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Benefits and Limitations of a Community-Engaged Emergency Referral System in a Remote, Impoverished Setting of Northern Ghana
Sneha Patel, John Koku Awoonor-Williams, Rofina Asuru, Christopher B Boyer, Janet Awopole Yepakeh Tiah, Mallory C Sheff, Margaret L Schmitt, Robert Alirigia, Elizabeth F Jackson and James F Phillips
Global Health: Science and Practice December 2016, 4(4):552-567; https://doi.org/10.9745/GHSP-D-16-00253
Sneha Patel
a New York City Department of Health and Mental Hygiene, New York, NY, USA.
John Koku Awoonor-Williams
b University of Basel, Swiss Tropical and Public Health Institute, and Ghana Health Service, Accra, Ghana.
Rofina Asuru
Christopher B Boyer
c Innovations for Poverty Action, New York, NY, USA.
Janet Awopole Yepakeh Tiah
d University Research Corporation, Accra, Ghana.
Mallory C Sheff
e Columbia University Mailman School of Public Health, New York, NY, USA.
Margaret L Schmitt
Robert Alirigia
f Jhpiego Ghana, Accra, Ghana.
Elizabeth F Jackson
James F Phillips
For correspondence: James.Phillips@columbia.edu
A low-cost emergency and communication transportation system used 3-wheeled motorcycles driven by trained community volunteers. Delivery referrals were redirected from health centers to hospitals capable of advanced services including cesarean deliveries, which was associated with reduced facility-based maternal mortality.
Although Ghana has a well-organized primary health care system, it lacks policies and guidelines for developing or providing emergency referral services. In 2012, an emergency referral pilot—the Sustainable Emergency Referral Care (SERC) initiative—was launched by the Ghana Health Service in collaboration with community stakeholders and health workers in one subdistrict of the Upper East Region where approximately 20,000 people reside. The pilot program was scaled up in 2013 to a 3-district (12-subdistrict) plausibility trial that served a population of approximately 184,000 over 2 years from 2013 to 2015. The SERC initiative was fielded as a component of a 6-year health systems strengthening and capacity-building project known as the Ghana Essential Health Intervention Program. Implementation research using mixed methods, including quantitative analysis of key process and health indicators over time in the 12 intervention subdistricts compared with comparison districts, a survey of health workers, and qualitative systems appraisal with community members, provided data on effectiveness of the system as well as operational challenges and potential solutions. Monitoring data show that community exposure to SERC was associated with an increased volume of emergency referrals, diminished reliance on primary care facilities not staffed or equipped to provide surgical care, and increased caseloads at facilities capable of providing appropriate acute care (i.e., district hospitals). Community members strongly endorsed the program and expressed appreciation for the service. Low rates of adherence to some care protocols were noted: referring facilities often failed to alert receiving facilities of incoming patients, not all patients transported were accompanied by a health worker, and receiving facilities commonly failed to provide patient outcome feedback to the referring facility. Yet in areas where SERC worked to bypass substandard points of care, overall facility-based maternal mortality as well as accident-related deaths decreased relative to levels observed in facilities located in comparison areas.
African nations achieved considerable progress in child health during the Millennium Development Goal era. Despite this progress, maternal and perinatal mortality remain among the leading causes of death throughout Africa. According to the World Health Organization, approximately 800 women die from pregnancy or childbirth-related complications every day.1 Nearly 99% of these deaths occur in developing countries and over half occur in sub-Saharan Africa, where only 7% of the global population resides. Most maternal deaths could be prevented if women received timely care when emergencies arise from associated causes, such as hemorrhaging, unsafe abortions, obstructed labor, infection, or eclampsia.2
Most maternal deaths could be prevented if women received timely care during medical emergencies.
Nearly all maternal deaths are accompanied by associated neonatal deaths. Although most neonatal deaths are preventable if skilled attendants assist during deliveries,3,4 rates remain high even where child health and survival are otherwise improving. Yet evidence repeatedly shows that facility delivery and appropriate support for newborn care can reduce neonatal mortality if referral services are functioning and attendants are skilled in recognizing problems and immediately providing post-delivery interventions such as "Kangaroo Mother care," asphyxia management, care for febrile illness, and tetanus prevention.5–8
Public health systems in Africa are therefore making the development of emergency care systems a priority.6,7 The World Health Organization defines 3 core components of emergency care: care provided in the community, during transportation, and at the health facility.8,9 Each component incurs corresponding sources of risk that elevate death and disability: delays in (1) seeking care,10 (2) reaching care,11,12 and (3) receiving care upon arrival at the referral facility.13 In rural Ghana, and elsewhere in Africa, these delays are driven, respectively, by (1) lack of awareness of the importance of emergency care,14 lack of family resources to cover referral costs,15,16 and concerns about the quality of care17; (2) poor road conditions,18 a scarcity of vehicles,19,20 and limited means of communication21; and (3) inaccessibility of competent providers of essential acute care.20–22
Public health systems in Africa are making development of emergency care systems a priority.
While Ghana has a well-organized, decentralized primary health care system, the country has yet to develop clear emergency referral service guidelines. The Upper East Region is one of Ghana's most impoverished and remote localities: The 13 districts of the region are characterized by a scarcity of vehicles, poor road networks, impassible terrain, and geographic barriers to reaching health services.23,24 Patients in urgent need of acute care reach health facilities by walking or riding bicycles, donkey carts, or motorbikes. In all districts of the Upper East Region, ambulances are typically absent, in disrepair, or located so remotely from communities that they fail to address emergency needs. Even where equipment is available, there is no organized emergency communication system to link one level of care to another and ensure that referrals are successfully executed. Cultural norms can also constrain timely care seeking behavior. Moreover, since Ghana's National Health Insurance Scheme does not cover costs associated with emergency transportation, referral can be prohibitively expensive, with costs further increasing people's hesitation to seek acute care.
In Ghana's Upper East Region, ambulances are absent, in disrepair, or located so remotely that they fail to address emergency needs.
The Ghana Essential Health Intervention Programme (GEHIP) is a systems-strengthening initiative that was designed to increase universal access to health care.25 GEHIP's aims are to expand coverage of the national primary health care system with the Community-Based Health Planning and Services (CHPS) initiative at the community level,26 and to identify gaps in care for newborns, children, and pregnant women at multiple levels of the health system. In addition to addressing issues that had hindered CHPS scale-up, GEHIP has trained midwives in neonatal resuscitation, provided frontline CHPS community nurses with skills in emergency delivery, and trained CHPS community nurses and community volunteers in community-based newborn care.25
GEHIP also documented the urgent need for emergency referral services, including emergency obstetric care, in the Upper East Region. In response, the Ghana Health Service (GHS) pilot tested an emergency referral program, the Sustainable Emergency Referral Care (SERC) initiative, for all types of medical emergencies. This article provides a summary of the initiative components and evaluates the effectiveness of the program using results from mixed-methods implementation research.
THE SERC INITIATIVE
The SERC initiative aimed to develop a community- and subdistrict-level emergency referral system that would improve survival in impoverished rural Ghanaian communities. To address common access, organizational, and knowledge barriers to emergency care services, SERC was designed as a low-cost emergency transportation and communication system together with community education activities. The program aimed to facilitate rapid transport of patients from their community locations or subdistrict health center to higher levels of care.
SERC was designed to address barriers to emergency care services through a low-cost system of transportation, communication, and education.
GEHIP used the tools and methods of participatory planning27–29 to design and implement SERC in collaboration with community members as well as community, subdistrict, district, and regional health system officials. GEHIP research staff held meetings, focus group discussions, and in-depth interviews with community members, frontline workers, and supervisors throughout the planning process to solicit stakeholder advice. Project research assistants were recent graduates of local universities who were hired by GEHIP and assigned to each District Health Management Team to support SERC implementation activities and liaise across levels of the health system.
Three-wheeled motorcycles, known as Motorkings, served as emergency transport vehicles in the pilot districts of northern Ghana. Structural modifications were made to enhance patient safety and comfort, including extended reviewmirrors and a tarpaulin to provide privacy and protection.
SERC was conducted initially as a 5-month pilot program with community stakeholders and health workers in a subdistrict of Bongo District in 2012. In July 2013, the program added 12 subdistricts of the Upper East's Bongo, Builsa North, and Builsa South districts for a trial that served a population of approximately 184,000. Remaining districts of the Upper East Region, where social, economic, and ecological conditions are comparable to the SERC coverage areas, served as comparison areas for evaluating the program. The SERC interventions included a referral strategy informed by an assessment of population needs and health systems capabilities; adequately resourced referral centers; active collaboration between referral levels and across sectors; formalized communication and transportation arrangements, with specific protocols specified for referrer and receiver and mechanisms for ensuring supervision and accountability; affordable service costs; capacity to monitor effectiveness; and policy support.
