Organic CurrantsOrganic Currants Currants are produced from small seedless black grapes that have been dried. These naturally sweet Australian Currants, which are smaller and firmer than sultanas, are packed with intense fruit flavour and have a deep purple-black colour. They are Certified Organic, and have no added preservatives. Currants are a delicious and convenient snack, that are also great added to breakfast foods, baked goods and sweet or savoury recipes.
How to Use: Enjoy Organic Australian Currants as a quick snack, in lunch boxes, or with cheese and nuts. Currants add a burst of sweet flavour to muesli and porridge, acai bowls, or natural yoghurt. Combine them with other dried fruits, seeds and nuts in moreish trail mixes. In savoury recipes, versatile dried currants can be used in pickles, chutney and stuffing; and go well with rice, cous cous or quinoa, curries and hotpots. Used in many sweet and savoury raw food recipes, Organic currants are great with nut butter or tahini in wraps, tossed through salads, or in slices and muesli bars. Or add yummy, natural sweetness to home-baked bread, fruit buns, muffins, biscuits, cakes and puddings. Currants can be pre-soak in a little warm water or juice to soften, or to prevent them from absorbing moisture from your dough or cake mix - if they are an addition to a baking recipe. Ingredients: Organic Currants. Preservative Free, Non GMO, No Added Sugar. Paleo. Allergens: No Known Allergens. This product may contain traces of Allergens. Storage: Store in an air tight container in a cool, dry place, away from direct sunlight. Refrigeration recommended. Shelf Life: Up to 12 months when stored as above. See Best Before date. SKU: 200600.
Currants are produced from small seedless black grapes that have been dried. These naturally sweet Australian Currants, which are smaller and firmer than sultanas, are packed with intense fruit flavour and have a deep purple-black colour. They are Certified Organic, and have no added preservatives. Currants are a delicious and convenient snack, that are also great added to breakfast foods, baked goods and sweet or savoury recipes.
Enjoy Organic Australian Currants as a quick snack, in lunch boxes, or with cheese and nuts. Currants add a burst of sweet flavour to muesli and porridge, acai bowls, or natural yoghurt. Combine them with other dried fruits, seeds and nuts in moreish trail mixes.
In savoury recipes, versatile dried currants can be used in pickles, chutney and stuffing; and go well with rice, cous cous or quinoa, curries and hotpots. Used in many sweet and savoury raw food recipes, Organic currants are great with nut butter or tahini in wraps, tossed through salads, or in slices and muesli bars.
Or add yummy, natural sweetness to home-baked bread, fruit buns, muffins, biscuits, cakes and puddings. Currants can be pre-soak in a little warm water or juice to soften, or to prevent them from absorbing moisture from your dough or cake mix – if they are an addition to a baking recipe.


Chuck Aron, 70, of Chicago, completes his 23rd race this year at the Run with a Nun fundraiser Sunday at St. Francis of Christ the King of Mount Assisi convent in Lemont.
Two years ago, the sisters at St. Francis of Christ the King of Mount Assisi convent put their "Run with a Nun" fundraiser on hold when Mount Assisi Academy school closed.
The 5K run / walk was only run once before the all-girls high school in Lemont closed, said Sister Therese Ann Quigney, Provincial Superior of the Sisters of St. Francis of Christ the King. The sisters decided to restart the event last year, but thunderstorms scared off many runners, she said.
On Sunday, more than 200 participants signed up by 8 a.m. for the start of the charity event on the convent grounds, Quigney said.
"The first time, it was for the benefit of the school," Quigney said. "Now, since the school closed, it's for the benefit of the sisters."
The same seven nuns who participated last year signed up for this year's event, including Sister Cindy Drozd and her dog, Mr. Buddy.
All participants received a race medal and a shirt with the Run with the Nun logo.
Chuck Aron, 70, of Chicago's Lakeview neighborhood, said the Run with a Nun race is just one of 73 races he will run this year to help raise money in the memory of his brother-in-law, who died in 2001 from Alzheimer's disease. Run with a Nun was Aron's 27th race this year. He'll finish with the Chicago Marathon in October.
Sister Cindy Drozd and her dog, Mr. Buddy, lead a pack of walkers Sunday at the Run with a Nun fundraiser at St. Francis of Christ the King of Mount Assisi convent in Lemont.
"This is the first time I've done (a race) on grass," Aron said. "It was tough. I did a 10K yesterday on pavement."
Rita Pratl, of Chicago Ridge, had three daughters attend Mount Assisi Academy and served on the Run with a Nun committee.
"We made a bigger push this year," Pratl said. "Our plan is to do this every year, and the proceeds all go to the sisters."
In 2014, academy officials said the school closed because of declining enrollment and climbing costs.
The school drew students from Chicago's Southwest side and the south suburbs. It had graduated more than 6,000 students since opening in 1951.


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According to the readers of VegasTripping, there is no such thing as a bad whorehouse! Obviously you've never been to Winnemucca, Nevada. Of those actual whorehouses in the survey, Heidi Fleiss' stud ranch had the most votes for Worst Whorehouse, which would make sense because it's a stud farm, not a whorehouse.


Our trial attorneys are adept in a broad range of civil litigation, including commercial, banking, corporate, real estate, employment, and contract cases. We have extensive experience representing plaintiffs and defendants in both state and federal courts. Occasionally, litigation does not end in the trial court. We represent our clients as appellate counsel at all levels of the state and federal court systems.


Pancakes are a breakfast delight for most people, and they can be cooked in a number of ways. For the pros, however, grill/griddle cooking has some great advantages over cooking in a pan. For example, you need less oil, which makes them more nutritious than most traditional methods. Cooking on a grill with a griddle plate will also make your pancakes more flat and standard looking.
A grill with a large surface can also allow you to cook more portions at once than the traditional way of cooking. Like a waffle maker, electric grills have removable plates that are usually stick-proof and easy to clean.
So there's a lot to love about grilling your pancakes!
This electric grill for pancake is a great addition to any kitchen, and fits on countertops, easily storing when not in use. You can use the handles or remove them. A nonstick surface offers easy cooking and clean up, and if you're cooking eggs or bacon on the side, the waste will be caught in a drip tray, too.
This electric griddle / grill for pancake comes with some distinguishing features, such as an extra tray below so that you can cook things like eggs and bacon below without tainting the pancake surface. It cooks up to 20 times faster because of its ceramic tray making breakfast an easy task even for a family of four. All trays are removable.
This "little" electric griddle for pancake is better for breakfast for two, rather than a family or multiple courses. There's plenty of room for at least two pancakes, and like the other models, there's a drip tray for easy clean up. The nonstick surfaces help a lot with that, too. It can heat up to 400 degrees, so you can easily cook meat instead of simply pancakes on it. A great and versatile kitchen device for all.
This Japanese-style electric griddle/grill for pancake is meant to sit in the center of your table so that the whole family can watch and enjoy. It can cook pancakes with ease, and if you like them a little darker, you can place the lid on top of them for a minute or two. Or, even better, just have more pancakes waiting as you eat your first round and use the lid to keep them warm. When you're not cooking breakfast, this grill is also perfect for Japanese teppanyaki or Korean style BBQ. Or, whatever meat your family enjoys the absolute most. It's easy to clean up and it heats quickly, too. It can braise, grill, boil, and even bake for you.
This durable electric griddle cooks quickly with a perfect surface for even pancakes, and gives you a space of about 11X20″. It can fit about six small pancakes alongside side dishes such as some bacon or ham slices. It's pretty versatile, and heats quickly to 400 degrees. The only downside is that there really aren't very specific temperature controls, and if you want to turn it off, you have to unplug it. Otherwise, it's a perfectly functional grill for your breakfast needs.
The griddle you choose may have one of several options. Usually, the larger models will have a built-in temperature dial. Smaller or less expensive models will instead usually give you a choice of low, medium or high heat.
If you get to use precise temperatures, you should preheat your grill to 350 degree Fahrenheit. (This usually equals medium heat on other types of grills.) Be careful not to touch the surface; it will heat up quickly.
When you pour the batter, it will usually pour out roundly. I prefer to use a mixing bowl that has a pouring slot at the top of it, but my parents always poured their batter into a large measuring cup.
Pour the pancakes about an inch and a half apart so you can fit your spatula under each one individually. Now it's time to wait and watch — small bubbles should form as your pancake begins to cook. This is the typical sign that they're ready to flip.
Important: If you're not using a typical batter recipe, and are cooking something like gluten-free batter, bubbles just aren't the best indicator. Gently lift corner of the pancake instead and check for a medium-brown glow to it.
When the pancakes look ready, flip each one and cook for about two minutes longer on the other side. Usually, this is the final flip of the pancake. Sometimes, however, the batter consistency will require another flip or two. That's fine. You can also do this if you like your pancakes darker.
Let your electric grill sit for a minute or two before you do a second round of pancakes. In fact, if the grill seems to hot, you may want to turn it down a notch or so. Sometimes grills get much hotter after you remove the food from them. This means you'll want to turn it down just a bit under medium heat or to 325 degrees on a griddle with precise controls.
A pancake just can't be great if you don't have a great batter recipe. No matter which batter recipe you use, you usually should allow it to rest and rise for about 5 minutes before you do your final mix.
Your batter should be thin and pour easily. If you're not sure what kind of batter to use, try this simple old-fashioned batter recipe from Allrecipes. Or, if you need a gluten-free option, test out this gluten-free batter recipe from Laura Fuentes.
Pancakes are fun to make and using an electric griddle or grill can only make them easier! Find your favorite batter recipe and you'll have the perfect tool for breakfast in minutes, with a quarter of the effort it normally takes to make your pancakes.
And what will be the best electric grill for pancake in 2020? If you are interested in this subject subscribe us and share your opinion in a comment. Thank you!


