g
e
.
2
.
9
.
Study
lim
it
a
t
io
ns
a
nd
mitig
a
t
io
n m
e
a
s
ures
L
i
m
i
t
at
i
o
n
s
i
n
cl
u
d
e
d
i
n
c
o
m
p
l
e
t
e
a
c
c
es
s
t
o
a
r
c
h
i
v
e
s
,
p
e
r
ce
i
v
e
d
l
e
n
g
t
h
o
f
i
n
t
e
r
v
i
e
w
g
u
i
d
e
s
,
a
n
d
i
n
t
e
r
m
i
tt
e
n
t
u
n
a
v
a
i
l
a
b
il
i
t
y
o
f
k
e
y
a
c
t
o
r
s
.
M
it
i
g
a
t
i
o
n
m
e
as
u
r
e
s
c
o
m
p
r
i
s
e
d
r
e
s
c
h
e
d
u
l
i
n
g
o
f
s
ess
i
o
n
s
,
m
a
x
i
m
al
u
s
e
o
f
a
v
a
i
l
a
b
l
e
d
o
c
u
m
e
n
t
a
ti
o
n
,
t
r
ia
n
g
u
l
a
t
i
o
n
o
f
d
a
t
a
s
o
u
r
c
e
s
,
a
n
d
d
o
c
u
m
e
n
t
a
t
i
o
n
o
f
u
n
c
e
r
t
a
i
n
ti
e
s
d
u
r
i
n
g
a
n
a
l
y
s
i
s
.
T
h
e
s
e
l
i
m
i
t
at
i
o
n
s
w
e
r
e
t
a
k
e
n
i
n
t
o
a
c
c
o
u
n
t
i
n
t
h
e
i
n
te
r
p
r
e
t
a
ti
o
n
o
f
f
i
n
d
i
n
g
s
.
3.
RE
SU
L
T
S AN
D
D
I
SCU
SS
I
O
N
3
.
1
.
Resul
t
s
3
.
1
.
1
.
Cha
ra
ct
er
is
t
ics o
f
t
he
hea
lt
h f
a
cilit
ies a
nd
re
s
po
nd
ent
s
inclu
ded
A
to
tal
o
f
elev
e
n
h
ea
lth
ce
n
t
er
s
wer
e
o
b
s
er
v
ed
a
cr
o
s
s
f
o
u
r
d
ep
ar
tm
en
ts
.
T
h
ese
f
ac
ilit
ies
co
m
p
r
is
ed
ce
n
t
er
s
with
at
lea
s
t
a
d
i
s
p
en
s
ar
y
o
r
m
ater
n
ity
u
n
it,
all
o
f
f
er
in
g
u
n
iv
e
r
s
al
r
o
u
tin
e
v
ac
cin
atio
n
th
r
o
u
g
h
f
ix
ed
an
d
o
u
tr
ea
c
h
s
tr
ateg
ies.
T
h
e
p
r
esen
ce
o
f
q
u
alif
ie
d
s
taf
f
(
p
h
y
s
ician
s
,
n
u
r
s
es,
m
id
wiv
es)
in
v
ar
y
in
g
n
u
m
b
e
r
s
was
co
n
f
ir
m
ed
in
ea
c
h
h
ea
lth
f
ac
ilit
y
.
I
n
2
0
2
5
,
th
ese
ce
n
t
er
s
co
v
er
ed
a
p
o
p
u
latio
n
o
f
2
2
9
,
2
7
6
in
h
a
b
itan
ts
,
co
r
r
esp
o
n
d
in
g
t
o
a
cu
m
u
lativ
e
s
em
i
-
an
n
u
al
v
ac
ci
n
atio
n
tar
g
e
t o
f
3
,
6
5
9
c
h
ild
r
en
.
C
o
n
ce
r
n
in
g
th
e
3
8
r
esp
o
n
d
en
t
s
in
clu
d
ed
in
th
e
s
tu
d
y
,
th
e
y
a
r
e
d
is
tr
ib
u
ted
alm
o
s
t
e
q
u
ally
ac
r
o
s
s
th
e
f
o
u
r
d
ep
a
r
tm
en
ts
.
T
h
e
a
v
er
a
g
e
ag
e
was
4
1
.
4
7
±
9
.
5
7
y
ea
r
s
.
T
h
e
ag
e
g
r
o
u
p
4
6
y
ea
r
s
an
d
ab
o
v
e
was
p
r
ed
o
m
i
n
an
t
(
4
2
.
1
1
%),
f
o
llo
wed
b
y
th
e
2
3
–
35
-
y
ea
r
a
g
e
g
r
o
u
p
(
3
1
.
5
8
%).
Ma
le
p
a
r
ticip
an
ts
wer
e
m
o
r
e
r
ep
r
esen
ted
(
5
5
.
2
6
%)
.
Mo
s
t
r
e
s
p
o
n
d
en
ts
h
ad
r
ec
eiv
ed
a
b
r
ief
in
g
o
n
m
o
n
ito
r
i
n
g
(
8
4
.
2
1
%),
a
n
d
th
e
d
is
tr
ib
u
tio
n
o
f
p
r
o
f
ess
io
n
al
r
o
les wa
s
b
alan
ce
d
(
2
1
.
0
5
% in
ea
ch
ca
teg
o
r
y
)
.
3
.
1
.
2
.
P
ro
g
re
s
s
io
n o
f
m
o
nito
ring
ind
ica
t
o
rs (
2
0
2
3
–
2
0
2
4
)
I
n
2
0
2
4
,
th
e
av
ailab
ilit
y
o
f
in
p
u
ts
an
d
ac
ce
s
s
ib
ilit
y
to
s
er
v
i
ce
s
r
em
ain
ed
g
en
e
r
ally
o
p
tim
al
(
1
0
0
%),
with
o
n
ly
two
ce
n
t
er
s
r
ep
o
r
tin
g
av
ailab
ilit
y
le
v
els
b
etwe
en
9
4
%
an
d
9
6
%.
C
o
m
p
ar
ed
with
2
0
2
3
,
p
e
r
f
o
r
m
an
ce
was
alm
o
s
t
id
en
tical,
r
ef
lectin
g
co
n
tin
u
ed
co
n
tr
o
l
o
f
th
e
s
u
p
p
ly
ch
ai
n
,
an
ess
en
tial
f
ac
to
r
f
o
r
s
u
s
tain
in
g
p
er
f
o
r
m
an
ce
d
y
n
am
ics.
Utili
z
atio
n
in
2
0
2
4
s
h
o
wed
m
a
r
k
ed
o
v
er
p
er
f
o
r
m
a
n
ce
(
‘
s
u
p
er
r
ate’
,
>>
1
0
0
%)
in
s
ev
er
al
ce
n
t
er
s
,
r
ep
r
esen
tin
g
a
n
im
p
r
o
v
em
en
t
o
v
er
2
0
2
3
,
p
ar
ticu
lar
ly
in
f
o
u
r
ce
n
t
er
s
wh
er
e
s
er
v
ice
u
p
tak
e
f
a
r
ex
ce
ed
ed
e
x
p
ec
ted
lev
els.
T
h
e
s
e
2
0
2
4
r
esu
lts
in
d
icate
a
n
in
c
r
ea
s
ed
u
s
e
o
f
s
er
v
ices b
y
th
e
p
o
p
u
latio
n
.