SERC was developed as a component of the health systems development program GEHIP, and SERC scale-up was led by GEHIP staff based at the Upper East Regional Health Directorate (RHD).
For the expanded pilot study that began in 2013, GHS procured a fleet of 3-wheeled motorcycles known as Motorkings to serve as emergency transport vehicles. The 24 SERC Motorkings were distributed among 12 subdistricts of Bongo, Builsa North, and Builsa South districts in the Upper East Region. Based on driver advice from SERC's pilot phase, structural modifications were made to the Motorkings to enhance patient safety and comfort. These adjustments involved installing a welded frame and tarpaulin to provide privacy and protection for patients during transport, extended rearview mirrors for maximum visibility, a mattress and safety belt for patients, a seat for an accompanying health worker, and a hook for intravenous drips. To identify the Motorking vehicles as ambulances, each was marked with the GHS logo and a red cross. Each vehicle was equipped with a first aid kit, a spare tire and jack, and protective rain gear for drivers. Recognizing the importance of vehicle maintenance, vehicles were routinely serviced by staff mechanics from the Upper East RHD. Spare parts were procured and kept in stock at the RHD to ensure timely repair in the event of breakdowns.
GHS purchased and modified 24 three-wheeled Motorking motorcycles for use as ambulances.
Geographic information systems (GIS) data were used to estimate the optimal placement of ambulance stations and configuration of catchment areas to ensure community access to an ambulance.28 The SERC ambulances were deployed to 9 subdistrict health centers, 12 community health posts, and 3 communities that lacked facilities or community resident nurses. In Ghana, community health posts function as the first point of care, but only half of the planned locations for these facilities are functional. In the 3 locations that lacked health facilities, community leaders were engaged to determine an appropriate location for the community-based ambulance station. In each of these 3 villages, the community chose an assemblyman's or subchief's home as the station due to its centrality, relative security, and social acceptability for this responsibility. The number of Motorkings was based on an appraisal of the equipment required to effectively cover all communities of the 12 subdistricts. The size of the study area, in turn, was determined by the volume of referrals that would be required to provide statistical power for evaluation.
The community selected 48 volunteers (2 per ambulance), who were trained to serve as drivers. Drivers varied in age, but were typically literate young adult men. A collaboration of the RHD's Transport Unit, the Motorking vendor, the Driver and Vehicle Licensing Authority, and the Ghana Red Cross provided training to all drivers in basic first aid, infection prevention, defensive driving, basic maintenance, transport policies, communications protocols, and recordkeeping.
Before SERC, no integrated emergency communication system had been established to link patients to emergency care services at the community and subdistrict levels. Therefore, the RHD procured communication equipment: dual-SIM mobile phones were distributed to health facilities, health workers, and volunteer drivers. Emergency phones were assigned to nurses called community health officers who were based at community facilities, in subdistrict health centers, or in district hospitals' outpatient departments. In communities that lacked a resident nurse, a volunteer was provided an emergency phone and cell phone time for calls to emergency numbers. This collaboration with a cell phone vendor ensured that every community had access to a mobile phone for eliciting rapid referral. At the tertiary referral point, the regional hospital designated a phone line in each ward for receiving incoming calls about impending cases.
The regional hospital dedicated phone lines to receiving calls about incoming emergencies.
Ghanaian cultural groups have well-defined systems of social organization and community consensus building that rely upon durbars, which are open forums for discussing matters of collective importance to the community. In concert with these traditions, the SERC program convened durbars in all ambulance catchment areas to explain the intended use of the ambulance, introduce the local SERC health workers and volunteers and review their roles, and discuss the importance of seeking care during emergencies. An emergency phone number was provided to each community and placed on posters at the nearby health facilities and community gathering points. Participating health workers also liaised closely with traditional chiefs and elders, whose support was essential.
GEHIP equipped SERC staff and volunteers with emergency phones and trained them in mobile phone use, criteria for ambulance use, protocols, and recordkeeping. GEHIP staff held quarterly refresher training sessions to ensure that knowledge and skills were retained, and trained district- and subdistrict-level supervisors to oversee SERC activities and provide routine monitoring and supervision. Monthly review meetings were held across worker tiers to discuss challenges that arose and system improvements needed.
Protocols specified various emergency scenarios in the community and facility setting. Key guidelines included verification of emergency by a health worker and alerts to facilities to prepare for incoming patients and minimize delays. Frontline workers at community health posts were trained in basic triage procedures. All patients being transported were to be accompanied by a health worker. Facilities that received an emergency case were required to provide feedback to the referring facility upon discharge to facilitate follow-up scheduling. The program design included routine monitoring of resources and supplies to assess availability of human resources, equipment, medication, and forms.
GHS supported the operating costs of the SERC emergency referral system. Pregnant women and children under 5 years of age were provided free emergency transport. To encourage facility-based delivery, normal labor cases were transported free of charge. Other ambulance users were charged a nominal cost recovery fee (US$2.50–$5.00) that was determined by each District Health Management Team. In one district, the district assembly covered maternal and child referral fuel costs.
Pregnant women and children under 5 years of age were provided free emergency transport.
Health worker feedback was solicited on SERC to continually inform strategies for educating communities about emergencies. Qualitative appraisal methods were used to determine what community members needed to learn regarding emergencies and to identify strategies for developing a culturally appropriate community education program. The aim was to increase capacity in the community to recognize signs and symptoms of emergencies, encourage prompt decision making to seek care, and increase use of SERC. Opinion leaders and community members contributed to the development of educational materials, which were translated into local languages. These materials included educational flip charts (for use by health workers) and informative songs played on local radio stations and on speaker systems in outpatient hospital wards. Dramas depicting emergency scenarios were developed, filmed, and shown at evening durbars, and posters displayed in health facilities and meeting points depicted actions to be taken in emergency situations.14 Discussions of the possible harm to SERC that could arise if equipment was misused were integrated into community education sessions.
An iterative systems development approach was employed to continuously refine the SERC initiative in response to community reactions and administrative realities. GEHIP staff and consultants conducted implementation research to identify operational challenges and potential solutions. Methods included a quantitative analysis of key process and health indicators over time, a survey of health workers, and continuous qualitative systems appraisal with frontline workers and community members.
Time Series Analysis of Key Indicators
Volunteers, health workers, and district supervisors completed monthly SERC monitoring records and submitted them to GEHIP staff at the RHD, who created visualizations of results to help supervisors assess both referral volume by location and the types of cases associated with referral operations. Monitoring included station-specific information on distances traveled, transit times, adherence to protocols, types of emergency, and patient outcomes. The monitoring used technology designed to integrate SERC monitoring into the routine GHS data system operations known as the District Health Information Management System (DHIMS). Educational aids and training sessions were developed to help regional and district-level managers use the DHIMS database for practical decision making.
Monitoring information included distances traveled, travel times, types of emergency, and patient outcomes.
DHIMS data are aggregated at the facility level and provide indicators of the monthly care caseload by indicator and by type of facility (e.g., CHPS, subdistrict health center, or hospital). Monthly DHIMS data are routinely available for all primary health care service points in Ghana, including the community health posts and community nurses involved in SERC, and we used these aggregated data to support the program evaluation. For the purpose of this analysis, the 12 SERC-exposed "treatment" subdistricts provided a basis for assessing the effect of the program. District facilities in the Upper West Region and the remaining subdistricts of the Upper East Region served as comparison areas. The dependent variable was monthly case volume of each relevant indicator; exposure versus nonexposure to SERC in the facility catchment area was the key independent variable.
For the SERC evaluation, we compared DHIMS time series data from SERC facilities with data from facilities located in unexposed districts of the Upper East and Upper West regions. The comparison applied generalized linear mixed models with an exchangeable covariance structure to account for repeated observations.30 This basis for inference ensures simultaneous adjustment for autoregressive error in time series models31 and hierarchical adjustment formultilevel clustering.32 For each dependent variable of interest, a model of monthly time series data takes the form:
yij is a DHIMS-reported value of outcome y from facility j at time i,
xij is a dummy variable defining whether facility j is in the SERC area or in a control area,
tij is a dummy variable defining whether time i is before or after the start of the SERC intervention,
uj is a random intercept for facility j, and
εij is a random error term for facility j at time i.
The parameters β0, β1, β2, and β3 are estimated by maximum likelihood, with β3 estimating the difference-in-difference association of SERC exposure with the number of events of interest recorded by 14 hospital facilities over 70 months of observation. This approach to evaluation represents a regression extension of the Heckman procedure for estimating the impact of interventions in nonexperimental designs.33,34
The sign of the
3 coefficient in the equation indicates the direction of the net change in expected monthly case volume between treatment and control: A positive sign implies a positive SERC effect on case volume (i.e., an increase in the treatment facility volume relative to the control), and a negative sign implies a negative SERC effect on case volume (i.e., a decrease in the treatment facility volume relative to the control). For example, a value of +6 for β3 in the equation for an analysis of facility-based delivery would indicate that the expected mean number of monthly deliveries in the treatment facilities increased by 6 deliveries relative to the mean volume of deliveries in the comparison area between the pre- and post-intervention periods. Statistical tests for this coefficient assess whether this relative change is significant. We employed a similar difference-in-difference approach to evaluate the effect of SERC on maternal mortality; however, we substituted a generalized linear Poisson model to properly estimate the maternal mortality ratio. Repeated observations within a facility were adjusted by assuming an exchangeable correlation structure.35,36 Table 1 reports robust standard errors obtained via the sandwich operator.37 Although the time series models in this analysis have employed conventional adjustments and statistical safeguards, all such models incur an element of instability. Results therefore merit further investigation and validation.38
Difference-in-Differences Estimates of the Impact of the SERC Initiative on Hospital-Based Health Measures, Upper East and Upper West Regions, Ghana 2009–2015
Survey of Health Workers
A survey was administered to health workers by trained professional interviewers in December 2013 to assess their perspectives on SERC components and challenges. The questionnaire was pretested and then revised based on feedback provided. The sampling frame comprised all staff based at subdistrict- and community-level health facilities that were involved in the SERC program, including staff affiliated with ambulance stations, responsible for referral operations at ambulance stations, or charged with receiving SERC referrals. This yielded a list of 124 health workers and a response rate of 89% (N = 110), as 14 potential respondents were on annual leave during the week the survey was administered. During that 1-week period, the 110 respondents completed the survey instruments as self-administered questionnaires. Respondents were encouraged to provide candid feedback, and were provided with de-identified forms and blank envelopes to preserve anonymity. These procedures assured respondents of confidentiality so that they could answer questions without risk that critical comments would incur supervisory concern or reprisal.
Qualitative Systems Appraisal
Trained professional facilitators conducted a qualitative systems appraisal in March 2014 to assess community stakeholder, patient, and volunteer experiences with SERC, employing qualitative research procedures that have been applied to CHPS assessment in the past.28,29 An analysis of focus group discussions (FGDs) and in-depth interviews (IDIs) with community stakeholders assessed the acceptability of the intervention at the community level. IDIs were also used to examine patient experiences with SERC, satisfaction with care, and suggestions for improvement. A total of 16 FGDs were conducted with men, women, drivers, and volunteers from the subdistricts implementing the SERC program. Twenty-three IDIs were conducted with chiefs, emergency referral users, and volunteers equipped with emergency phones. To enhance representativeness, each focus group category (i.e., women, men, community health volunteers) was sampled in a different community, and each FGD was held within the community to promote discussion. Respondents provided written consent; all IDIs and FGDs were conducted in local languages Buili and Guruni; and all interviews were tape-recorded, transcribed, and analyzed using the NVivo 9 software package.39
Findings From the Time Series Analysis of Key Indicators
From July 2013 through June 2015, 1,290 patients used SERC transport services. The average trip time and distance traveled were 56.6 minutes and 9.92 kilometers, respectively. Most referrals were to higher levels of care at subdistrict health centers and district hospitals, with a high concentration of care occurring at 2 facilities that are well staffed and equipped to manage emergencies (Figure 1). The next most common reasons for referral included malaria, anemia, diarrhea, acute respiratory illnesses, and injury. Most patients (98%) were treated and discharged successfully, while 2% of all emergency referrals resulted in death.
Transportation Routes of Patients Using SERC Services, July 2013–June 2015
Abbreviation: SERC, Sustainable Emergency Referral Care.
The referral profile changed over time as SERC progressed (Figure 2). However, regardless of time period, obstetric cases were the predominant type of referral. Consequently, nearly three quarters of patients were women. Although inappropriate use of the referral system could not be monitored directly, care for minor situations that were not emergencies tended to be labeled as "other" types of referrals. As Figure 2 shows, the proportion of such referrals declined with time, suggesting that the high initial frequency of inappropriate SERC referrals may have diminished as operations progressed.
Trends in Aggregated Reasons for Referral Reported by 359 Facilities Unexposed and Exposed to the SERC System, July 2013–June 2015
Table 1 presents the association of SERC exposure with facility output indicators. At baseline, before the introduction of SERC services, there were approximately 53 fewer deliveries per month in hospitals in the SERC intervention area. These facilities also received fewer referrals and reported fewer upper respiratory tract infections at baseline than the facilities serving the comparison area. Cesarean delivery rates were no different between facilities in the SERC and comparison areas at baseline. SERC had no statistically significant effect on the number of deliveries; the cesarean delivery rate; the number of referrals "out" from sub-district clinics to district hospitals or the number of pneumonia cases, other respiratory tract infections, septicemia cases, or diarrheal disease cases. However, SERC did increase the number of referrals into district hospitals from CHPS workers and clinics by more than 12 patients per month and the number of accidents treated by almost 21 per month.
There was a shift in the location of delivery care within districts where SERC was introduced. In the SERC area, more deliveries occurred at facilities capable of acute care (i.e., district hospitals), displacing delivery care at health centers and clinics where surgical procedures are not performed (Figure 3). Hospitals staffed and equipped to provide acute care also received more referrals where SERC was operative than elsewhere (Table 1, column 3). This relocation of care was associated with a reduction in facility-based maternal mortality (incidence rate difference, −352; 95% confidence interval, −639 to −65; P<.05) (Table 2), although there was no significant effect on the cesarean delivery rate (Table 1, column 2). There were several specific indicators of volume of acute care episodes, and only the volume of care for accidents and for maternal emergencies appear to have been affected (Table 1, columns 3 and 8, respectively). The impact of SERC on acute care for accident victims is important, not only for the evidence shown in Table 1 but also because evidence now suggests that modest economic gains in the region have led to dramatic increases in the purchase of motorbikes, with accident-related morbidity and mortality rapidly expanding as a consequence.18 Time series regression results can be unstable owing to autoregressive error.38 Nevertheless, the relationships demonstrated in Table 1 suggest that SERC has had effects on mortality.
Trends in the Location of Facility Deliveries, SERC Intervention Areas vs. Comparison Areas, 2009–2015
Abbreviations: CHPS, community-based health planning and services; SERC, Sustainable Emergency Referral Care.
Differences between the baseline and intervention period were statistically significant at P<.001 for health centers and district hospitals.
Difference-in-Differences Estimates of the Impact of the SERC Initiative on Hospital-Based Maternal Mortality, Upper East and Upper West Regions, Ghana, 2009–2015
Hospitals staffed and equipped to provide acute care received more referrals where SERC was operative than elsewhere.
The information monitored included process indicators such as staff compliance with protocols. Contrary to guidelines, less than half (49%) of the patients transported were accompanied by referring health workers, and receiving facilities were alerted to incoming patients in only 46% of the monitored referral episodes.
Findings From the Health Worker Survey
Of the 110 survey respondents, over half were community health officers (56%); the remainder were clinic-based nurses (25%), midwives (13%), or physician assistants (6%). Places of work included community health posts (69%), subdistrict health centers (27%), and hospitals (4%). Nearly three-quarters (74%) of the respondents had personally referred patients using SERC's transport service since the program launched.
Perceived Effectiveness and Safety of Motorking Ambulances
The majority of health workers (66%) considered SERC to be "very effective" in improving the community- and subdistrict-level emergency referral system, and 33% considered Motorkings to be "somewhat effective." Most health workers perceived the Motorking to be safe, with 26% categorizing the vehicle as "very safe" and 61% considering it to be "somewhat safe."
Two-thirds of health workers considered SERC to be "very effective" in improving the emergency referral system.
Driver Dedication and Availability