text:
Муанакити () е емблематична фигура за редица народи в Танзания. Това е художествено изработена кукла за плодовитост, главно при племената зарамо, куере и лугуру в Източна Танзания. Тя е израз на майчинството и има магично-религиозна стойност с обредните си функции. Името се превежда като "дъщеря на трона", "жена на онзи, който е коронясан" или просто "дървено дете".

Предназначение
Муанакити е направена от едно-единствено парче дърво, представлява само горната част на тялото и е с много изчистени, почти символични контури. Фигурата може да бъде приемана едновременно като мъжка и женска – мъжка поради присъстващата фалическа форма и женска заради наличието на гърди. В началото на инициацията си всяка девойка от племето получава по една такава кукла. Тя се подготвя за бъдещото майчинство като се грижи за куклата, облича я, повива я, закриля я по всякакъв начин и не се разделя от нея. Фигурката се дава на момичето от една от сестрите на бащата, когато дойде време за уединението, предшестващо инициацията. Понякога може да се предава и от майка на дъщеря. Силата на фигурата се активира чрез жертвоприношения и поставянето ѝ в близост до тези на предците от бащиния клан.

Куклата получава името на някой от реалните или митични предци и се съхраняват на специално място в дома, на специален стол или в малка къщичка. В някои случаи фигурките се изработват по двойки. Умалени екземпляри се носят и пазят като амулети от жени, които искат да повишат плодовитостта си.

Изработка
Като цяло тялото на моделираната кукла обикновено е издялано без всякаква символика, като единствено пъпът и гърдите са отбелязани с лек релеф. Върху торса с леко заоблени краища е поставена цилиндричната шия. Лицето е остро, със силно стърчащи уши. Визуално доминиращият елемент в цялата кукла е косата. Формално представеното лице почти се губи за сметка на силно стилизираната прическа, съставена от един или два "петльови гребена" и наричана бедани. Девойката носи както такава прическа, така и куклата, не само докато се омъжи, но и докато се роди първото ѝ дете.

Инициацията все още присъства по селата, но в градовете вече е загубила своето значение. Там резбованите фигурки красят облегалките на столове, музикални инструменти, съдове, дръжки на лъжици, гребени, фиби, украшения за коса и много други. Изработката на столове с облегалки стил муанакити е особено характерна за племето лугуру в региона Морогоро.

Понякога, особено в по-късно време, когато изработването на тези фигурки получава комерсиално значение, цялото тяло е напълно ясно изобразено, с добре определени ръце, крака и лице. Много пъти очите са маркирани с по едно мънисто и фигурката има къса огърлица също от мъниста, поставена на врата или в долната, стеснена част на тялото.

Външни препратки
 Изложба на мунакити
 Фигурки муанакити

Източници

Африканско изкуство
Африкански митологии
Дървени скулптури
Кукли

redpajama_set_name: RedPajamaWikipedia


text:
Q: Why am I receiving a key error using .loc on a known observation I'm getting a key error when trying to pull a row of my data by index.  I'm choosing the index based off looking at the .head() command so I know the value is there.  My index is based off of a policy id.
I've looked at a few posts like the following but they don't answer the question:
KeyError in Python Pandas dataframe using .loc
Here is a screenshot of the data frame:

Then I try:
df_test.loc[92026963:]
This gives me a key error.  Then I tried:
df_test.loc[92026963]

This gave me the same error.  I even tried putting the policy id in quotes.  Full traceback below:
ValueError                                Traceback (most recent call last)
C:\ProgramData\Anaconda3\lib\site-packages\pandas\core\indexes\base.py in get_slice_bound(self, label, side, kind)
   4804             try:
-> 4805                 return self._searchsorted_monotonic(label, side)
   4806             except ValueError:
C:\ProgramData\Anaconda3\lib\site-packages\pandas\core\indexes\base.py in _searchsorted_monotonic(self, label, side)
   4764
-> 4765         raise ValueError('index must be monotonic increasing or decreasing')
   4766
ValueError: index must be monotonic increasing or decreasing
During handling of the above exception, another exception occurred:
KeyError                                  Traceback (most recent call last)
<ipython-input-45-85aa3a940778> in <module>
----> 1 df_test.loc[92026963:]

C:\ProgramData\Anaconda3\lib\site-packages\pandas\core\indexing.py in __getitem__(self, key)
   1498
   1499             maybe_callable = com.apply_if_callable(key, self.obj)
-> 1500             return self._getitem_axis(maybe_callable, axis=axis)
   1501
   1502     def _is_scalar_access(self, key):

C:\ProgramData\Anaconda3\lib\site-packages\pandas\core\indexing.py in _getitem_axis(self, key, axis)
   1865         if isinstance(key, slice):
   1866             self._validate_key(key, axis)
-> 1867             return self._get_slice_axis(key, axis=axis)
   1868         elif com.is_bool_indexer(key):
   1869             return self._getbool_axis(key, axis=axis)

C:\ProgramData\Anaconda3\lib\site-packages\pandas\core\indexing.py in _get_slice_axis(self, slice_obj, axis)
   1531         labels = obj._get_axis(axis)
   1532         indexer = labels.slice_indexer(slice_obj.start, slice_obj.stop,
-> 1533                                        slice_obj.step, kind=self.name)
   1534
   1535         if isinstance(indexer, slice):

C:\ProgramData\Anaconda3\lib\site-packages\pandas\core\indexes\base.py in slice_indexer(self, start, end, step, kind)
   4671         """
   4672         start_slice, end_slice = self.slice_locs(start, end, step=step,
-> 4673                                                  kind=kind)
   4674
   4675         # return a slice

C:\ProgramData\Anaconda3\lib\site-packages\pandas\core\indexes\base.py in slice_locs(self, start, end, step, kind)
   4870         start_slice = None
   4871         if start is not None:
-> 4872             start_slice = self.get_slice_bound(start, 'left', kind)
   4873         if start_slice is None:
   4874             start_slice = 0

C:\ProgramData\Anaconda3\lib\site-packages\pandas\core\indexes\base.py in get_slice_bound(self, label, side, kind)
   4806             except ValueError:
   4807                 # raise the original KeyError
-> 4808                 raise err
   4809
   4810         if isinstance(slc, np.ndarray):

C:\ProgramData\Anaconda3\lib\site-packages\pandas\core\indexes\base.py in get_slice_bound(self, label, side, kind)
   4800         # we need to look up the label
   4801         try:
-> 4802             slc = self._get_loc_only_exact_matches(label)
   4803         except KeyError as err:
   4804             try:

C:\ProgramData\Anaconda3\lib\site-packages\pandas\core\indexes\base.py in _get_loc_only_exact_matches(self, key)
   4770         get_slice_bound.
   4771         """
-> 4772         return self.get_loc(key)
   4773
   4774     def get_slice_bound(self, label, side, kind):