Ser
v
ice
co
n
tin
u
ity
r
ea
ch
e
d
h
i
g
h
lev
els
in
f
iv
e
ce
n
t
er
s
in
2
0
2
4
,
with
im
p
r
o
v
em
en
ts
o
v
er
2
0
2
3
i
n
ce
n
t
er
s
s
u
ch
as
Hea
lth
C
en
ter
1
an
d
Hea
lth
C
en
ter
6
.
T
h
e
q
u
ality
o
f
v
ac
cin
atio
n
s
er
v
i
ce
s
a
ls
o
ten
d
ed
to
im
p
r
o
v
e
ac
r
o
s
s
s
ev
er
al
ce
n
t
er
s
in
2
0
2
4
,
with
h
ig
h
o
r
v
er
y
h
ig
h
lev
els
o
b
s
er
v
ed
in
f
iv
e
ce
n
t
er
s
a
n
d
o
v
er
p
e
r
f
o
r
m
an
ce
in
two
.
C
o
m
p
ar
ed
with
2
0
2
3
,
th
ese
r
esu
lts
s
u
g
g
est
a
g
r
ad
u
al
r
ea
d
ju
s
tm
en
t
an
d
s
tr
en
g
th
en
in
g
o
f
q
u
ality
p
r
ac
tices.
3
.
1
.
3
.
Co
nd
uct
o
f
t
he
s
em
i
-
a
nn
ua
l m
o
nito
ring
i)
Pre
p
ar
atio
n
an
d
co
n
d
u
ct
o
f
s
elf
-
m
o
n
ito
r
in
g
-
Pre
p
ar
atio
n
Pre
p
ar
atio
n
was
c
h
ar
ac
ter
is
ed
b
y
th
e
t
r
an
s
m
is
s
io
n
o
f
an
o
f
f
icial
in
f
o
r
m
atio
n
n
o
te
f
r
o
m
t
h
e
h
ea
lth
zo
n
e
o
f
f
ice
to
h
ea
lth
ce
n
t
er
s
s
p
ec
if
y
in
g
th
e
s
ch
ed
u
le
(
8
1
.
8
1
%)
at
least
o
n
e
wee
k
b
ef
o
r
e
th
e
ac
tiv
ity
(
6
3
.
6
4
%).
Stak
eh
o
ld
er
in
v
o
lv
em
e
n
t d
u
r
in
g
p
r
e
p
ar
atio
n
was e
f
f
ec
tiv
e
i
n
5
4
.
5
5
% o
f
h
ea
lth
ce
n
t
er
s.
“N
o
t
a
ll
tea
m
me
mb
ers
g
et
in
vo
lved
…
I
h
a
ve
to
d
o
ev
eryth
in
g
myself
to
p
r
ep
a
r
e
f
o
r
th
e
mo
n
ito
r
in
g
.
” (
Hea
lth
ce
n
t
er
h
ea
d
)
In
d
icato
r
s
o
f
in
ter
est
f
o
r
d
ata
an
aly
s
is
an
d
u
s
e
ass
ess
ed
at
th
is
s
tag
e
v
ar
ied
:
av
ailab
ilit
y
o
f
m
o
n
th
ly
s
taf
f
m
ee
tin
g
r
ep
o
r
ts
(
7
2
.
7
3
%)
a
n
d
m
o
n
ito
r
in
g
r
ep
o
r
ts
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
A
s
s
es
s
in
g
th
e
effec
tiven
ess
o
f a
s
emi
-
a
n
n
u
a
l m
o
n
ito
r
in
g
m
o
d
el
fo
r
d
a
ta
a
n
a
lysi
s
…
(
La
mid
h
i S
a
l
a
mi
)
587
-
Self
-
m
o
n
ito
r
in
g
Ov
er
all,
th
e
ex
ec
u
tio
n
lev
els
o
f
s
elf
-
m
o
n
ito
r
in
g
task
s
co
n
tr
asted
with
th
e
s
elf
-
ass
ess
m
en
t
r
ep
o
r
ted
b
y
r
esp
o
n
d
en
ts
.
T
ec
h
n
ical
ac
tiv
ities
r
elate
d
to
d
ata
p
r
o
ce
s
s
in
g
,
s
o
r
tin
g
ca
r
d
s
,
ex
tr
ac
tin
g
d
ata
f
r
o
m
s
o
u
r
ce
d
o
cu
m
e
n
ts
,
an
d
ca
lcu
latin
g
in
d
icato
r
s
wer
e
m
o
r
e
f
r
eq
u
en
tly
p
er
f
o
r
m
ed
(
8
2
%)
th
a
n
an
aly
t
ical
task
s
.
Fo
r
th
e
latter
,
3
6
%
o
f
ce
nt
er
s
co
n
d
u
ct
ed
a
“r
ev
iew
o
f
th
e
p
r
ev
io
u
s
PR
P,”
6
4
%
p
er
f
o
r
m
ed
“g
r
ap
h
p
lo
ttin
g
,
”
an
d
5
5
%
co
n
d
u
cte
d
“b
o
ttlen
ec
k
id
en
tifi
ca
tio
n
.
”
E
x
ce
p
t
f
o
r
th
e
“
r
ev
iew
o
f
th
e
p
r
ev
io
u
s
m
o
n
ito
r
i
n
g
PR
P”,
wh
ich
5
6
%
o
f
r
esp
o
n
d
e
n
ts
r
ep
o
r
ted
b
ein
g
ab
le
to
ca
r
r
y
o
u
t,
r
esp
o
n
d
en
ts
r
a
ted
th
eir
ca
p
ac
ity
to
p
er
f
o
r
m
all
o
th
er
task
s
m
o
r
e
f
av
o
u
r
ab
ly
(
≥
7
5
%).
T
h
e
s
itu
atio
n
was
m
o
r
e
cr
itical
f
o
r
PR
P
d
ev
elo
p
m
en
t,
ca
r
r
ied
o
u
t
in
o
n
ly
9
.
0
9
%
o
f
ce
n
t
er
s
,
alth
o
u
g
h
7
5
.
0
0
%
o
f
m
an
ag
er
s
s
tated
th
at
th
ey
h
ad
a
h
ig
h
ca
p
ac
ity
to
d
o
s
o
.
Ov
er
all
p
er
ce
p
tio
n
o
f
s
elf
-
m
o
n
ito
r
in
g
am
o
n
g
r
esp
o
n
d
en
ts
was satis
f
ac
to
r
y
(
8
1
.
5
8
%)
o
r
v
er
y
s
atis
f
ac
to
r
y
(
7
.
8
9
%).
ii)
Data
v
alid
atio
n
Valid
atio
n
was
ch
ar
ac
ter
is
ed
b
y
g
o
o
d
ad
m
in
is
tr
ativ
e
p
r
ep
a
r
atio
n
(
7
2
.
7
3
%),
in
d
icate
d
b
y
in
f
o
r
m
atio
n
n
o
tes
s
en
t
to
ac
to
r
s
,
an
d
h
ig
h
er
in
v
o
lv
e
m
en
t
o
f
d
is
p
en
s
ar
y
/m
ater
n
ity
u
n
it
m
an
a
g
er
s
(
1
0
0
%)
co
m
p
ar
e
d
to
C
OGE
C
S
m
em
b
er
s
(
5
0
%).