Respondents generally perceived drivers to be dedicated to their roles (56% reported finding them "very dedicated"; 41% found them "somewhat dedicated," and only 3% found them "not at all dedicated"). However, there were instances when health workers were unable to promptly contact the volunteer drivers. When asked whether health workers at ambulance stations should be trained to drive Motorkings in such instances, the majority of respondents (75%) said yes.
Protocol Adherence
Protocol noncompliance was evident for some aspects of care. For instance, referring facilities often failed to call in advance to alert receiving facilities of an incoming patient. Moreover, many patients transferred were unaccompanied by a health worker despite the protocol requiring it. Although surveyed health workers nearly universally affirmed the importance of these procedures, 67% of the referred patients who were interviewed reported that they had been transferred without accompaniment. When workers were asked why they were unable to accompany the patient, the most commonly cited reasons (respondents could choose more than one) were that another health worker accompanied the patient (37%); the respondent was the only staff member at the facility and could not leave the post (35%); or the respondent was attending another patient (32%). Some respondents reported that they did not accompany the patient because they did not feel comfortable riding in the ambulance (16%), while 4% thought the patient would not benefit from riding with a health worker. Protocols also obligate receiving facilities to provide patient outcome feedback to the referring facilities for every case, but this requirement was typically ignored.
Referring facilities often failed to alert receiving facilities of an incoming patient, and many patients were unaccompanied by a health worker during transit.
Frontline Worker Perspectives
Surveyed health workers were asked to identify the primary challenges to effective emergency referral services (the health workers could choose more than one challenge). Poor road conditions (95%) was the most commonly reported challenge, followed by lack of driver motivation (59%); cultural practices that delay care seeking and lack of knowledge of the importance of seeking care (40%); poor communications networks (32%); and adverse weather conditions (29%). Less frequently reported responses included patient inability to take time away from work or family obligations (20%); the cost or unavailability of fuel (19%); poor communication between health facilities (18%); lack of readily available transport options (13%); or lack of Motorking acceptability (12%).
Findings From the Qualitative Systems Appraisal
The qualitative systems appraisal shed light on the acceptability of services and on community perspectives on potential areas for improvement. Four main categories of themes emerged during data analysis: community endorsement of SERC; logistical challenges; communication challenges; and interpersonal relationships.
Community Endorsement of SERC
Overall, community members strongly endorsed SERC and expressed appreciation for the service. SERC was generally perceived as reliable and reactive, with a committed staff that supported the system. For instance, a woman who had used SERC said this:
It sent me to the clinic to deliver and I did that safely without any bad thing happening to me. I delivered safely. That is the beauty of it.
Several users reported that they would recommend SERC services to anyone in need of emergency care. The removal of fees for pregnant women and children under 5 was seen as a key contributor to high SERC uptake. Although some participants preferred 4-wheeled ambulances, respondents generally believed that the 3-wheeled ambulance was better than the available alternatives, such as walking, bicycles, donkey carts, or motorbikes:
The removal of fees for transporting pregnant women and children under 5 was seen as a key contributor to high uptake.
It has been so beneficial to the pregnant women and the children under 5 because they do not pay when the vehicle is transporting them. In the past, we used to transport pregnant women in donkey carts and on bicycles but today there is ready and reliable means of transport for them in emergencies. —Community volunteer participating in an FGD
Some participants acknowledged that 3-wheeled vehicles such as the Motorking can traverse narrow passages that are inaccessible to 4-wheeled vehicles:
If not for the Motorking, women, especially pregnant women and children, would have been suffering a lot. … It is able to go to the interior [of communities] to carry cases like the one I told you about with the woman who was in labor and nearly died if not for the sake of the Motorking ambulance. —Community subchief, in an IDI
Perceptions of reduced delays and increased numbers of facility-based births as a result of SERC were mentioned by several participants, along with the impression that SERC services were helpful, safe, quick, and lifesaving:
When a woman is in labor and is not quickly sent to the health facility, she might deliver. She might also lose either the baby or even herself. Kids like this, once they are weak, they can easily pass on. So the impact I see is that the emergency referral saves lives. —SERC driver participating in an FGD
Community and household consensus endorsing SERC was uniformly evident in each FGD and IDI and was a key determinant of the sustainability of the system.
Logistical Challenges
While communities were receptive to SERC services, several logistical challenges were identified. Some intervention areas remained inaccessible due to harsh weather and terrain, especially during the rainy season. (These challenges were perceived to affect all vehicle types, not just the Motorkings.) Some communities conveyed interest in overcoming logistical or geographical barriers through collective action or political advocacy. As 2 FGD respondents suggested:
Some communities conveyed interest in overcoming logistical or geographical barriers through collective action or political advocacy.
I am of the view that the community members can contribute something, however little, and seek assistance from the authorities to work on our routes or roads for us.
Our youth, if they could help us to repair our roads small, small [bit by bit], and when the motors come, they can be running without problems.
Although concerns about roads did not constrain SERC use, some participants noted that communities that were remote from an ambulance station anticipated delay and often sought alternative means of emergency care. Indeed, this observation is consistent with GIS data analyses showing that communities located far from ambulance stations had lower use rates than proximate communities.
Communication Challenges
Communication problems introduced further complications. Poor phone networks, which are common in rural Ghana, exacerbated service delays. Although this did not compromise care seeking resolve, solutions to communication gaps sometimes involved walking great distances to alert a health worker or volunteer.
Poor phone networks did not compromise decisions to seek care, but solutions sometimes involved walking great distances to alert a health worker or volunteer.
Patient perspectives on comfort during transport varied: Some patients described the vehicle as being unstable and uncomfortable, while others described feeling very safe, with minimal discomfort. This problem was associated with poor road quality. Any discomfort, however, did not appear to be severe enough to deter people from using SERC in the event of emergencies:
There are issues like discomfort, safety, and others when you are being transported, but as a sick person you do not have those issues in mind when there is an emergency. Anything that can hurriedly get you to the place on time is what you will be looking for. All vehicles have the tendency of falling when transporting people so it will not be fair relating safety issues to the Motorking alone. —Man participating in an FGD
Everyone has his problem, and when the vehicle picked me [up] the driver knew that it was a painful thing being in labor, so they also became careful with the way they were driving and we got there safely. Now I will not be able to speak for another person, but for my experience it was comfortable. —Woman who had used SERC, in an IDI
Community members also expressed support for improving the work conditions for drivers. There were concerns over drivers being exposed to unfavorable weather and the risk of robbery during late-night service. Although no such incidents were reported, a few drivers worried about driving at night:
There are beasts at night and also ghosts. From where I come, there are so many spirits that it is not advisable to move out at night. The people sit protected in the vehicle while you are left alone in front. In addition to that you are not supposed to speed the vehicle, and you can imagine how exposed you are if someone intends to harm you. —SERC driver participating in an FGD
Drivers advised SERC to develop roadside repair protocols for addressing unanticipated mechanical problems. Drivers also noted that personal transportation was a challenge, as many drivers had no means of personal transportation home following late-night referrals. Drivers were provided with 2 bars of soap monthly as a token of appreciation, and this was universally perceived as being insufficient. Cash incentives were preferred by all drivers who were interviewed. Staff participating in an FGD considered cash payments as being critical to sustaining driver motivation in the future. Some community members recommended that SERC choose drivers from the ranks of existing community health volunteers, given prevailing volunteer commitment to community health.
Community Trust and Expectations
Some participants noted instances of mistrust between health workers and drivers. For example, a driver mentioned an episode where the network was down but a health worker accused him of having turned off his phone. In another example, a man explained during an FGD how at times users might misconstrue basic triage practices as health worker neglect:
Some of the pregnant women will be complaining that they came and they are thrown away, they don't care about them. Because there is no understanding between the pregnant women and the midwife when she tells them it's not time for them to deliver and they should wait. Because of that, the women say the workers are not serious, but for me, the way I know about the work, I know they are serious.
Although some patients experienced negative interactions with health workers, many described satisfaction with their performance during emergencies:
We think that the child was saved by the nurses because of the timeliness of our arrival. We were happy when we got into the hands of the nurses. —Woman who had used SERC, in an IDI