C:\ProgramData\Anaconda3\lib\site-packages\pandas\core\indexes\base.py in get_loc(self, key, method, tolerance)
   2657                 return self._engine.get_loc(key)
   2658             except KeyError:
-> 2659                 return self._engine.get_loc(self._maybe_cast_indexer(key))
   2660         indexer = self.get_indexer([key], method=method, tolerance=tolerance)
   2661         if indexer.ndim > 1 or indexer.size > 1:

pandas/_libs/index.pyx in pandas._libs.index.IndexEngine.get_loc()

pandas/_libs/index.pyx in pandas._libs.index.IndexEngine.get_loc()

pandas/_libs/hashtable_class_helper.pxi in pandas._libs.hashtable.Int64HashTable.get_item()

pandas/_libs/hashtable_class_helper.pxi in pandas._libs.hashtable.Int64HashTable.get_item()

KeyError: 92026963

A: It seems here is necessary assign back DataFrame.set_index:
df_test = df_test.set_index('policy')

Or use inplace=True:
df_test.set_index('policy', inplace=True)

redpajama_set_name: RedPajamaStackExchange


Many investors would like to get involved in hot commodities in some capacity. However, investing in commodities is not as widely understood as investing in stocks. Here are the basics of how you can take advantage of the commodity market.
The most direct way to take advantage of a hot commodity is to get involved in futures contracts. A futures contract allows you to speculate on the price of a commodity. For example, if you believe that the price of a commodity is going to increase, you can purchase a futures contract based on today's prices. Then, as time passes and the price of the commodity increases, you can sell your right to the commodity at the new price and make a profit. In order to get involved in futures contracts, you will have to open a special trading account with a futures broker instead of using a traditional brokerage account.
Another way you could take advantage of the commodities market is to purchase commodity stocks. These are stocks that are linked to corporations that deal with commodities. With this method, you can take advantage of price swings and still use your same brokerage account.


text: Q: How can I fix TypeError: a bytes-like object is required, not 'str' on travis cause the test run fine on my local machine Am setting up Travis for a Django project and I want to be able to get test coverage but am getting some error and Here's a link to my Travis build


Décider a durée qui termine à ou plusieurs pouces sous vos genoux. Tote Bags. absolute for any season and oh-so useful, personalized tote bags make excellent wedding favors. Plain tote bags are inexpensive, and they are easy to customize yourself, should you hope to create your own wedding favors. brusque upon time? Some wedding shops pay for personalized totes, but they will cost you more than if you design them yourself.
Unique keyword Galerie. Sunglasses. Having the ideal summer wedding? Candies and chocolates might not be the best wedding favor to depart for guests in the warm summer sun. Sunglasses are a great quirk to save your guests courteous and to remind them of your special hours of daylight for years to come. A plus? Frames come in a variety of styles and can be personalized in fittingly many ways. You are limited unaided by your imagination! past tote bags, sunglasses can next be personalized professionally by many wedding and party vendors.
S'mores Kits. absolute for weddings in late summer or to the front fall, individual s'mores kits are substitute creative swap to more agreeable wedding favors. These can be as basic or as decadent as you prefer, and for that reason they can appear in for any budget. every you craving are some graham crackers, marshmallows, chocolate bars and gorgeous craft supplies to create these saintly and unforgettable gifts for your guests.
Candy in Personalized Wrappers. A bit more upon the conventional side, personalized candy wrappers and candy seem to be mainstays afterward it comes to wedding favors. From those oft-present Jordan almonds to the more unprejudiced chocolate bars, this is other easy and inexpensive quirk to mount up a personal adjoin to your wedding. Why mess past a classic? pick your candy and pick out those personalized candy wrappers. It's a great way to make an way of being on wedding guests later a sweet-tooth, and it after that makes for a well-appreciated shower or bachelorette party gift.
Individual Bath Salts. Do-it-yourself bath salts are every the rage these days. Whether they are for personal use, a Christmas gift for a relative or birthday present for a relative, chances are you've already got a recipe or two on one of your Pinterest boards. Individual bath salts are a unique and affordable habit to pamper your wedding guests. Luxurious, tiny jars of bath salt furthermore make astounding bridal shower favors.
Hangover Rescue Kits. Hangover rescue kits or "cures" are a must-have if your guests will be drinking. From a personalized bottle of water, to a hangover remedy-packed kit, you can create this wedding favor as easy or as profound as you like. As when the extra do-it-yourself ideas, this concept is flexible and budget friendly. Hangover rescue kits then create good bachelor and bachelorette party favors!
Sachets. You probably already know that sachets are tiny bags of perfumed flowers or aromatic herbs that people typically place in drawers or closets to create the circulate smell pleasant. What you might not know is that these herb and flower-filled pouches create creative wedding favors as well. As behind sunglasses or totes, these unconventional wedding party favors can either be bought or made at home.
Travel Kits. Whether you're having a summer or winter wedding, a homemade travel kit can be a useful and memorable wedding favor that doesn't rupture the bank. This idea is highly versatile, as the kits can be made in a variety of ways on not quite any budget, and it's the absolute favor for a destination wedding.


Barn weddings can be rustic chic, down-home country, and outdoor wedding bliss.
Sarah and Michael married on June 21, 2017 in rural Covelo, CA. The couple chose to get married at Sarah's family home, where they first met, and where Sarah gave birth to their daughter, Maddie. The ceremony began with the groomsmen and bridesmaids having a dance-off down the aisle, and, as Sarah began to walk down the aisle, one of Michael's friends surprised him by taking the mic and singing "Kiss the Girl" from The Little Mermaid, which then led to the entire audience singing along.
Emily and Rodney had a vintage-inspired wedding in Michigan with fall colors, tattoos, Princess Bride and Harry Potter cameos, and woodworking details. Emily is a woodworker and made the inlay for Rodney's ring. She and her grandfather own a woodworking business so they were able to make most of the decor together.
Her uncle officiated the wedding, starting off with a homage to The Princess Bride, which had everyone laughing. She had some Harry Potter-inspired vows which made everyone sob.


text:
Q: Working with images in tableView:editActionsForRowAt: Here is some trouble I am having working with a UITableView, more precisely using an image in tableView:editActionsForRowAt:
Below follows my relevant code. It may be useful to say that the images I am using here are all square 70x70.
func tableView(_ tableView: UITableView,
               editActionsForRowAt indexPath: IndexPath) -> [UITableViewRowAction]? {
    var patternImg:UIImage?

    let upBtn = UITableViewRowAction(style: .normal, title: "") {
        action, index in
        print("upBtn button tapped")
    }
    patternImg = self.swipeCellImage(named: "UpIcn", side: 46.0)
    upBtn.backgroundColor = UIColor(patternImage: patternImg!)

    let downBtn = UITableViewRowAction(style: .normal, title: "") {
        action, index in
        print("downBtn button tapped")
    }
    patternImg = swipeCellImage(named: "DownIcn", side: 46.0)
    downBtn.backgroundColor = UIColor(patternImage: patternImg!)

    let rmvBtn = UITableViewRowAction(style: .destructive, title: "") {
        action, index in
        print("rmvBtn button tapped")
    }
    patternImg = swipeCellImage(named: "TrashIcn", side: 46.0)
    rmvBtn.backgroundColor = UIColor(patternImage: patternImg!)

    return [downBtn,upBtn,rmvBtn]
}

func swipeCellImage(named name: String, side: CGFloat) -> UIImage? {
    let theImage = UIImage(named: name)
    UIGraphicsBeginImageContextWithOptions(CGSize(width: side*2, height: side), false, UIScreen.main.scale)
    let context = UIGraphicsGetCurrentContext()
    context!.setFillColor(UIColor.clear.cgColor)
    theImage?.draw(in: CGRect(x: 0, y: 0, width: side, height: side))
    let resultImage = UIGraphicsGetImageFromCurrentImageContext()
    UIGraphicsEndImageContext()
    return resultImage
}

Things work, but unfortunately only up to a certain point.
Looking at this screen shot shows that there is an unwanted repetion of the images. Clearly I want each button(Icon) to only appear one time each.

Can anyone see how I need to fix my code to avoid this repetion?