T
h
e
s
elf
-
m
o
n
ito
r
in
g
r
e
p
o
r
t
was
av
ailab
le
in
6
0
%
o
f
h
ea
lth
ce
n
t
er
s
.
Oth
er
f
in
d
in
g
s
at
th
is
s
tag
e
in
clu
d
e
d
:
“r
e
p
o
r
t
p
r
ep
ar
atio
n
”
(
9
.
0
9
%)
an
d
“r
ep
o
r
t
tr
an
s
m
is
s
io
n
”
to
th
e
h
ea
lth
zo
n
e
o
f
f
ice
(
0
%).
Ov
er
all
p
er
ce
p
tio
n
o
f
v
alid
a
tio
n
was
f
av
o
u
r
ab
le
(
7
3
.
6
8
%
s
atis
f
ac
to
r
y
,
1
5
.
7
9
%
v
er
y
s
atis
f
ac
to
r
y
)
,
an
d
o
b
s
er
v
atio
n
s
ar
is
in
g
f
r
o
m
v
alid
atio
n
wer
e
r
ec
o
r
d
e
d
in
th
e
s
u
p
er
v
is
io
n
n
o
teb
o
o
k
(
7
0
%).
iii)
Feed
b
ac
k
on
r
esu
lts
-
Ar
o
u
n
d
5
0
%
o
f
r
esp
o
n
d
en
ts
d
id
n
o
t
s
y
s
tem
atica
lly
p
ar
ticip
a
te,
p
ar
ticu
lar
ly
C
OGE
C
S
m
em
b
er
s
,
d
u
e
to
th
e
p
er
ce
iv
ed
in
f
o
r
m
al
n
atu
r
e
o
f
th
e
p
r
o
ce
s
s
an
d
s
ch
ed
u
lin
g
co
n
f
licts
.
Att
en
d
an
ce
an
d
in
v
o
lv
em
en
t
wer
e
co
n
s
id
er
ed
p
o
s
itiv
e
(
7
8
%)
a
n
d
u
s
ef
u
l (
≈
9
2
%).
-
Feed
b
ac
k
was
co
n
d
u
cte
d
in
7
1
.
4
3
%
o
f
h
ea
lth
zo
n
es,
with
r
e
g
u
lar
p
ar
ticip
atio
n
o
f
5
8
.
3
3
%
o
f
s
tak
eh
o
ld
er
s
,
g
en
er
ally
s
atis
f
ac
to
r
y
in
v
o
lv
em
en
t,
an
d
c
o
n
ten
t
co
v
er
i
n
g
r
esu
lts
,
b
o
ttlen
ec
k
s
,
m
icr
o
p
lan
s
o
r
PR
Ps
,
s
o
m
etim
es tem
p
o
r
al
co
m
p
ar
is
o
n
s
,
an
d
f
in
an
cial
asp
ec
ts
.
3
.
1
.
4
.
Use o
f
m
o
nito
ring
re
s
ults
i)
Qu
ality
o
f
p
r
o
b
lem
r
eso
lu
tio
n
p
lan
s
(
PR
Ps
)
At
th
e
tim
e
o
f
th
e
s
u
r
v
e
y
,
9
0
.
9
0
%
o
f
h
ea
lth
ce
n
t
er
s
h
ad
a
PR
P.
Ass
es
s
m
en
t
o
f
PR
P
q
u
ality
s
h
o
wed
a
m
ix
ed
p
r
o
f
ile:
o
n
e
h
ea
lth
ce
n
t
er
ac
h
iev
ed
s
atis
f
ac
to
r
y
q
u
ality
(
h
ig
h
s
co
r
es
o
n
all
th
r
ee
cr
iter
ia)
,
wh
ile
m
o
s
t
PR
P
s
wer
e
ac
ce
p
tab
le
(
T
ab
le
1
)
.
Ov
er
all,
f
ea
s
ib
ilit
y
was
g
o
o
d
,
b
u
t
in
n
o
v
atio
n
was
lo
w
,
an
d
r
elev
a
n
ce
r
eq
u
ir
ed
s
tr
en
g
th
en
i
n
g
.
T
ab
le
1
.
Ass
ess
m
en
t o
f
th
e
q
u
ality
o
f
th
e
co
r
r
ec
tiv
e
ac
tio
n
p
lan
s
(
PR
P
s
)
d
ev
elo
p
ed
f
o
llo
wi
n
g
th
e
m
o
n
ito
r
in
g
o
f
ac
tiv
ities
f
o
r
th
e
s
ec
o
n
d
s
e
m
ester
o
f
2
0
2
4
H
e
a
l
t
h
c
e
n
t
er
A
v
a
i
l
a
b
i
l
i
t
y
a
n
d
d
i
s
p
l
a
y
R
e
l
e
v
a
n
c
e
I
n
n
o
v
a
t
i
o
n
F
e
a
si
b
i
l
i
t
y
O
v
e
r
a
l
l
q
u
a
l
i
t
y
o
f
t
h
e
P
R
P
H
e
a
l
t
h
c
e
n
t
e
r
1
Y
e
s
0%
1
0
0
%
1
0
0
%
A
c
c
e
p
t
a
b
l
e
H
e
a
l
t
h
c
e
n
t
e
r
2
Y
e
s
0%
1
0
0
%
1
0
0
%
A
c
c
e
p
t
a
b
l
e
H
e
a
l
t
h
c
e
n
t
e
r
3
Y
e
s
5
0
%
5
0
%
1
0
0
%
A
c
c
e
p
t
a
b
l
e
H
e
a
l
t
h
c
e
n
t
e
r
4
Y
e
s
1
0
0
%
1
0
0
%
1
0
0
%
S
a
t
i
sf
a
c
t
o
r
y
H
e
a
l
t
h
c
e
n
t
e
r
5
Y
e
s
0%
0%
1
0
0
%
A
c
c
e
p
t
a
b
l
e
H
e
a
l
t
h
c
e
n
t
e
r
6
Y
e
s
NA
NA
NA
NA
H
e
a
l
t
h
c
e
n
t
e
r
7
Y
e
s
6
6
%
3
3
%
1
0
0
%
A
c
c
e
p
t
a
b
l
e
H
e
a
l
t
h
c
e
n
t
e
r
8
No
ND
ND
ND
ND
H
e
a
l
t
h
c
e
n
t
e
r
9
Y
e
s
NA
NA
NA
NA
H
e
a
l
t
h
c
e
n
t
e
r
10
Y
e
s
5
0
%
5
0
%
1
0
0
%
A
c
c
e
p
t
a
b
l
e
H
e
a
l
t
h
c
e
n
t
e
r
11
Y
e
s
6
6
%
6
6
%
1
0
0
%
A
c
c
e
p
t
a
b
l
e
3.
1
.
5
.
I
m
plem
ent
a
t
i
o
n o
f
P
R
P
a
ct
io
ns
I
m
p
lem
en
tatio
n
lev
els
v
ar
ied
co
n
s
id
er
ab
ly
:
3
6
.
3
6
%
o
f
h
ea
lth
ce
n
t
er
s
h
ad
co
m
p
leted
1
0
0
%
o
f
ac
tio
n
s
;
o
th
er
s
d
is
p
lay
e
d
in
ter
m
ed
iate
(
6
6
%)
o
r
lo
w
(
3
3
%)
i
m
p
lem
en
tatio
n
le
v
els
(
T
ab
le
2
)
.