Drivers expressed concern that the community lacked respect for their contribution. Some community members believed that drivers were paid employees rather than volunteers, and some drivers reported frustration over receiving dismissive and ungrateful comments. Although most community members interviewed indicated gratitude for drivers' services, some complained that drivers operated Motorkings at unsafe speeds.
Mixed-methods implementation research enriched learning about the scalability, acceptability, and potential impact of implementing a community-based emergency referral system in a severely resource-constrained setting. The findings suggest that the strategies used for the emergency referral system can be adapted to the needs of impoverished, remote communities elsewhere in Ghana.
Overall, the SERC system was well received by communities and health workers alike as an effective means of reducing acute care risks. A key lesson learned was the importance of people-centered planning for obtaining and sustaining community endorsement and use of services. Without the engagement of community leaders from the very beginning, acceptance of the program would have been limited. Focused outreach targeting heads of household and familial gatekeepers is also crucial to ensuring continued support and understanding of services. Moreover, the collaborative role of transportation authorities and vehicle manufacturers in the planning, training, and implementation processes proved vital to program success.
While SERC aimed to use process evaluation results to improve system functioning, the pursuit of such improvements was constrained by resource limitations, poor communication network infrastructure, and impassible roads. Nearly all the health workers consulted in this appraisal expressed willingness to use emergency radios to offset poor mobile phone coverage. However, given limited funds for equipment purchases and lack of locally available communication equipment, use of radio devices could not be implemented. Instead, workers were obligated to develop improvised solutions when networks were not functioning.
The Motorking was locally available, affordable, and suitable for traversing rough terrain. Nonetheless, Motorking ambulances received mixed reviews for comfort and safety, indicating a need to explore additional equipment options. A costing analysis that compares 3-wheeled motorcycle ambulances with enhanced Motorkings or higher-quality vehicles is warranted. Similarly, strategies should be investigated for determining an appropriate and sustainable incentive and recruitment system for drivers in order to minimize turnover, improve motivation, and optimize efficiency.
Quite apart from equipment considerations, the quality of emergency care services will be limited by the poor state of infrastructure more generally. Several of the community members who were interviewed expressed concern about the status of the development of primary health care facilities and the slow pace of CHPS implementation, highlighting the fact that effective referral care requires a fully functioning primary health care system.
Effective referral care requires a fully functioning primary health care system.
The SERC experience attests to the value of routine monitoring and evidence-based supervision, in conjunction with refresher training for health workers and volunteers. Lack of accountability mechanisms, supervision, and training can lead to poor adherence to protocols.
Feedback mechanisms are needed to foster timely implementation of systems improvements. For instance, after it was discovered that 30% of the trip report forms were incomplete, the forms were simplified, the format of review meetings was revised, and GIS-based vehicle tracking procedures were instituted to facilitate practical use of data for decision making. Similarly, adhering to a routine vehicle maintenance protocol that ensures prompt repairs was found to be crucial for preventing breakdowns and minimizing service disruptions.
Training for quality assurance is important. Although most patients reported positive experiences with staff involved in facilitating referrals, some patients experienced negative or insensitive comments. While clinical skills are crucial to operations, it is equally essential to foster health workers' patience and understanding of patients' perspectives on the quality of emergency care operations.
For quality emergency care, clinical skills, patience, and understanding of patients' perspectives are equally essential.
Some volunteer drivers perceived community members to be unappreciative of their services. Although FGD participants may have been reluctant to criticize drivers, the general discussion suggests that drivers were, in fact, appreciated, and participants generally agreed that the incentives provided to drivers should be increased. The exchanges among FGD participants nonetheless suggested a need for durbars and other means of community engagement that would promote awareness of the lifesaving service and dedication of volunteers.
Focus group discussions suggested a need for community engagement to promote awareness of the service and dedication of volunteers.
Remote communities sometimes preferred to find their own means of transport to offset ambulance delays. This fact attests to the need for implementation research that investigates the mechanisms such communities use for emergency referral and transport. Community-based solutions to referral problems may be relevant to operations more generally.
SERC has made its impact by transporting emergency cases, at considerable cost, to distant hospitals where physicians are available to provide essential acute care. However, bypassing subdistrict clinics and relocating care to hospitals is less sustainable than developing service capability at the subdistrict level. While bypassing for delivery is a logical and common strategy in Ghana40,41 and elsewhere in Africa,42,43 the implication of this finding is clear: A new round of implementation research is needed to explore implementing SERC in concert with a program that trains midlevel providers to manage emergencies directly.
While facility-based emergency health care is important to reducing mortality, facility-focused approaches can fail to achieve their full lifesaving potential in the absence of effective referral. Moreover, if receiving facilities are poorly equipped, inadequately staffed, and unable to respond to clinical emergency needs, effective referral will be little more than a program for relocating mortality. The SERC time series research presented in this article attests to the lifesaving potential of redirecting referral to facilities where emergencies can be competently managed. In the areas where SERC rechanneled acute care to specified facilities, we found decreased facility-based maternal mortality and accident-related deaths relative to comparison facilities. In the future, SERC could expand its intervention regimen with training and capacity building to enable more frontline care providers in smaller facilities to more effectively manage emergencies that arise. This strategy would offset the existing strategies for bypassing substandard care facilities.
In the future, SERC could train more frontline care providers to more effectively manage emergencies that arise.
Just as SERC's success was dependent on implementation research and evidence, effective scale-up of these results will require effective systems approaches to replication trials in other regions of Ghana, with contrasting social, economic, and ecological conditions. The need for reform of referral systems persists throughout the country, but care should be taken to develop solutions that are informed by SERC, yet tailored to local contexts in the central and southern regions. The transition from pilot to trial clarified training and engagement requirements; replication of SERC elsewhere in Ghana could clarify the practical milestones in establishing a large-scale system of referral care.
The Ghana Health Service has adopted the SERC model and has included it in the national CHPS implementation guidelines. Donors including the Japan International Cooperation Agency, the Korean International Cooperation Agency, and the U.S. Agency for International Development have funded the purchase of Motorkings, which are being used in 4 of Ghana's 10 regions, with plans to use them in 2 additional regions.
The SERC initiative was funded by grants to the University of Ghana School of Public Health and the Ghana Health Service by the British charity Comic Relief and by grants to the Columbia University Mailman School of Public Health by the Doris Duke Charitable Foundation.
Competing Interests: None declared.
Cite this article as: Patel S, Awoonor-Williams JK, Asuru R, Boyer CB, Tiah JAY, Sheff MC, Schmitt ML, Alirigia RM, Jackson EF, Phillips JF. Benefits and limitations of a community-engaged emergency referral system in a remote, impoverished setting of Northern Ghana. Glob Health Sci Pract. 2016;4(4):552–567. http://dx.doi.org/10.9745/GHSP-D-16-00253
Received: 2016 Aug 9.
Accepted: 2016 Oct 11.
Published: 2016 Dec 23.
© Patel et al.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are properly cited. To view a copy of the license, visit http://creativecommons.org/licenses/by/3.0/. When linking to this article, please use the following permanent link: http://dx.doi.org/10.9745/GHSP-D-16-00253
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Sneha Patel, John Koku Awoonor-Williams, Rofina Asuru, Christopher B Boyer, Janet Awopole Yepakeh Tiah, Mallory C Sheff, Margaret L Schmitt, Robert Alirigia, Elizabeth F Jackson, James F Phillips
Global Health: Science and Practice Dec 2016, 4 (4) 552-567; DOI: 10.9745/GHSP-D-16-00253
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This entry was posted in 1-Minute Inspiration Video Clip and tagged Alice Walker, greater, purple, see, spirit. Bookmark the permalink.
My father passed away in October, at Christmastime, I thought I can't do the Holiday thing, then I read Christmas in Deep Purple,(found in Thoughts from Thornburg, Dean of Marsh Chapel 12/96) It states, purple is the color of royalty, it is a virtual aid helping us to see the majesty of God. But deep purple is also the color of dark shadows that crowd in on our lives at times of pain and sorrow. This writing inspired me to get out of my sad thoughts and I did. I put up a Christmas tree decorated in all purple, in honor of my dad, Duke and enclosed a copy of the writing with all of my Christmas cards. Thank you for the video. It touched my heart.
Love this! Purple is my favorite color. If this winter ever is done (I'm here in Minnesota) I will treasure seeing my first purple flower of the season! White…is getting on my nerves!