A: To avoid that, you have to increase width size asper your requirement.
    UIGraphicsBeginImageContextWithOptions(CGSize(width:      self.view.frame.width, height: commonHei), false, UIScreen.main.scale)
    let context = UIGraphicsGetCurrentContext()

    context!.setFillColor(textColor.cgColor) // CHECK BY CHANGE BGCOLOR
    context!.fill(CGRect(x: 0, y: 0, width: (self.view.frame.width) / 3, height: commonHei)) // INCREASE WIDTH SIZE
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Sanjay Adhia, M.D. Forensic Psychiatrist
Sanjay Adhia
5826 New Territory Blvd., Suite 803 Sugar Land, TX 77479
Dr. Adhia is triple Board-Certified in Forensic Psychiatry, Brain Injury Medicine and Psychiatry consulting in civil, criminal and probate cases and testifying as needed. Recent cases include evaluating PTSD in victims of human trafficking, date rape (DFSA), competency where a video fo rape was posted on YouTube by perpetrators, matricide, medical malpractice between treater and patient, toxicity in transplant patient. Dr. Adhia is skilled in diagnosis, prognosis, and treatment plans for anxiety and depression disorders, PTSD, medication, drug, and alcohol addiction. Dr. Adhia has served on the faculties of University of Texas Health and Science Center, University of Texas Medical Branch Department of Psychiatry. In 2019, Dr. Adhia was appointed by the Governor of Texas to the Governor's Advisory Committee to the Texas Board of Criminal Justice on Offenders with Medical or Mental Impairments. Prior to private practice, Dr. Adhia conducted evaluations and treatment in a maximum security correctional facility requiring his skill in diagnosing and treating severe psychotic disorders and Impulse disorders; he treated psychosis with hallucination and delusional disorders, and schizophrenia. Psychiatric conditions among offenders were often combined with drug and/or alcohol addiction. Dr. Adhia conducts forensic evaluations with Physicians for Human Rights Asylum Network assessing victims of human trafficking, kidnapping, false imprisonment and undue influence. His skill in diagnosing PTSD is an asset in this setting. Dr. Adhia is experienced in institutional standards of care and medical malpractice in hospital and institutional settings with application to private treatment, rehab or senior care.
Brain injury Medicine
Correctional Healthcare
Medical Case Review
Medical Literature Research
Neuropsychology - Head Injury
PTSD - Post Traumatic Stress Disorder
Pharmacology & Pharmaceutical
Sexual Offenses
Sports & Recreation Injuries
Tobacco & Health
Dr. Adhia is triple Board-Certified in Forensic Psychiatry, Brain Injury Medicine and Psychiatry consulting and testifying in civil, criminal, military and probate cases. Recent cases include date rape (DFSA), matricide, and medical malpractice between treater and patient, toxicity in transplant patient and evaluating PTSD in victims of human trafficking. Dr. Adhia is skilled in diagnosis, prognosis, and treatment plans for anxiety and depression disorders, PTSD, medication, drug, and alcohol addiction.
Dr. Adhia has served on the faculties of University of Texas Health and Science Center, University of Texas Medical Branch Department of Psychiatry.
In 2019, Dr. Adhia was appointed by the Governor of Texas to the Governor's Advisory Committee to the Texas Board of Criminal Justice on Offenders with Medical or Mental Impairments.
Prior to private practice, Dr. Adhia conducted evaluations and treatment in a maximum security correctional facility requiring his skill in diagnosing and treating severe psychotic disorders and Impulse disorders; he treated psychosis with hallucination and delusional disorders, and schizophrenia. Psychiatric conditions among offenders were often combined with drug and/or alcohol addiction.
Dr. Adhia conducts forensic evaluations with Physicians for Human Rights Asylum Network assessing victims of human trafficking, kidnapping, false imprisonment and undue influence. His skill in diagnosing PTSD is an asset in this setting.
Dr. Adhia is experienced in institutional standards of care and medical malpractice in hospital and institutional settings with application to private treatment, rehab or senior care.
Forensic Psychiatry Fellowship, Oregon Health & Science University, Portland, Oregon (2014)
Psychiatry Residency, University of Texas HSC, Houston, Texas (2012)
Psychiatry Internship, University of Kansas Medical Center, Kansas City, Kansas (2009)
Doctor of Medicine, Ramaiah Medical College (2004)
Board-Certified in Brain Injury Medicine, American Board of Psychiatry and Neurology (Certificate #101). (2018)
Texas Medical License, Board of Medical Examiners; Q0720
Board Certified in Psychiatry, American Board of Psychiatry and Neurology (Certificate #67625), (2014)
Board-Certified in Forensic Psychiatry American Board of Psychiatry and Neurology (Certificate #2127), (2015)
Psychiatry Residency In-Service (PRITE), Ranked #1, 2010
Naras Bhat, M.D., FACP, Sanjay Adhia, How to Reverse and Prevent Heart Disease and Cancer, 1994
Competency (Competency to Stand Trial)
Psychiatric Malpractice (Standard of Care)
Medical Malpractice; pharmacology malpractice
Criminal Responsibility
Immigration Court: Competency to Testify
Psychiatric Malpractice, Standard of Care
Malpractice (Medication Error)
Pre-Emminent Death & Grief
Appointed to Texas Governor G. Abbot's "Governor's Advisory Committee to the Texas Board of Criminal Justice on Offenders with Medical or Mental Impairments."
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Weaponized Chemistry: Date Rape Drugs
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Sanjay Adhia, M.D. Forensic Psychiatrist is listed with ExpertPages in the following jurisdictions: All US Regions and States, Canada (all Provinces).
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Home Research Topics Other Topics Education K-12
Nearly two-thirds of U.S. secondary schools have sworn officers on site – but not all the time
By A.W. Geiger
(Pat Greenhouse/The Boston Globe via Getty Images)
Nearly two-thirds of public secondary schools in the United States (65%) had sworn law enforcement officers on site in the 2015-16 school year, up from 58% a decade earlier. Yet the presence of sworn officers varied considerably by factors including school size and the specific times the officers were present, according to a March report by the Bureau of Justice Statistics and the National Center for Education Statistics.
The report comes amid heightened attention to school security following the February mass shooting at a high school in Parkland, Florida. The shooting, which left 17 people dead, has led to protests and school walkouts around the country. It has also sparked discussions about policy responses to prevent school shootings, including proposals to let teachers carry firearms.
While the presence of sworn officers at secondary schools has become more common over the past decade, many schools report that these officers were only present at specific times rather than throughout the entire school day, according to the report (data are for the 2015-16 school year, the most recent available). Secondary schools include middle and high schools, as well as combined schools.
Less than half (46%) of secondary schools with sworn law enforcement officers present at least once a week had officers present for all instructional hours every day; larger shares of schools said officers were present when students were arriving or leaving (88%) or at selected school activities (87%), such as science fairs or athletic events.
The presence of sworn officers on school grounds also varied by school size, as well as the racial and ethnic composition of the student body.
Larger secondary schools were particularly likely to report the presence of sworn officers on their school grounds. Nine-in-ten schools with 1,000 or more students reported the presence of sworn officers at school, compared with 72% of schools with 500 to 999 students, 59% of schools with 300 to 499 students and 34% of schools of less than 300 students.
Secondary schools with the largest shares of nonwhite students were more likely to report having sworn officers on site than schools with the smallest shares of minorities. Nearly seven-in-ten schools (69%) where at least half of the students are racial or ethnic minorities reported having sworn officers at school at least once a week. That compares with 56% of schools where less than 5% of the student body is nonwhite. Over the past decade, secondary schools in which less than 5% of students are nonwhite saw the largest percent increase in sworn officers reported on site (up 53%, compared with a 12% increase among secondary schools overall).
Sworn law enforcement officers routinely carried a firearm in the vast majority (93%) of U.S. public secondary schools where such officers were present, according to the report.
The report also includes CDC survey data on what share of students said they'd carried a weapon, such as a gun, knife or club, on school property at least one day in the past month; 4% of students in grades 9-12 said they had done so in 2015. Furthermore, about 6% of students said they had been threatened or injured with a weapon on school property during the previous year, a share that was lower than in every survey year between 1993 and 2011. (There was no measurable difference between the shares in 2013 and 2015.)
In the main report survey, 6% of high schools and 3% of middle schools reported taking at least one disciplinary action for the use or possession of a firearm or explosive device during the 2015-16 school year.
Many schools reported being actively prepared for several crisis scenarios, including shootings. Vast majorities of both middle (94%) and high schools (95%) had written procedures to be performed in a shooting scenario, up from around 86% each for middle and high schools in 2003-04.
Concerns about school shootings are widespread
A majority of U.S. teenagers today worry that a shooting could happen at their school (57%) and many parents of teens share that concern (63%), according to Pew Research Center surveys conducted in March and April.
Large majorities of teens say that preventing people with mental illnesses from purchasing guns and improving mental health screening and treatment – 86% each – would be at least somewhat effective at preventing school shootings. Roughly eight-in-ten teens (79%) say that having metal detectors in schools would be effective and 66% say the same about banning assault-style weapons.
By contrast, a much smaller share of teens (39%) say that allowing teachers and school officials to carry guns in schools would be very or somewhat effective at preventing school shootings. Teens' views on proposals to prevent school shootings generally mirror those of the general public, with the strongest support for mental health-related policies and relatively lower support for banning assault-style weapons or allowing school personnel to carry guns. (The survey did not ask about the effectiveness of having sworn law enforcement officers armed in schools.)
Correction: In a previous version of this post, the second chart gave an incorrect end date for the period during which parents and teens were surveyed. The survey ended April 10.
Political IssuesGun PolicyEducationK-12
A.W. Geiger is a former associate digital producer and writer for Pew Research Center.
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Rising share of U.S. primary schools have sworn officers on the premises
America's public school teachers are far less racially and ethnically diverse than their students
U.S. public school students often go to schools where at least half of their peers are the same race or ethnicity
Ready or not, 77 million kids and adults heading back to school soon
How Hispanic police officers view their jobs
Political IssuesEducationK-12Gun Policy