C
o
m
m
o
n
ac
tio
n
s
in
clu
d
ed
en
g
ag
in
g
co
m
m
u
n
it
y
h
ea
lth
wo
r
k
er
s
f
o
r
m
o
b
ili
z
atio
n
,
s
y
s
tem
atic
s
ea
r
ch
in
g
o
f
ch
ild
h
ea
lth
ca
r
d
s
,
an
d
im
p
r
o
v
e
d
s
to
ck
m
an
a
g
em
en
t.
Sev
er
al
h
ea
lth
p
o
s
t
h
ea
d
s
r
ep
o
r
ted
u
n
d
o
cu
m
e
n
te
d
im
p
lem
e
n
tatio
n
,
u
n
d
er
s
co
r
i
n
g
th
e
n
ee
d
f
o
r
f
o
r
m
al
f
o
llo
w
-
u
p
to
o
ls
.
“…la
ck
o
f fo
llo
w
-
u
p
…
a
n
o
th
e
r
a
ctivity
ca
r
r
ied
o
u
t wi
th
n
o
p
r
o
o
f…” (
Hea
lth
p
o
s
t h
ea
d
)
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
15
,
No
.
2
,
J
u
n
e
20
26
:
5
8
3
-
5
9
2
588
3.
1
.
6
.
F
o
llo
w
-
up
m
ec
ha
nis
ms
f
o
r
P
RP
im
plem
ent
a
t
io
n
PR
P
f
o
llo
w
-
u
p
o
cc
u
r
r
ed
d
u
r
in
g
m
ee
tin
g
s
in
4
5
.
4
5
%
o
f
h
ea
lth
ce
n
t
er
s
.
N
o
s
tan
d
ar
d
i
z
ed
d
o
cu
m
e
n
tatio
n
s
y
s
tem
was
id
en
tifie
d
.
T
wo
ce
n
t
er
s
r
ep
o
r
ted
h
a
v
in
g
n
o
f
o
r
m
al
f
o
ll
o
w
-
u
p
m
ec
h
an
i
s
m
(
T
ab
le
2
)
.
At
th
e
co
m
m
u
n
e/h
ea
lth
zo
n
e
le
v
el,
f
ew
s
tr
u
ct
u
r
ed
ac
tio
n
s
wer
e
o
b
s
er
v
e
d
.
Al
th
o
u
g
h
co
m
m
u
n
e
-
lev
el
C
ODI
R
m
ee
tin
g
s
d
is
cu
s
s
ed
p
er
f
o
r
m
an
ce
a
n
d
p
lan
n
e
d
co
r
r
ec
tiv
e
m
ea
s
u
r
es,
PR
P
f
o
llo
w
-
u
p
was
n
o
t
f
o
r
m
ally
i
n
clu
d
ed
o
n
th
e
ag
e
n
d
a.
L
o
ca
l
m
an
ag
e
r
s
r
ep
o
r
t
ed
b
ein
g
u
n
awa
r
e
th
at
s
u
ch
f
o
llo
w
-
u
p
was
ex
p
ec
te
d
with
in
th
e
m
o
n
ito
r
in
g
f
r
am
ew
o
r
k
.
“S
in
ce
th
e
r
emo
va
l
o
f
in
ce
n
ti
ve
s
…
co
mmitmen
t
h
a
s
d
ec
r
ea
s
ed
…
a
n
d
I
d
i
d
n
’
t
k
n
o
w
th
a
t
fo
llo
w
-
u
p
w
a
s
my
r
esp
o
n
s
ib
ilit
y.
” (
Hea
lth
p
o
s
t h
ea
d
)
T
ab
le
2
.
Ma
in
f
in
d
in
g
s
o
n
r
ec
o
m
m
en
d
atio
n
s
,
f
o
llo
w
-
up
,
a
n
d
th
e
im
p
lem
en
tatio
n
r
ates
o
f
co
r
r
ec
tiv
e
ac
tio
n
p
lan
s
(
PR
P)
H
e
a
l
t
h
c
e
n
t
e
r
A
v
a
i
l
a
b
i
l
i
t
y
o
f
a
f
o
l
l
o
w
-
u
p
me
c
h
a
n
i
s
m fo
r
P
R
P
i
m
p
l
e
me
n
t
a
t
i
o
n
P
R
P
i
m
p
l
e
me
n
t
a
t
i
o
n
l
e
v
e
l
H
e
a
l
t
h
c
e
n
t
e
r
l
e
v
e
l
C
o
mm
u
n
e
l
e
v
e
l
H
e
a
l
t
h
z
o
n
e
l
e
v
e
l
H
e
a
l
t
h
c
e
n
t
e
r
1
Y
e
s
No
No
8
3
%
H
e
a
l
t
h
c
e
n
t
e
r
2
Y
e
s
No
No
1
0
0
%
H
e
a
l
t
h
c
e
n
t
e
r
3
No
No
No
1
0
0
%
H
e
a
l
t
h
c
e
n
t
e
r
4
Y
e
s
No
No
NA
H
e
a
l
t
h
c
e
n
t
e
r
5
Y
e
s
No
No
1
0
0
%
H
e
a
l
t
h
c
e
n
t
e
r
6
Y
e
s
No
No
NA
H
e
a
l
t
h
c
e
n
t
e
r
7
Y
e
s
No
No
3
3
%
H
e
a
l
t
h
c
e
n
t
e
r
8
Y
e
s
No
No
1
0
0
%
H
e
a
l
t
h
c
e
n
t
e
r
9
Y
e
s
No
Y
e
s
NA
H
e
a
l
t
h
c
e
n
t
e
r
10
No
No
No
5
0
%
H
e
a
l
t
h
c
e
n
t
e
r
11
Y
e
s
No
No
6
6
%
3.
1
.
7
.
P
er
ce
iv
ed
co
ntr
ibu
t
io
n o
f
P
RP
s
t
o
perf
o
rma
nce
I
n
8
1
.
8
2
%
o
f
h
ea
lth
ce
n
t
er
s
,
m
an
ag
er
s
esti
m
ated
th
at
im
p
lem
en
tatio
n
o
f
PR
P
ac
tio
n
s
im
p
r
o
v
ed
in
d
icato
r
s
(
b
etter
in
p
u
t
m
an
ag
em
en
t,
r
ed
u
ce
d
d
u
p
licate
ca
r
d
s
,
in
ten
s
if
ied
o
u
tr
ea
ch
s
tr
ateg
ies,
in
cr
ea
s
ed
co
v
er
ag
e
o
f
tar
g
ets).
“…it
s
t
r
en
g
th
en
s
s
ystema
tic
r
etri
ev
a
l
o
f
ch
ild
h
ea
lth
ca
r
d
s
…
ce
n
tr
a
li
z
a
tio
n
a
t
th
e
p
h
a
r
ma
cy
…
imp
r
o
ve
d
d
a
ta
q
u
a
lity a
n
d
fo
ll
o
w
-
u
p
.
”
(
Hea
lth
p
o
s
t h
ea
d
)
3
.
2
.