I had the pleasure of attending the premiere of the Luisa Fernanda Opera on the Broad Stage at the Santa Monica Theatre on June 5th. This was a great evening and a wonderful production. I was given the opportunity to return to the opera and take some pictures backstage before the final performance. I have posted some selections below from that evening. The opera was directed by Dr. Janelle Destefano and conducted by Dr. James Martin. I want to thank them, and the entire cast and crew for being so generous and allowing me to take these pictures.


Life in the twentieth century demands preparation. Today, all individuals in a country must have adequate schooling to prepare them for their work as well as for their responsibilities as citizens. With this in mind, national leaders everywhere are placing more emphasis on the education of the young. In the United States, government officials, parents, and teachers are working hard to give their children - tomorrow s decision makers - the best preparation available.
When they become six years old, children begin elementary school. After six years in elementary school, they go into junior high school and remain there for three years. The last three years of their public school education are spent in senior high school, from which they graduate at the age of eighteen.


Can I get workers' compensation benefits if I was injured while working, but am no longer working for the same employer?
You may be able to claim benefits from an employer for injuries sustained while you were working even if you are no longer working for this employer. Workers' compensation insurance usually covers medical expenses and lost wages incurred as a result of an accident that happened during the course of employment and during working hours. If you are injured during your working hours, workers' compensation benefits may be claimed regardless of what happens afterwards.
If you were injured while working, we can help to set up your workers' compensation claim. Call us today for your free consultation at 1-800-WORK-4-YOU (1-800-967-5496).