text:
Мартемьяново — название населённых пунктов в России:

 Мартемьяново — деревня в Ковровском районе Владимирской области.
 Мартемьяново — деревня в Судиславском районе Костромской области.
 Мартемьяново — деревня в Наро-Фоминском районе Московской области.
 Мартемьяново — село в Венёвском районе Тульской области.
 Мартемьяново — деревня в Борисоглебском районе Ярославской области.


text:
Volume 4, Issue Suppl 5
Referral transit time between sending and first-line receiving health facilities: a geographical analysis in Tanzania
Michelle M Schmitz1,
Florina Serbanescu1,
George E Arnott1,
Michelle Dynes1,
Paul Chaote2,
Abdulaziz Ally Msuya3,
Yi No Chen1
1Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
2Kigoma Regional Medical Office, Kigoma, Tanzania, United Republic of
3AMCA Inter-Consult Ltd, Dar es Salaam, Tanzania, United Republic of
Correspondence to Michelle M Schmitz; MSchmitz1{at}cdc.gov
Background Timely, high-quality obstetric services are vital to reduce maternal and perinatal mortality. We spatially modelled referral pathways between sending and receiving health facilities in Kigoma Region, Tanzania, identifying communication and transportation delays to timely care and inefficient links within the referral system.
Methods We linked sending and receiving facilities to form facility pairs, based on information from a 2016 Health Facility Assessment. We used an AccessMod cost-friction surface model, incorporating road classifications and speed limits, to estimate direct travel time between facilities in each pair. We adjusted for transportation and communications delays to create a total travel time, simulating the effects of documented barriers in this referral system.
Results More than half of the facility pairs (57.8%) did not refer patients to facilities with higher levels of emergency obstetric care. The median direct travel time was 25.9 min (range: 4.4–356.6), while the median total time was 106.7 min (22.9–371.6) at the moderate adjustment level. Total travel times for 30.7% of facility pairs exceeded 2 hours. All facility pairs required some adjustments for transportation and communication delays, with 94.0% of facility pairs' total times increasing.
Conclusion Half of all referral pairs in Kigoma Region have travel time delays nearly exceeding 1 hour, and facility pairs referring to facilities providing higher levels of care also have large travel time delays. Combining cost-friction surface modelling estimates with documented transportation and communications barriers provides a more realistic assessment of the effects of inter-facility delays on referral networks, and can inform decision-making and potential solutions in referral systems within resource-constrained settings.
AccessMod
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
What is already known?
Strengthening obstetric inter-facility referral systems in developing countries, including reducing delays due to inadequate transportation and unreliable communication, increases access to timely, appropriate obstetric and neonatal care.
About 57.8% of facility pairs in Kigoma did not refer to facilities providing higher levels of care.
When accounting for communication and transportation delays, only 47.5% of the facility pairs have an estimated overall referral transit times below 2 hours.
What do the new findings imply?
Interventions for reducing referral transit times in Kigoma could include increasing the number of ambulances, developing an ambulance dispatch system and improving radio and ambulance communications.
Combining cost-friction surface modelling with fieldwork data provides stakeholders with a better understanding of their healthcare referral system.
Almost 99% of all maternal deaths, and most perinatal deaths, occur in low- and middle-income countries.1–6 Strengthening the district-level referral system is a key government strategy to improve maternal health in Tanzania.7 8
An inter-facility first-line obstetric referral system allows patients delivering at primary care facilities to obtain emergency obstetric and neonatal care (EmONC) at higher-level facilities if life-threatening complications occur.9 Within the Three Delays Model of maternal mortality, the efficiency of a referral system affects the third delay (delay in receiving appropriate care on arrival to a health facility, including time to travel between facilities if the appropriate level of care is not available at the initial facility).10 Efforts to improve referral systems contribute to two of the United Nation's Sustainability Development Goals: Goal 3 (ensuring healthy lives and promoting well-being) and Goal 9 (building resilient infrastructure).11 The timeliness of a referral process may be affected by the quality of the communication network among facilities, transportation resources, and road conditions.12 Understanding the current use and existing gaps of the emergency referral system is key to expanding coverage of high-quality intrapartum services.
Geographic information systems (GIS) and spatial analyses can play an important role in assessing estimated physical access, distance and travel time to both obstetric care and EmONC facilities.13–15 To our knowledge, only one study in sub-Saharan Africa has conducted spatial analyses on obstetric care referrals, taking into account existing transport and communication factors.16 Research related to developing and evaluating strategies for locally appropriate transport, communication and referral systems for obstetric emergencies has been identified as a high priority by the public health and medical community and policymakers.17
We describe observed inter-facility referral patterns found in Kigoma Region overall, and by facility type or EmONC level. We assess if these pairs transported patients to higher levels of care and consider the effect of travel delays due to transportation and communication barriers on the referral network. These observations will guide regional and programmatic efforts in improving the efficiency and effectiveness of the regional referral network.
Study site
Kigoma Region is a remote region in the western part of Tanzania bordering Lake Tanganyika and Burundi (figure 1). In 2012, the region had a total population of 2 127 930—of which 22% were women of reproductive age (aged 15–49 years)—and was predominantly rural (83% of the total population).18
Contextual map of Kigoma Region, Tanzania.
More than one-quarter of Kigoma Region (27%) is arable/grazing land, with the remainder either as forests or bodies of water. Paved primary roads exist between the main towns of Kigoma, Ujiji, Manyovu, Uvinza and Kasulu; remaining roads are packed dirt. Additionally, many communities along Lake Tanganyika are isolated from roads, relying on boat transportation.19
Compared with Tanzania as a whole, women in Kigoma have a higher total fertility rate (6.5 births per woman vs 5.4 per woman), lower contraceptive use (27% vs 34%) and a lower proportion of facility deliveries (60% vs 63%).20 21 The Tanzanian Ministry of Health, Community Development, Gender, Elderly and Children—or the MoH—has identified Kigoma as a high-priority region for health systems strengthening efforts to improve reproductive, maternal and newborn health outcomes.8
Most healthcare services in Tanzania are provided in public-sector health facilities: dispensaries, health centres and hospitals.22 Dispensaries provide primary outpatient care, including maternal and child health services, for their catchment areas. Health centres, usually the first level of referrals from dispensaries, provide outpatient and inpatient care, and may contain operating facilities. Hospitals, typically referral centres for dispensaries and health centres, provide outpatient and inpatient care in various wards (eg, obstetric/gynaecological, surgical). Obstetric healthcare services are provided by the government (92.5%) and by faith-based and voluntary organisations (7.5%).23 The health system is decentralised, and district health offices (DHOs) provided administrative and management support to facilities.
Data source: Health Facility Assessment
We based our analyses on the 2016 Health Facility Assessment (HFA) conducted in Kigoma Region by the Centers for Disease Control and Prevention, AMCA Interconsult, and the Tanzanian MoH.23 The HFA assessed 174 facilities providing delivery services, including all six hospitals, all 25 health centres (excluding a health centre located in a refugee camp), and 143 dispensaries (ie, 88% of all dispensaries providing routine obstetric care). The HFA collected information on each facility's geographical location, self-reported inter-facility referral networks for obstetric cases, observable transportation resources (eg, presence of functional vehicles, drivers, fuel and vehicle maintenance) and communication capacity (eg, mobile phones, radios, landline telephones) for both facilities and ambulances.
We classified facilities based on their performance of life-saving interventions (signal functions) during the 3 months prior to the HFA. We defined a facility as basic EmONC (BEmONC) if it performed all of the seven basic signal functions: (1) administration of parenteral antibiotics, (2) administration of oxytocic drugs, (3) administration of anticonvulsants, (4) manual removal of the placenta, (5) removal of retained products of conception, (6) assisted vaginal delivery and (7) neonatal resuscitation. Comprehensive EmONC (CEmONC) facilities additionally performed (8) caesarean deliveries and (9) blood transfusions. We classified remaining facilities in the health system that did not meet either standard as providing non-EmONC, or routine, obstetric care (eg, skilled labour provision, partograph use, active management of third stage of labour).
During HFA fieldwork, we measured the geographical coordinates of each facility using Garmin eTrex 20 GPS devices (accuracy ±10 m).23 We cross-referenced these coordinates with a geocoded inventory of government facilities available from the health management information system maintained by the MoH.24