Dis
cus
s
io
n
T
h
is
s
tu
d
y
an
aly
s
es
th
e
im
p
le
m
en
tatio
n
o
f
th
e
s
em
i
-
an
n
u
al
m
o
n
ito
r
in
g
o
f
v
ac
cin
atio
n
ac
tiv
ities
in
B
en
in
,
co
n
f
ir
m
s
p
r
ev
i
o
u
s
o
b
s
er
v
atio
n
s
,
an
d
id
e
n
tifie
s
cr
itic
al
g
ap
s
an
d
ch
allen
g
es
in
th
e
cy
cle
o
f
g
en
er
atin
g
an
d
ju
d
icio
u
s
ly
u
s
in
g
e
v
id
en
c
e
f
o
r
ac
tio
n
.
3
.
2
.
1
.
Str
eng
t
h o
f
t
he
m
o
nito
ring
m
o
del a
nd
da
t
a
qu
a
lity
Sem
i
-
an
n
u
al
m
o
n
ito
r
in
g
,
r
o
u
tin
ely
ca
r
r
ied
o
u
t
in
h
ea
lth
f
ac
ilit
ies
f
o
r
n
ea
r
ly
th
r
ee
d
ec
ad
es,
is
f
o
r
m
ally
a
n
d
r
o
b
u
s
tly
estab
lis
h
ed
in
B
en
in
,
s
u
p
p
o
r
ted
b
y
n
o
r
m
ativ
e,
r
e
g
u
lato
r
y
,
an
d
ev
e
n
cu
ltu
r
al
d
y
n
am
ics,
as
well
as
m
im
etic
o
r
co
er
civ
e
r
atio
n
alities
[
9
]
.
Alth
o
u
g
h
s
o
lid
,
th
e
m
o
n
ito
r
in
g
s
y
s
tem
m
u
s
t
b
e
s
u
p
p
o
r
ted
b
y
a
s
u
r
v
eillan
ce
m
ec
h
a
n
is
m
to
e
n
s
u
r
e
f
u
n
ctio
n
al
o
wn
e
r
s
h
ip
an
d
g
en
er
ate
t
h
e
ex
p
ec
te
d
r
esu
lts
[
9
]
.
T
y
p
ical
o
f
h
ea
lth
in
f
o
r
m
atio
n
s
y
s
tem
s
in
lo
w
-
an
d
m
id
d
le
-
in
co
m
e
c
o
u
n
tr
ies,
t
h
e
co
n
tr
ast
o
b
s
er
v
e
d
b
etwe
en
,
o
n
th
e
o
n
e
h
a
n
d
,
th
e
h
ig
h
a
v
ailab
ilit
y
o
f
in
p
u
ts
an
d
u
n
iv
e
r
s
al
ac
ce
s
s
ib
ilit
y
o
f
s
er
v
ices,
an
d
,
o
n
t
h
e
o
th
er
h
an
d
,
wid
e
f
lu
ctu
atio
n
s
in
u
tili
z
atio
n
,
co
n
tin
u
it
y
,
an
d
q
u
ality
,
as we
ll a
s
th
e
r
ec
u
r
r
en
ce
o
f
o
v
er
-
co
v
e
r
ag
e
r
ates
(
>1
0
0
%),
co
n
f
ir
m
s
th
e
n
ee
d
f
o
r
co
n
tin
u
o
u
s
s
u
p
p
o
r
t
[
4
]
,
[
1
0
]
-
[
1
3
]
.
Prio
r
ity
s
h
o
u
l
d
th
er
ef
o
r
e
b
e
g
iv
en
to
s
tr
en
g
th
en
in
g
t
h
e
m
o
n
ito
r
in
g
s
y
s
tem
to
en
s
u
r
e
its
ef
f
ec
tiv
e
ca
p
ac
ity
to
ad
d
r
ess
r
ec
u
r
r
en
t
p
r
o
b
lem
s
in
v
ac
cin
atio
n
d
ata,
wh
ich
o
f
ten
d
is
r
u
p
t d
ec
is
io
n
-
m
a
k
in
g
a
n
d
p
r
o
g
r
am
m
e
ac
tio
n
in
m
an
y
co
u
n
tr
ies [
1
4
]
.
T
h
e
in
tr
o
d
u
ctio
n
o
f
r
eg
u
lar
au
d
it
an
d
co
n
tr
o
l
to
o
ls
,
en
s
u
r
in
g
v
e
r
if
icatio
n
o
f
co
m
p
le
ten
ess
an
d
co
n
s
is
ten
cy
,
co
u
ld
im
p
r
o
v
e
d
a
ta
r
eliab
il
ity
an
d
t
h
eir
u
s
e
f
o
r
d
ec
is
io
n
-
m
ak
in
g
[
1
1
]
,
[
1
5
]
,
[
1
6
]
.
Ho
wev
e
r
,
s
u
ch
im
p
r
o
v
em
e
n
ts
ca
n
o
n
l
y
b
e
s
u
s
tain
ed
if
h
ea
lth
wo
r
k
er
s
ar
e
co
n
s
is
ten
tly
m
o
tiv
ated
a
n
d
tr
ai
n
ed
in
d
ata
m
an
ag
em
en
t
[
1
7
]
.
3
.
2
.
2
.
Da
t
a
a
na
ly
s
is
a
nd
us
e
T
h
e
co
m
p
ar
ativ
e
r
e
v
iew
o
f
p
er
f
o
r
m
a
n
ce
b
etwe
en
2
0
2
3
an
d
2
0
2
4
h
i
g
h
lig
h
ts
a
s
tab
le
an
d
o
p
tim
al
p
er
f
o
r
m
an
ce
in
te
r
m
s
o
f
in
p
u
ts
an
d
ac
ce
s
s
ib
ilit
y
,
alo
n
g
s
id
e
a
p
r
o
g
r
ess
iv
e
im
p
r
o
v
e
m
en
t
in
u
tili
z
atio
n
,
Evaluation Warning : The document was created with Spire.PDF for Python.
I
n
t J Pu
b
lic
Hea
lth
Sci
I
SS
N:
2252
-
8
8
0
6
A
s
s
es
s
in
g
th
e
effec
tiven
ess
o
f a
s
emi
-
a
n
n
u
a
l m
o
n
ito
r
in
g
m
o
d
el
fo
r
d
a
ta
a
n
a
lysi
s
…
(
La
mid
h
i S
a
l
a
mi
)
589
co
n
tin
u
ity
,
a
n
d
q
u
ality
,
p
a
r
ticu
lar
ly
in
ce
n
t
er
s
wh
er
e
o
v
e
r
p
er
f
o
r
m
an
ce
(
‘
s
u
p
er
r
ate
’
)
w
as
o
b
s
er
v
ed
.
T
h
ese
f
in
d
in
g
s
u
n
d
e
r
s
co
r
e
t
h
e
im
p
o
r
tan
ce
o
f
s
em
i
-
an
n
u
al
m
o
n
ito
r
in
g
,
wh
ic
h
en
a
b
les
th
e
id
en
tific
atio
n
o
f
b
o
ttlen
ec
k
s
an
d
g
u
id
es o
p
er
ati
o
n
al
ad
ju
s
tm
en
ts
.
Ho
wev
er
,
th
e
ass
ess
m
en
t
o
f
th
e
m
o
n
ito
r
in
g
p
r
o
ce
s
s
s
h
o
ws
th
at
h
ea
lth
ce
n
t
er
s
ca
r
r
y
o
u
t
d
ata
co
llectio
n
an
d
tech
n
ical
ca
lc
u
latio
n
task
s
ea
s
ily
an
d
d
ilig
e
n
tly
,
y
et
p
e
r
f
o
r
m
v
e
r
y
litt
le
in
-
d
ep
th
a
n
aly
s
is
an
d
p
lan
n
in
g
(
9
.