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Workers' Compensation Law Prof Blog
Sedgwick Institute Publishes White Paper Cautioning Against Presumptions for COVID-19
By David B. Torrey
In an important white paper, published by Sedgwick, the authors review the recent popularity of presumptions (including those for COVID-19) in workers' compensation laws. David Langham & Chris Mandel, American Workers' Compensation – A Study in Disparities and the Expanded Use of Presumptions (Sedgwick Institute, July 2020), https://www.sedgwick.com/assets/uploads/documents/Sedgwick-Institute_Workers-Comp_7.8.20-1.pdf.
The authors first provide a short history of workers' compensation from its inception. They note, among other things, that in some jurisdictions, laws provided for presumptions of compensability, giving the injured worker the "benefit of the doubt" in ambiguous cases that the injury arose out of the employment. These types of laws (never the rule in my state, Pennsylvania), have, over the recent decades, been repealed, with most jurisdictions currently obliging the injured worker to prove his or her claim as in a tort case.
Now, however, a narrower type of presumption has developed, legislated typically at the behest of certain lobbies (firefighters seeking cancer presumptions; police officers seeking mental trauma presumptions). The authors, perhaps with provocative intent, describe such presumptions as "discriminating" and reflecting "disparate treatment by government."
The authors discuss, accurately, how the development of these laws has laid the groundwork for executive and legislative action in the form of presumptions of causation in the realm of worker infection by COVID-19. The authors analyze the likely cost increases to the system brought about by the virus, and the application of presumptions, and caution against their indiscriminate use in this and other contexts. In the authors' view, the overuse of presumptions unfairly upsets the bargain or compromise which is the basis of the system. This is particularly so, they suggest, because the etiology of non-occupation-specific diseases (and psychic injuries, for that matter) is still not well understood.
With regard to costs, the authors seem to acknowledge that the true total costs of COVID-19 in the workplace, and the effect of the presumptions enacted as a consequence, is difficult to estimate. Some of the cases will feature modest costs while others will exhibit serious expenditures. Still, the authors posit that, whatever the total costs, a particular jurisdiction's adoption of a COVID-19 presumption may induce businesses to relocate to another state, or offshore its operations altogether. Notably, the authors reject the idea that such a phenomenon reflects some "race to the bottom" but, instead, characterize the same as a legitimate attempt by such businesses to avoid increased costs – particularly medical expenditures.
It is difficult to argue with many of the points made by the authors. Still, it is important to remember that occupational disease presumptions have long been part of workers' compensation laws. A list of diseases, paired with occupations in which incurrence was thought to be a special risk, was a feature of the second British law of 1907. E.P. Hennock, The Origin of the Welfare State in England and Germany, 1850-1914: Social Policies Compared (Cambridge University Press. 2007). Pennsylvania, notably, was to emulate that approach in its enactments of 1937 and 1939.
It is also important to remember that not all presumptions are created equal. For example, in Pennsylvania, the Section 301(e) presumption enjoyed by an occupational disease victim "drops out" as soon as the employer presents evidence of an alternate cause for the disease. And, when it does so, the injured worker once again carries the burden of proof on causation. Thus, to a certain extent, the presumption is a paper tiger. (It may be that the dynamic is different under Act 46 of 2011 (cancer in firefighters)).
In any event, in Pennsylvania we know from decades of workers' compensation black lung litigation that no lawyer would ever rely on the presumption alone; he or she would always develop expert evidence on the causation issue.
Finally, not all presumptions are created equal for another reason, and in an aspect which the authors, in their brief against this legal device, do not discuss. In this regard, one presumption which has gained popularity works in employers' favor. That device is the presumption (rebuttable) that when, in the wake of an injury, the worker is found to have any level of marijuana metabolites in his or her blood, intoxication from that agent is the cause of the accident. Arkansas and Florida seem to maintain such laws; a leading case is Brinson v. Hospital Housekeeping Services, LLC, 263 So.3d 106 (Fl. Ct. App. 2018) (housekeeper, at end of shift, rushing to report an emergency, who slipped and fell, dislocating shoulder, barred from recovery when it was found that she had THC in her blood).
This type of presumption, which operates free of any intoxication "threshold," does not seem to be supported by scientific evidence and, when coupled with mandatory drug-test rules, no doubt suppresses the prosecution and payment of many claims where drug use had nothing to do with the accident.
Though this type of presumption (still a minority approach) is not noted by the authors, they would be unapologetic, one senses, about such results. In this regard, a well-known social science dictum is that mass justice programs can, at times, work inequities. Here, the authors describe that phenomenon more poetically: "It is … generally accepted that workers' compensation systems are imperfect…. The systems operate on a macro analysis of compromise. As a result, there are individual outlier examples in which the results are less than ideal. The systems are imperfect, drawn by people who are imperfect, and therefore necessarily imperfect results will ensue."
https://lawprofessors.typepad.com/workerscomplaw/2020/08/sedgwick-institute-publishes-white-paper-cautioning-against-presumptions-for-covid-19-.html
I wonder if the same arguments would be made in the absence of tort immunity. Think employers would not want to be covered by workers' compensation in a lively tort environment.
Posted by: Michael C. Duff | Aug 17, 2020 1:59:23 PM
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Adjunct Professor Law
Workers' Compensation Judge
Pennsylvania Department of Labor & Industry