Referral pair case definitions
We built facility pairs based on receiving facilities' staff reports collected in the HFA, where respondents named facilities which sent patients to their own facility. We defined an inter-facility referral pair as two facilities connected through the provision of care: a sending facility referring out patients experiencing delivery complications, and a receiving facility accepting patients providing an equivalent, or higher, standard of care. Health facilities may have more than one referral relationship, and some facilities, particularly hospitals, participate in multiple referral pairs. Additionally, 12 facilities acted as both sending and receiving facilities.
We paired facilities not mentioned as sending to any receiving facility (ie, 'orphaned facilities') with the nearest facility of equal or higher level, measured by straight-line distance between the two facilities. There were 77 orphaned facilities, which were dispensaries (97.4%) or health centres (2.6%).
Direct travel time estimation
We calculated the estimated travel time between sending and receiving facilities in each pair, called the direct travel time, using a cost-friction surface approach. We used AccessMod V.5.0, revisions 5.15 and earlier (WHO; Geneva, Switzerland), to estimate direct travel times between sending and receiving facilities, inclusive of miles and travel time from an external ambulance facility.25 26 AccessMod uses a cost-friction surface algorithm to generate a raster surface showing estimated direct travel time, based on geographical coordinates of health facilities, road network coverage, land cover raster data,27 digital elevation model raster data,28 water bodies and a travel scenario table (ie, travel speeds based on land cover classification and transportation mode), as described elsewhere.29
Road network data were obtained via OpenStreetMap, and were reclassified into primary, secondary and local roads.30 Local roads were then classified based on road width to reflect car-accessible and non-car-accessible roads; the latter included motorcycle-accessible, bicycle-accessible and walking-accessible roads.29 For our analysis, we considered all non-car-accessible roads as walking areas.
We assumed most transportation between facilities was motorised, and included Tobler's function to allow for slope-dependent walking speeds.31 To define motorised speed values for each road category, we cross-referenced the authors' direct observations in Kigoma Region with a cost-surface analysis conducted in Dar es Salaam, and the WHO's Tanzania road safety brief.32 33 In line with the WHO recommendation of all women reaching EmONC services within 2 hours, we assessed a maximum of 2-hour travel time between sending and receiving facilities. However, as the direct travel time between distant pairs sometimes exceeded 2 hours, we modelled a maximum of 6-hour travel time for these pairs.
To obtain direct travel times to each receiving facility from each sending facility, we spatially joined the sending facilities' geographical coordinates to each receiving facility's modelled travel time surface using ArcGIS V.10.4. We divided direct travel times into five categories: 0 to <30 min ('0–30'), 30 to <60 min ('30–60'), 60 to <90 min ('60–90'), 90 to <120 min ('90–120') and 120 min or more ('120+').
Total travel time estimation
To make the direct travel time estimates reflect actual travel conditions, we added standardised travel time adjustments to the direct travel times to create a set of total travel times (online supplementary appendix 1). We made a djustments based on ambulance availability and communication capacity, and used project partner feedback to influence our adjustments for the vehicle agreement and self-transport scenarios. As all referrals originated at the sending facility, we inferred adjustments using the characteristics of the sending facility. We performed a sensitivity analysis on the total travel times, by modifying the time adjustments to have low, moderate and high values. This allowed us to create uncertainty intervals, to observe the extent that transportation and communication adjustments had on the overall analysis when using the lowest possible and maximum possible parameters.
[bmjgh-2019-001568supp001.pdf]
We defined ambulance capacity at a sending facility as the presence of a functional motorised vehicle on-site explicitly designated to carry patients, with available driver and sufficient fuel. If a facility lacked any of these elements, the facility was considered to lack ambulance capacity.
Primary mode of transportation was based on a transportation allocation process that allocated transportation for a facility pair based on the highest form of primary transportation available at the sending facility (online supplementary appendix 2). While Tanzania lacks official guidelines on facility transportation and referrals, the MOH recommends that each hospital and health centre have ambulance capacity. Sending facilities without ambulance capacity could potentially use an ambulance from a nearby facility, or a vehicle from the DHO. We accounted for borrowing an off-site ambulance with an ambulance travel time from ambulance location to sending facility time adjustment. If no ambulance was available within a pair, we estimated time adjustments for identifying and mobilising privately hired motorised vehicles, whether through an agreement between facilities or in a self-transport situation.
We defined communication capacity at a sending facility as either a functioning cell phone, a functioning landline telephone or a radio transmitter available for external communications. If the sending facility had both a mobile phone and a functional landline/radio, the pair was classified as having high communication capacity. If a sending facility had either a mobile phone or a landline/radio, the pair had moderate communication capacity; if a sending facility had neither form of communication, the pair had low communication capacity.
Mobilisation times include the time needed to call for transportation, and to prepare and depart, and is estimated based on ambulance and communication capacity (online supplementary appendix 1). We used the mobilisation time adjustments described in Appendix 1 to account for potential time delays according to documented ambulance and communication capabilities within the pair. We sum the direct travel time calculated with AccessMod with the corresponding mobilisation times to estimate the total travel time for the pair (total travel time = direct travel time + mobilisation time).
We used SAS V.9.3 to add transportation and communication adjustments to the estimated direct travel times. We created maps of the referral network using ArcGIS to show both direct travel time and total travel time between sending and receiving facilities.34 We calculated summary statistics for travel time—median, min, and max values—to better represent travel time distributions.
Patients and the public involvement
This research was performed without any patient or public involvement. The analysis was based on the HFA survey, collected through the Bloomberg Philanthropies-supported 'Maternal and Reproductive Health in Tanzania Project', and publically-available geospatial data.
Health Facility Assessment
When assessing the primary means of transportation for the 174 facilities included in the HFA, 8.6% of facilities had functioning ambulances located on-site at the facility (table 1).
Facility-based quality of care, transportation and communication variables, 2016 Kigoma Health Facility Assessment
Over half of the facilities (54.6%) used an external ambulance, 2.3% used private vehicles and one-third (34.5%) required patients to self-transport. The majority of facilities reported multiple means of motorised transportation (ie, including self-transport means). Hospitals either had an ambulance on-site (66.7%) or required patients to self-transport (33.3%). Most health centres had an on-site or external ambulance (84.0%) or required patients to self-transport (16.0%). Dispensaries rarely had an on-site ambulance (0.7%) and depended on external ambulances (58.7%) or patients self-transporting (37.8%).
The majority of facilities relied on mobile phones for communication; nearly all facilities (97.1%) had mobile phones. However, less than one-eighth of facilities (12.1%) reported having a facility landline telephone/radio transmitter in working order.
Facility pair characteristics
We created 166 facility pairs, which used 169 distinct facilities of the 174 facilities included in the HFA. The number of pairs did not include dispensary/dispensary pairs, nor did referral pairs include facilities not in our HFA. Our facility pairs included 140 distinct sending facilities, 17 distinct receiving facilities and 12 distinct facilities that served as both sending and receiving facilities.
Distinct sending facilities were either hospitals (0.7% of sending facilities), health centres (1.4%) or dispensaries (97.9%) (table 2). Distinct receiving facilities were either health centres (76.5% of receiving facilities) or hospitals (23.5%). Distinct facilities with both sending and receiving functions were either hospitals (16.7% of simultaneous sending/receiving facilities) or health centres (83.3%).
Percent of facility pairs using transportation and communication characteristics, overall, by facility pair type and by EmONC pair type
Most referral pairs originated from a dispensary (83.3%). Overall, most referral pairs referred to a health centre (77.1%); few pairs referred directly to a hospital (22.9%). Few sending facilities (10.9%) referred patients to more than one receiving facility. Most receiving facilities (82.7%) received patients from four or more sending facilities. The receiving facility accepting the highest number of referrals, Kibondo Hospital, linked to 13 sending facilities.