0
9
%)
.
T
h
is
f
in
d
in
g
is
co
r
r
o
b
o
r
ated
b
y
s
elf
-
ass
ess
m
en
ts
s
h
o
win
g
th
at
s
taf
f
f
ee
l
m
o
r
e
ca
p
a
b
le
an
d
co
m
p
eten
t
with
tec
h
n
ical
task
s
th
an
with
b
o
ttlen
ec
k
an
al
y
s
is
an
d
co
r
r
ec
tiv
e
p
la
n
n
in
g
.
T
h
i
s
lack
o
f
a
n
aly
tical
ca
p
ac
ity
co
n
s
titu
tes
a
m
ajo
r
b
ar
r
ier
t
o
estab
lis
h
in
g
r
o
u
tin
e
p
r
ac
tices
o
f
d
ata
an
aly
s
is
an
d
u
s
e
f
o
r
lo
ca
l
d
ec
is
io
n
-
m
ak
in
g
[
1
8
]
.
Dig
itali
z
atio
n
,
wh
o
s
e
p
a
r
tial
p
ilo
t
wa
s
s
atis
f
ac
to
r
y
in
o
n
e
h
ea
lth
z
o
n
e,
co
u
l
d
s
er
v
e
as
a
T
r
o
jan
h
o
r
s
e
to
r
e
d
u
ce
wo
r
k
lo
ad
an
d
im
p
r
o
v
e
d
ata
an
al
y
s
is
an
d
u
s
e
[
1
9
]
.
3
.
2
.
3
.
Q
ua
lity
a
nd
us
e
o
f
pro
blem
re
s
o
lutio
n pla
ns
(
P
RP
s
)
I
n
ad
d
itio
n
to
th
e
l
o
w
p
r
o
d
u
c
tio
n
o
f
PR
Ps
d
u
r
in
g
s
elf
-
m
o
n
ito
r
in
g
(
9
.
0
9
%),
t
h
e
v
ar
ia
b
le
q
u
ality
o
f
av
ail
ab
le
PR
P
s
r
ef
lects
lo
w
lev
els
o
f
d
ata
u
s
e
[
4
]
.
T
h
is
m
ir
r
o
r
s
p
er
s
is
ten
t
o
p
er
atio
n
al
ch
allen
g
es
in
m
icr
o
p
lan
n
i
n
g
a
n
d
th
e
lim
ited
lo
ca
l
ca
p
ac
ity
f
o
r
d
ata
u
s
e
[
1
8
]
.
Fin
d
in
g
s
o
f
m
o
d
e
r
ately
r
el
ev
an
t
ac
tio
n
s
,
lo
w
in
n
o
v
atio
n
,
an
d
in
s
u
f
f
icien
t
d
o
cu
m
e
n
tatio
n
o
f
f
o
ll
ow
-
u
p
alig
n
with
an
aly
s
es
an
d
r
e
co
m
m
en
d
atio
n
s
b
y
Gav
i
[
7
]
an
d
Sco
b
ie
et
a
l
.
[
2
0
]
.
T
h
ese
h
ig
h
lig
h
t
th
at
im
p
r
o
v
in
g
d
ata
u
s
e
r
eq
u
ir
es
h
a
r
m
o
n
is
ed
to
o
ls
,
r
o
b
u
s
t
tech
n
ical
s
u
p
p
o
r
t,
clea
r
d
elin
ea
tio
n
o
f
r
esp
o
n
s
ib
ilit
ies,
in
s
titu
tio
n
alis
ed
f
ee
d
b
ac
k
lo
o
p
s
,
an
d
in
t
e
g
r
atio
n
o
f
r
eg
u
lar
m
o
n
ito
r
in
g
m
ec
h
a
n
is
m
s
(
d
ash
b
o
ar
d
s
,
task
ass
ig
n
m
en
t
,
an
d
tim
elin
es)
with
in
co
o
r
d
in
atio
n
b
o
d
ies
.
E
s
tab
lis
h
in
g
a
co
m
p
lete
d
ec
is
io
n
cy
cle,
co
u
p
led
with
o
p
tim
al
d
ig
itali
z
atio
n
o
f
th
e
d
ata
m
an
ag
em
en
t
s
y
s
tem
,
is
a
k
ey
f
ac
to
r
i
n
s
u
s
tain
ab
ly
i
m
p
r
o
v
i
n
g
v
ac
ci
n
atio
n
p
e
r
f
o
r
m
an
ce
[
1
]
,
[
1
7
]
,
[
2
0
]
,
[
2
1
]
.
3
.
2
.
4
.
Co
mm
un
it
y
pa
rt
icipa
t
io
n in da
t
a
us
e
T
h
e
in
s
u
f
f
icien
t
in
v
o
lv
em
en
t
o
f
C
OGE
C
S
m
em
b
er
s
in
m
o
n
ito
r
in
g
ac
tiv
ities
,
esp
ec
ia
lly
d
u
r
i
n
g
f
ee
d
b
ac
k
s
ess
io
n
s
,
co
n
s
titu
tes
a
m
ajo
r
wea
k
n
ess
,
as
s
tr
u
ctu
r
ed
co
m
m
u
n
ity
en
g
a
g
em
en
t
s
u
p
p
o
r
ts
v
ac
cin
atio
n
d
em
an
d
g
en
e
r
atio
n
,
s
tr
en
g
th
en
s
tr
an
s
p
ar
en
c
y
,
a
n
d
f
o
s
ter
s
tr
u
s
t
in
th
e
h
ea
lth
s
y
s
tem
[
2
2
]
.
I
n
teg
r
atin
g
co
m
m
u
n
ity
r
ep
r
esen
tativ
es
in
to
f
ee
d
b
ac
k
ac
tiv
ities
co
u
l
d
,
th
r
o
u
g
h
a
s
o
cial
ac
c
o
u
n
tab
ilit
y
ap
p
r
o
ac
h
,
s
tr
en
g
th
en
o
wn
er
s
h
ip
o
f
th
e
m
o
n
ito
r
in
g
p
r
o
ce
s
s
an
d
p
r
o
m
o
te
th
eir
ac
tiv
e
in
v
o
lv
em
e
n
t
i
n
d
ec
is
io
n
-
m
ak
in
g
an
d
im
p
lem
e
n
tatio
n
o
f
ac
tio
n
p
lan
s
an
d
r
ec
o
m
m
en
d
atio
n
s
[
2
2
]
.
3
.
2
.
5
.
Co
ntr
ibu
t
io
n t
o
perf
o
r
m
a
nce
a
nd
pro
g
ra
m
ma
t
ic
i
m
pli
ca
t
io
ns
T
h
e
p
o
s
itiv
e
p
er
ce
p
tio
n
o
f
th
e
im
p
ac
t
o
f
PR
Ps
an
d
d
ata
u
s
e
o
n
v
ac
cin
atio
n
in
d
icato
r
s
(
8
1
.
8
2
%)
is
co
n
s
is
ten
t
with
f
in
d
in
g
s
b
y
Ma
f
ig
ir
i
et
a
l
.