Less than one-third of facility pairs (31.9%) referred from a BEmONC or non-EmONC facility to a CEmONC facility. Only 10.2% of facility pairs referred from a non-EmONC facility to a BEmONC facility (table 2). All other pairs were non-EmONC/non-EmONC or CEmONC/CEmONC pairs.
Transportation/communication policies in facility pairs
Transportation and communication policies differed prominently by facility pair type (table 2). Ambulances at health facilities were at all hospital/hospital pairs (100.0%) and few health centre/hospital pairs (10.0%). Around two-thirds of dispensary/health centre (60.7%) and health centre/health centre pairs (66.7%) used external ambulances. Self-transports were also reported at dispensary/health centre (36.9%) and dispensary/hospital pairs (52.2%). Private vehicles were used by dispensary/health centre (2.5%) or health centre/hospital pairs (10.0%). Communication capacity also differed across the pairs; 11.4% had high communication capacity, whereas 85.5% had moderate communication capacity (owning a mobile phone).
Transportation modes also varied by communication capacity (data not shown). Within the 19 pairs with high communication capacity, 52.6% used an external ambulance, whereas the remainder used an ambulance at the sending facility (21.1%) or required patients to self-transport (26.3%). In the 142 facility pairs with moderate communication capacity, most used an external ambulance (59.2%) or required patients to self-transport (37.3%), whereas others used an ambulance present at the facility (1.4%) or a private vehicle agreement (2.1%). The remaining 5 facility pairs with low communication capacity either used an external ambulance (40.0%), required patients to self-transport (40.0%), or used a private vehicle agreement (20.0%).
Direct travel times
The median direct travel time was 25.9 min (range: 4.4–356.6) (table 3).
Direct and total travel times, reported in minutes, overall, by health facility pair type, and by EmONC pair type (median (min-max))
More than half of facility pairs (61.5%) had direct travel times between 0–30 min. Nearly one-quarter of facility pairs (24.1%) had direct travel times between 30 and 60 min, 9.6% had direct travel times between 60 and 120 min and 4.8% of facility pairs had direct travel times above 2 hours.
Direct travel times varied by pair types (table 3). Dispensary/hospital pairs had the shortest direct travel times (19.8 min (range: 10.0–37.4)), followed by dispensary/health centre pairs (26.0 min (4.4–260.7)), health centre/hospital pairs (29.8 min (7.7–127.3)) and health centre/health centre pairs (38.4 min (12.1–69.3)). The longest direct travel time was for hospital/hospital pairs (156.4 min (7.8–356.6)). When considering EmONC status, BEmONC/CEmONC pairs had the shortest median direct travel times (15.2 min (15.1–43.5)), followed by non-EmONC/non-EmONC (24.9 min (4.4–260.7)), non-EmONC/CEmONC (26.1 min (7.7–127.3)) and non-EmONC/BEmONC pairs (30.9 min (10.8–198.7)). CEmONC/CEmONC pairs had the highest median direct travel time (156.4 min (7.9–356.6)).
Total travel times and shifts in travel time category
When communications and transportation adjustments were applied, the median travel time was 81.1 min (17.9–366.6) for low-adjusted times, 106.7 min (22.9–371.6) for moderate-adjusted times and 131.2 min (27.9–376.6) for high-adjusted times (table 3).
Most facility pairs (94.0%) shifted to a higher time category regardless of the adjustment type (online supplementary appendix 3). When comparing direct and moderate-adjusted total travel times, over one-quarter of facility pairs (27.2%) with under 2 hours of direct travel time had moderate-adjusted total travel times that exceeded 2 hours. Travel time pattern-shifting within the lower time categories were less drastic for the low-adjusted travel time scenarios compared with the moderate-adjusted and high-adjusted travel time scenarios.
Some facility pairs, by facility type or EmONC, had large travel time shifts between direct travel times and moderate-adjusted total travel times (data not shown). Nearly one-third of dispensary/health centre (31.4%) and health centre/health centre pairs (33.3%) with a direct travel time under 2 hours shifted to a moderate-adjusted travel time over 2 hours. No significant travel time shifts occurred for dispensary/hospital, health centre/hospital, and hospital/hospital pairs. When considering EmONC status, 27.3% of non-EmONC/non-EmONC pairs, 43.8% of non-EmONC/BEmONC pairs and 24.0% of non-EmONC/CEmONC pairs with a direct travel time under 2 hours shifted to a total travel time over 2 hours (data not shown). No extensive travel time category shifts occurred for BEmONC/CEmONC or CEmONC/CEmONC pairs.
Geographical analyses
The referral network was concentrated in the main towns of the region—Kigoma, Kasulu, Kibondo and Kakonko—with higher-level facilities acting as both sending and receiving facilities (figures 1–2).
Visualisation of estimated travel times for all facility pairs.
Several referrals were sent to Kigoma Town from distant northern locations such as Kakonko District (1.2% of referral pairs) or Kibondo District (0.6%). However, some facilities located within the southernmost district of Uvinza—specifically Uvinza Health Centre in the centre, Nguruka Health Centre in the east, and Buhingu Health Centre in the south—reported not sending patients to any other facility. Facility pairs did not extend out from these facilities; these facilities were disconnected from the referral network.
We displayed direct and moderate-adjusted total travel times for the overall referral network and for referral pairs which refer to higher levels of care (figure 2). Facility pairs experiencing the shortest direct transportation times, shown in green, were located in Kasulu, Kibondo and Kigoma Town administrative councils. These were the more urbanised areas of the region, and facility pairs primarily referred patients to the hospitals in these regions (eg, Kibondo District Hospital, Maweni Hospital and Baptist Hospital). Most pairs sending patients within the same district had shorter direct travel times compared with pairs sending patients outside of the originating district, with a median direct travel time of 22.5 versus 37.4 min respectively.
Most facility pairs referring to higher EmONC levels were in western Kigoma region, stretching from Uvinza in the south to Kibondo in the north. Facility pairs referring up to a BEmONC facility were concentrated in the south, central and west of the region. Examples include Gungu Health Centre, in Kigoma Town near Lake Tanganyika, Uvinza Health Centre, in Uvinza District in the central south area of the region, and Rusesa Health Centre, in Kasulu Rural (figure 2). In contrast, facility pairs referring up to a CEmONC facility occurred along the main highway running parallel to the Burundian border, primarily in the central-south area of the region (Kigoma Town, Kigoma Rural, Buhigwe, Kasulu Town and Kasulu Rural districts). Such referrals also happened in the north (Kibondo) and the southeast (Uvinza) of the region. Most of these facility pairs stretched between districts encompassing this main road, although some were located exclusively in Kibondo District in the north, Kasulu Rural in the centre of the region, Uvinza District in the south and Kigoma Town next to Lake Tanganyika.
Transportation and communication limitations are critical in understanding geographical access to EmONC and interventions that can improve access. Our findings highlighted characteristics associated with increased travel time between first-level and higher-level obstetric facilities, and demonstrated that transportation and communication policies between health facilities strongly differed by facility type and EmONC type. When accounting for referrals between all health facility types, Kigoma's health system has a high proportion of lateral referrals between facilities with the same standard of care, which potentially delays receipt of higher levels of obstetric care. Within Kigoma Region, a lack of sufficient or external ambulances strongly influenced the transportation mode used in the referral system. Our HFA analysis showed that only 12 of 174 facilities had ambulances on-site; 2 additional ambulances were available at 2 district councils. Our findings also showed that a facility's inability to use external ambulances affected dispensaries, the most common facility type to refer patients to higher-level facilities (87% of all facility pairs). A high percentage of referral pairs coming from dispensaries and health centres required patients to self-transport to a receiving facility, potentially increasing the travel time needed to reach adequate care, due to the extra time needed to identify and organise transportation.
A lack of communication methods between facilities was present in Kigoma Region, which could increase overall referral times; more than 97% of facilities had a mobile phone available, but only 12% of facilities had a working landline or radio transmitter. Even fewer facilities had an available ambulance-specific phone or radio. While our 2016 HFA could not adequately capture network coverage, field experience has shown that many facilities may be outside of adequate mobile network coverage, and mobile phones or landlines may not be specifically designated for referral purposes. Radios are more apt at breaching these barriers, particularly in areas that may lack mobile network coverage.35 Efforts to expand communications are being made within pilot referral projects as part of the broader project. For example, Thamini Uhai's Kakonko/Kibondo hospital referral project guidelines included an emphasis on prioritisation of cell phones for emergency referrals using a toll-free closed user group connexion.36 Alternatively, sites can consider using short-wave two-way radios for referrals, with specific radio channels dedicated to referrals in areas with unreliable mobile network coverage.37 We suggest using standard operating procedures (SOPs) detailing usage of communication devices between facilities.