[
1
8
]
,
wh
o
e
m
p
h
asis
ed
th
e
im
p
o
r
tan
t
r
o
l
e
o
f
m
icr
o
p
lan
s
in
id
en
tify
in
g
a
n
d
a
d
d
r
ess
in
g
co
m
m
u
n
ity
h
ea
lth
p
r
o
b
lem
s
an
d
i
n
im
p
r
o
v
in
g
s
er
v
ice
d
eliv
er
y
[
1
8
]
,
[
2
3
]
.
Sev
er
al
p
r
o
g
r
am
m
atic
p
r
io
r
iti
es e
m
er
g
e
f
r
o
m
th
ese
f
in
d
in
g
s
an
d
an
al
y
s
es:
i)
Simp
lific
atio
n
an
d
s
tan
d
ar
d
iz
atio
n
o
f
th
e
p
r
o
ce
s
s
,
p
ar
ticu
la
r
ly
th
e
s
elf
-
m
o
n
ito
r
in
g
an
d
P
R
P
f
o
llo
w
-
u
p
p
h
ases
,
th
r
o
u
g
h
f
o
r
m
ali
z
atio
n
an
d
d
ig
ita
lizatio
n
o
f
to
o
ls
an
d
p
r
o
ce
d
u
r
es [
1
]
,
[
1
9
]
,
[
2
4
]
.
ii)
Stre
n
g
th
en
in
g
c
o
m
m
u
n
ity
en
g
ag
em
en
t
ac
r
o
s
s
all
p
h
ases
an
d
en
h
a
n
cin
g
p
a
r
ticip
ato
r
y
ac
co
u
n
tab
ilit
y
th
r
o
u
g
h
a
f
u
n
ctio
n
al
PR
P
f
o
ll
o
w
-
u
p
m
ec
h
an
is
m
in
teg
r
ated
i
n
to
co
o
r
d
in
atio
n
p
latf
o
r
m
s
a
n
d
s
u
p
p
o
r
ted
b
y
h
ar
m
o
n
i
z
e
d
an
d
in
tellig
en
t to
o
ls
[
1
7
]
,
[
2
0
]
,
[
2
2
]
,
[
2
5
]
.
iii)
Pro
m
o
tin
g
an
ef
f
ec
tiv
e
an
d
in
n
o
v
ativ
e
co
n
ti
n
u
o
u
s
ca
p
a
city
-
b
u
ild
in
g
s
y
s
tem
,
b
ased
o
n
f
o
r
m
ativ
e
s
u
p
er
v
is
io
n
,
m
e
n
to
r
s
h
ip
,
e
x
p
e
r
ien
tial le
ar
n
in
g
,
a
n
d
c
o
llab
o
r
a
tiv
e
p
r
o
b
lem
-
s
o
lv
in
g
[
1
8
]
,
[
2
6
]
-
[
2
8
]
.
T
h
ese
r
ec
o
m
m
en
d
atio
n
s
alig
n
with
i
n
ter
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v
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ata
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is
io
n
-
m
ak
in
g
[
7
]
,
[
1
9
]
,
[
2
0
]
.
4.
CO
NCLU
SI
O
N
T
h
is
s
tu
d
y
co
n
f
ir
m
s
th
at
B
en
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ap
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ly
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0
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ed
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P
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o
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o
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m
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in
s
u
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ici
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m
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ity
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la
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ta
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ict
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Desp
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8
1
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2
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ce
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t
er
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ted
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im
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tatio
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e
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T
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ica
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ca
p
ac
ity
f
o
r
d
ata
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llectio
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o
es n
o
t a
u
to
m
atica
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tr
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s
late
in
to
an
aly
tical
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p
ac
ity
f
o
r
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io
n
-
m
ak
in
g
.
T
h
r
ee
p
r
io
r
ities
em
er
g
e:
ac
c
eler
atin
g
d
i
g
itali
z
atio
n
o
f
m
o
n
ito
r
in
g
to
o
ls
;
in
s
titu
tio
n
ali
s
in
g
PR
P
f
o
llo
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u
p
with
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ex
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o
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atio
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m
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an
d
s
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en
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en
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c
o
m
m
u
n
it
y
p
ar
ticip
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t
h
r
o
u
g
h
s
o
cial
ac
co
u
n
tab
ilit
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ap
p
r
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ac
h
es.
T
h
ese
in
v
estme
n
ts
ar
e
ess
en
tial
to
tr
a
n
s
f
o
r
m
m
o
n
ito
r
in
g
f
r
o
m
a
c
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m
p
lia
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cise
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to
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g
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u
in
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d
r
iv
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r
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f
co
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tin
u
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s
q
u
ality
im
p
r
o
v
em
e
n
t
in
v
ac
cin
atio
n
s
er
v
ices.
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DATA AV
AI
L
AB
I
L
I
T
Y
T
h
e
d
ata
th
at
s
u
p
p
o
r
t
th
e
f
in
d
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s
o
f
th
is
s
tu
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y
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e
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v
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l
e
f
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th
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co
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d
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g
a
u
t
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r
,
[
L
S],
u
p
o
n
r
ea
s
o
n
ab
le
r
eq
u
est.
RE
F
E
R
E
NC
E
S
[
1
]
W
o
r
l
d
H
e
a
l
t
h
O
r
g
a
n
i
z
a
t
i
o
n
(
W
H
O
)
,
“
G
l
o
b
a
l
st
r
a
t
e
g
y
o
n
d
i
g
i
t
a
l
h
e
a
l
t
h
2
0
2
0
–
2
0
2
5
,
”
W
H
O
.
[
O
n
l
i
n
e
]
.
A
v
a
i
l
a
b
l
e
:
h
t
t
p
s
:
/
/
w
w
w
.
w
h
o
.
i
n
t
/
d
o
c
s
/
d
e
f
a
u
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t
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s
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r
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e
/
d
o
c
u
me
n
t
s
/
g
s
4
d
h
d
a
a
2
a
9
f
3
5
2
b
0
4
4
5
b
a
f
b
c
7
9
c
a
7
9
9
d
c
e
4
d
.
p
d
f
.
[
2
]
T.
N
u
t
l
e
y
a
n
d
H
.
R
e
y
n
o
l
d
s,
“
I
mp
r
o
v
i
n
g
t
h
e
u
se
o
f
h
e
a
l
t
h
d
a
t
a
f
o
r
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e
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l
t
h
sy
st
e
m
s
t
r
e
n
g
t
h
e
n
i
n
g
,
”
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l
o
b
a
l
H
e
a
l
t
h
A
c
t
i
o
n
,
v
o
l
.
6
,
n
o
.
1
,
p
.
2
0
0
0
1
,
D
e
c
.
2
0
1
3
,
d
o
i
:
1
0
.
3
4
0
2
/
g
h
a
.
v
6
i
0
.
2
0
0
0
1
.
[
3
]
W
o
r
l
d
H
e
a
l
t
h
O
r
g
a
n
i
z
a
t
i
o
n
(
W
H
O
)
,
“
I
mm
u
n
i
z
a
t
i
o
n
A
g
e
n
d
a
2
0
3
0
:
A
g
l
o
b
a
l
s
t
r
a
t
e
g
y
t
o
l
e
a
v
e
n
o
o
n
e
b
e
h
i
n
d
,
”
W
H
O
.
[
O
n
l
i
n
e
]
.
A
v
a
i
l
a
b
l
e
:
h
t
t
p
s:
/
/
w
w
w
.
w
h
o
.
i
n
t
/
p
u
b
l
i
c
a
t
i
o
n
s
/
m/
i
t
e
m/
i
mm
u
n
i
z
a
t
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o
n
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n
d
a
-
2
0
3
0
-
a
-
g
l
o
b
a
l
-
st
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t
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y
-
to
-
l
e
a
v
e
-
no
-
one
-
b
e
h
i
n
d
.
[
4
]
F
.
Y
u
s
u
p
h
,
J
.
E.
N
t
w
e
n
y
a
,
A
.
K
i
n
y
a
g
a
,
a
n
d
N
.
S
.
G
i
b
o
r
e
,
“
R
o
u
t
i
n
e
h
e
a
l
t
h
d
a
t
a
u
s
e
f
o
r
d
e
c
i
s
i
o
n
ma
k
i
n
g
a
n
d
i
t
s
a
sso
c
i
a
t
e
d
f
a
c
t
o
r
s
a
mo
n
g
p
r
i
m
a
r
y
h
e
a
l
t
h
c
a
r
e
m
a
n
a
g
e
r
s
i
n
D
o
d
o
m
a
r
e
g
i
o
n
,
”
B
MC
H
e
a
l
t
h
S
e
rv
i
c
e
s
R
e
se
a
rc
h
,
v
o
l
.
2
4
,
n
o
.
1
,
p
.
1
1
6
8
,
O
c
t
.
2
0
2
4
,
d
o
i
:
1
0
.
1
1
8
6
/
s
1
2
9
1
3
-
0
2
4
-
1
1
6
5
8
-
w.
[
5
]
B
.
H
.
W
a
g
e
n
a
a
r
,
L.
R
.
H
i
r
sc
h
h
o
r
n
,
C
.
H
e
n
l
e
y
,
A
.
G
r
e
mu
,
N
.
S
i
n
d
a
n
o
,
a
n
d
R
.
C
h
i
l
e
n
g
i
,
“
D
a
t
a
-
d
r
i
v
e
n
q
u
a
l
i
t
y
i
mp
r
o
v
e
me
n
t
i
n
l
o
w
-
a
n
d
mi
d
d
l
e
-
i
n
c
o
m
e
c
o
u
n
t
r
y
h
e
a
l
t
h
sy
s
t
e
ms
:
l
e
ss
o
n
s
f
r
o
m
se
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o
g
y
De
p
a
rtme
n
t
a
t
th
e
Re
g
i
o
n
a
l
I
n
stit
u
te
o
f
P
u
b
li
c
He
a
lt
h
,
U
n
iv
e
rsit
y
o
f
Ab
o
m
e
y
-
Ca
lav
i
,
Ou
i
d
a
h
,
Be
n
in
.
F
o
rm
e
r
d
istri
c
t
m
e
d
ica
l
o
ffice
r
a
n
d
e
x
p
e
rt
i
n
h
e
a
lt
h
in
f
o
rm
a
ti
o
n
sy
ste
m
s
a
n
d
d
a
ta
m
a
n
a
g
e
m
e
n
t,
s
h
e
h
a
s
le
d
se
v
e
ra
l
h
e
a
lt
h
-
sy
ste
m
stre
n
g
th
e
n
in
g
p
r
o
jec
ts.
S
h
e
c
a
n
b
e
c
o
n
tac
ted
a
t
e
m
a
il
:
n
y
g
lele
@y
a
h
o
o
.
fr.
J
e
a
n
P
ier
r
e
d
e
La
m
a
ll
e
is
a
p
u
b
li
c
h
e
a
lt
h
sp
e
c
ialist
a
n
d
a
se
n
io
r
o
ff
icia
l
with
i
n
th
e
Eu
r
o
p
e
a
n
Ag
e
n
c
y
fo
r
De
v
e
lo
p
m
e
n
t
a
n
d
He
a
lt
h
in
Bru
ss
e
ls
(A
EDES
),
Be
lg
iu
m
.
He
h
a
s
led
n
u
m
e
ro
u
s
h
e
a
lt
h
-
sy
ste
m
su
p
p
o
rt
p
ro
jec
ts i
n
Afric
a
a
n
d
h
a
s u
n
d
e
rtak
e
n
m
a
n
y
m
issio
n
s a
ime
d
a
t
stre
n
g
th
e
n
in
g
h
e
a
lt
h
sy
ste
m
s
a
c
ro
ss
th
e
c
o
n
ti
n
e
n
t.
He
c
a
n
b
e
c
o
n
tac
ted
a
t
e
m
a
il
:
jp
d
e
lam
a
ll
e
@a
e
d
e
s.b
e
.
Alp
h
o
n
se
Bi
a
o
u
is
a
P
h
.
D
.
c
a
n
d
id
a
te
in
p
u
b
li
c
h
e
a
lt
h
a
t
t
h
e
Bio
sta
ti
stics
a
n
d
Ep
id
e
m
io
lo
g
y
De
p
a
rtme
n
t
o
f
th
e
Re
g
io
n
a
l
I
n
stit
u
te
o
f
P
u
b
li
c
He
a
lt
h
,
Un
iv
e
rsit
y
o
f
A
b
o
m
e
y
-
Ca
lav
i,
Ou
id
a
h
,
Be
n
in
.
He
se
rv
e
s
a
s
a
c
h
ief
te
a
c
h
in
g
a
ss
istan
t
a
n
d
c
o
n
tri
b
u
tes
to
h
e
a
lt
h
-
sy
ste
m
su
p
p
o
rt
p
r
o
jec
ts
imp
lem
e
n
ted
b
y
th
e
IRS
P
.
He
c
a
n
b
e
c
o
n
tac
ted
a
t
e
m
a
il
:
a
lp
h
o
n
se
.
b
iao
u
@y
a
h
o
o
.
fr.
Mo
u
ss
il
i
o
u
No
ë
l
Pa
r
a
ïso
is
a
lec
tu
re
r
-
re
se
a
r
c
h
e
r
a
n
d
se
n
io
r
lec
tu
re
r
in
p
u
b
li
c
h
e
a
lt
h
,
a
n
d
c
u
rre
n
t
ly
se
rv
e
s
a
s
He
a
d
o
f
th
e
He
a
lt
h
P
r
o
m
o
ti
o
n
De
p
a
rtme
n
t
a
t
th
e
Re
g
io
n
a
l
In
stit
u
te
o
f
P
u
b
li
c
He
a
lt
h
,
Un
i
v
e
rsity
o
f
Ab
o
m
e
y
-
Ca
lav
i,
Ou
i
d
a
h
,
Be
n
i
n
.
He
p
re
v
io
u
sly
c
o
o
rd
i
n
a
ted
p
r
o
jec
ts
with
i
n
th
e
IRS
P
a
n
d
h
a
s
c
o
n
d
u
c
ted
se
v
e
ra
l
re
se
a
rc
h
stu
d
ies
o
n
th
e
e
p
id
e
m
io
l
o
g
y
o
f
d
ise
a
se
s
a
ff
e
c
ti
n
g
o
l
d
e
r
a
d
u
lt
s
.
He
c
a
n
b
e
c
o
n
tac
ted
a
t
e
m
a
il
:
m
o
u
ss
p
a
ra
iso
@g
m
a
il
.
c
o
m
.
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