In Kigoma Region's referral system, less than half of all facility pairs referred to higher levels of EmONC; only 10.2% of all facility pairs referred to EmONC facilities from non-EmONC facilities, and 34.9% referred to CEmONC facilities from non-CEmONC facilities. The WHO recommends that all women with serious direct obstetric complications should receive treatment in EmONC facilities.38 In Kigoma region, only 42% of deliveries occurred in facilities providing EmONC services in 2015, yet EmONC facilities provided care for 83% of all direct obstetric complications.39 The process of referring to lateral facilities unnecessarily lengthens the time needed to reach the appropriate level of care, and may require multiple referrals for the same case. We hypothesise that lateral referrals may occur because providers at sending facilities believe receiving facilities have a certain standard of care based on previous experiences or official designation. As we assessed the EmONC status based on the provision of signal functions within the last 3 months,38 the facilities we classified as EmONC may not consistently act as EmONC facilities. Facilities may lack infrastructure, equipment, supplies or staffing when services are actually needed. Lateral referrals may occur because of geographical proximity or convenience, without consideration for the level of care provided at the receiving facility.40 An updatable list of facilities' current EmONC statuses, assessed quarterly, can be shared across the region, so providers can assess the most appropriate facilities for referral.
Our analysis demonstrated that total travel times were often longer than 2 hours, often considered the limit for acceptable travel time for patients experiencing severe obstetric complications, particularly obstetric haemorrhage.38 Across all facility pairs, the median total travel times neared 1.5 hours (81 min). Concernedly, the median total travel times for all pairs originating from a non-EmONC facility, regardless of where they were sending patients, was between 80 and 143 min (approximately 1.3–2.4 hours).
We observed two additional referral system characteristics that limit the system's functionality, including lack of standardised national guidelines or SOPs available for referrals and poor coordination of ambulances for referrals. Although national health strategies—National Road Map Strategic Plan to Improve Reproductive, Maternal, Neonatal, Child and Adolescent Health in Tanzania (2016–2020), the Health Sector Strategic Plan July 2015–June 2020 (HSSP IV) and the Big Results Now project—prioritise referral improvements, they do not delineate specific actions to be taken and how to monitor referral strengthening efforts.7 8 41 In this context, the Bloomberg Philanthropies-supported project created detailed referral guidelines and SOPs to improve referrals between selected health facilities and their catchment areas.36
Regarding ambulance availability, an increase in the number of health facilities with on-site ambulances may be costly to maintain 24/7. A more cost-effective solution is to link transportation systems via a dispatch system to coordinate use of available vehicles. Kigoma District relies on a district-coordinated dispatch system with little regional oversight. While Kigoma Region has a dispatch centre, only one health facility explicitly reported relying on the dispatch centre when referring patients. A dispatch centre has been shown to improve access to EmONC services, decreasing travel time for facility-to-facility referrals.42 As decentralised service provision can be effective only if health facilities have the ability to communicate between facilities and receive transportation 24/7, sites may benefit from a regionally coordinated system with the ability to link district dispatch systems and increased awareness of transportation availability for facilities providing obstetric care. A dispatch system's utility also depends on the density of patient demand.
Our analysis is unique as it measures travel time using geographical cost-friction modelling, communication and transportation availability, and documented facility-to-facility referral pattern. First, we identified opportunities for transportation and communication improvements in the referral system via direct observations collected in the survey. Second, we combined transportation and communication information with estimated cost-friction surfaces from AccessMod, V.5.25 43 44 While other authors used similar data sources and approaches to estimate travel times, they assumed a set adjustment across the entire referral network, rather than using field observations to determine transportation and communication types.16 Our methodology is designed to be accessible to those without extensive GIS knowledge, by simplifying the complicated process of creating cost-friction rasters used for travel time estimation with a graphical user interface. Our travel time measurement is grounded in an external estimation of travel and mobilisation times rather than using patient self-reports, making the direct travel more precise.45
It is important to reflect on the limitations of the study. Even when travel time is adequately measured using cost-friction surfaces, it is not an accurate reflection of the actual time spent within the referral process. Our transportation and communication adjustments are based on providers' self-reports, and may vary between facilities. We used these reports to estimate communication and mobilisation delays, as direct measurements are not available for all pairs, particularly when patients must arrange self-transport. We did not assess other delays related to receipt of appropriate care of transferred patients, nor did we delineate the exact reasons for referral. Theoretically, the modelling itself is also affected by data quality, such as incomplete road networks or inaccurate coordinates.
While our analysis accounted for ambulance travel or patients arranging transportation themselves, we assumed only one transportation mode per facility pair. With poor availability and the potentially high cost of transport by automobile, referred patients may turn to other forms of transportation, such as bicycles or motorcycles.46–50 We may have underestimated travel time for self-transport using slower motorised, or non-motorised transport, and overestimated travel time for self-transport with automobiles. We assumed that ambulances were available if the facility reported in the HFA that they had a functional on-site ambulance, but recognise that additional delays may be encountered if a facility's ambulance is in use for another emergency.
Travel times in this analysis were modelled on the land cover type, road network and travel speeds specified in dry season, and did not account for delays in the rainy season.16 44 51 This analysis could not account for degraded road conditions during the rainy season, though evidence suggests seeking transport for referral decreases as weather worsens, due to longer travel times and poorer road conditions.52
Adequate access to EmONC is essential to improve maternal and perinatal health, and our comprehensive analysis of travel time to EmONC takes into account availability, distances and patterns of inter-facility referrals.38 Additional research is needed to better understand how to optimise transport and referral pathways, including identifying barriers to direct referral to BEmONC and CEmONC facilities, rather than referring laterally. Understanding patients' and providers' current usage of the inter-facility referral systems in obstetric emergencies could improve resource allocation and optimise travel times. Future HFAs planned in the region can benefit from inclusion of factors influencing facility-to-facility referrals.
Emergencies during pregnancy, labour, delivery and postpartum often develop without warning, and not all facilities are able to provide appropriate and timely EmONC services. A functional referral system connects non-EmONC and EmONC care, and optimises the use of limited resources for women who access services.53 Systematic inter-facility referral protocols and SOPs—with an updatable and current list of facilities' EmONC capacity—could improve referral practices. A functional referral system, emphasising the awareness and use of a dispatch system, can optimise use of limited ambulances without increasing costs. Improvements in timely communication, mobilisation, inter-facility agreements, and readiness to transport and receive obstetric emergencies are needed to improve maternal and neonatal survival in Kigoma Region. Our findings suggest that while referrals between similar levels of facilities are common, this practice of lateral referring may contribute to increased delays when life-saving services are unavailable at the initial receiving site, necessitating additional referrals. Referrals may be improved through implementation of national guidelines and SOPs, coupled with consideration for current EmONC capacity of referral facilities.
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Contributors MMS, FS and YNC conceived and designed the study. MMS, GEA and YNC conducted the analysis and interpreted the data. MMS, FS and YNC coordinated the data collection and wrote the first draft of the manuscript. PC, AA, and MD were involved in revising the manuscript based on fieldwork-based experience. MMS, FS and YNC agreed to be accountable for all aspects of the work ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors read and approved the final manuscript submitted for publication.
Funding This study was funded by Bloomberg Philanthropies and the Fondation H&B Agerup.
Ethics approval This study was reviewed and approved by the CDC's Center for Global Health Human Subject Review Board and was determined not to comprise human subjects research.
Data availability statement Data may be obtained from a third party and are not publicly available.
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