redpajama_set_name: RedPajamaCommonCrawl


Noctua release three model of its case fans for silent operation: NF-S12A FLX, NF-S12A ULN and NF-12A PWM.
The FLX version comes with 1200/900/700 RPM speed preset and bundled with their low-noise adapters. ULN maintain lower RPM of 800/600 and aimed towards noise-sensitive users. The PWM comes with their proprietary NE-FD1 IC PWM controller which handles automatic speed control between the speeds of 900 to 1200 rpm.
These fans are already released in the market and come with the retail price of EUR 19.90 / U.S.$21.90.
cables should be flat ribbon and not with thick weave jacket so its easier to hide and reroute around the cases, but the fans are amazing if you want 24/7 operation and you can spend that much money for it. if you want bit cheaper, there are magnetic bearing or ceramic type ball bearing fans..


text:
Q: How could I make a Wi-Fi Hotspot with WEP security, or none? Brief history, but when Nintendo made the DS Classic, they only included WEP support for wifi. In the search of using a community DNS server to receive Pokemon I have found no device in my house which can produce a Wi-Fi signal with either WEP security, or no security at all
The most I can do is a Wi-Fi hotspot on my phone as it can do no security, but it not without using a mobile network with data, which is just too expensive where I live.
And no, my router's guest option forces WPA2, and cannot be unsecured. The windows laptop I have cannot produce a hotspot without WPA2 either, at a driver level as I've read.
I have a desktop running Ubuntu 18.04 LTS which has wifi capabilities, and I'm looking for any possible way to produce a signal which would work in my situation.

A: In nm-connection-editor you can create a new wifi connection and set to Hotspot mode.
In ipv4 settings set to "Shared to other computers"
In WI-FI Security you can set as desired.
Because you are going to be using this with a older device make sure the band is set to 2.4GHz.
After you setup the hotspot to enable it you might need to go to your wifi settings on the Ubuntu box and "Connect" to it to enable it.

redpajama_set_name: RedPajamaStackExchange


Gwalior, MP, Dec 5: A youngster has been placed under arrest while repeatedly demanding Rs 2.5 lakh from the principal-opposition Congress' Bhind assembly constituency candidate in exchange for hacking electronic voting machines, law-enforcement authorities said on Wednesday.
Neeraj Rathor, who hails from Jalaun and is not highly educated, used an assumed name while calling up Dr Ramesh Dubey on a cellular phone and asked the politician to hand over half the amount in advance. All this made Dr Dubey suspicious but he told the youth to meet him at a restaurant in the vicinity of the railway station and simultaneously alerted the police.


text:
Mountain Heart with EmiSunshine in McMinnville
Mountain Heart
Mountain Heart is the band that has been fearlessly revolutionizing the way acoustic music can be presented and played. The band's name has been synonymous with cutting-edge excellence in acoustic music circles since the group's creation in 1999. Widely known throughout the music industry for continually redefining the boundaries of acoustic music, the band has gained legions of loyal fans both as a result of their superlative musicianship, and just as notably, their incendiary live performances.
[su_youtube_advanced url="https://youtu.be/RhVUWrvto9Q " rel="no" modestbranding="yes"]
Opening Act: EmiSunshine
It's impossible to explain the exceptional talents of EmiSunshine, a 10-year-old East Tennessee prodigy who has captured the nation's attention as a singer, songwriter and multi-instrumentalist. Steeped in Appalachian music, she is a true vocal stylist, one who instinctively knows how to interpret the nuances of a song with her impressive range, even though she has yet to gain the life experience and empathy seemingly necessary to fully comprehend the words she sings. Despite a given name that reflects optimism, she is drawn to darker themes of pain, anguish and even murder, like that of The Louvin Brothers, whom she loves.
[su_youtube_advanced url="https://youtu.be/LWQnl9kJDnQ " rel="no" modestbranding="yes"]


text:
[New York Premiere] Big Dance Theater: ANTIGONICK
November 14 - November 17, 2018 @ 7pm and 8:30pm
Big Dance Theater's latest work, ANTIGONICK, is a "pop-up play under construction" of Anne Carson's one-act, radical-feminist take on Sophocles' Antigone.
Apple 11/14/2018 11/17/2018 America/New_York [New York Premiere] Big Dance Theater: ANTIGONICK Underground Theater
Google 11/14/2018 11/17/2018 America/New_York [New York Premiere] Big Dance Theater: ANTIGONICK Underground Theater
Yahoo! 11/14/2018 11/17/2018 America/New_York [New York Premiere] Big Dance Theater: ANTIGONICK Underground Theater
Outlook 11/14/2018 11/17/2018 America/New_York [New York Premiere] Big Dance Theater: ANTIGONICK Underground Theater
Outlook.com 11/14/2018 11/17/2018 America/New_York [New York Premiere] Big Dance Theater: ANTIGONICK Underground Theater
Big Dance Theater's latest work, ANTIGONICK, is a "pop-up play under construction" of Anne Carson's one-act, radical-feminist take on Sophocles' Antigone. In Carson's theatrical perspective on Antigone's role as a humanist and antagonist, the intellectual excitement of ANTIGONICK lies in how she loses, why her peaceful resistance matters, and the sobering consequences of the Antigone/Creon face-off.
Each night, ticket holders for the 7pm and 8:30pm shows are welcome to a Dionysian Libation with food and drinks beginning at 7:45pm.
Founded in 1991, Big Dance Theater is known for its inspired use of dance, music, text and visual design. The company often works with wildly incongruent source material, weaving and braiding disparate strands into multi-dimensional performance. Led by Co-Artistic Directors Annie-B Parson and Paul Lazar, Big Dance has delved into the literary work of such authors as Twain, Tanizaki, Wellman, Euripides and Flaubert, and dance is used as both frame and metaphor to theatricalize these writings.
ANTIGONICK is presented by Abrons Arts Center with generous grants from the Howard Gilman Foundation, the Mertz Gilmore Foundation, the Harkness Foundation for Dance, the Jerome Foundation, the Jerome Robbins Foundation, the Scherman Foundation, and other generous Henry Street Settlement funders. This program is also supported, in part, by public funds from the New York City Department of Cultural Affairs in partnership with the City Council. This season was also made possible by the New York State Council on the Arts with the support of Governor Andrew M. Cuomo and the New York State Legislature. ANTIGONICK was commissioned and originally produced by Williamstown Theatre Festival, Williamstown, MA Mandy Greenfield, Artistic Director


We had 'Winter Soldier' and "Guardians of the Galaxy" in 2014, 'Ultron' and "Ant-Man" this year, and in 2016 Marvel is continuing its approach of pumping out a high-profile sequel early in the Summer followed by a new property in the latter half of the year.
Whilst we get "Captain America: Civil War" early next year, after that will come Scott Derrickson's film adaptation of the "Doctor Strange" comics. As "Thor" and then 'Guardians' established and then further explored the cosmic aspects of the Marvel cinematic universe, 'Strange' is slated to introduce mystical aspects.
Speaking of the film, a new fan-made potential opening credits for the film is out and drawing a lot of attention. Check it out at Vimeo.


text:
package models.amt

import java.sql.Timestamp
import java.time.Instant
import models.utils.MyPostgresDriver.simple._
import play.api.Play.current

case class AMTAssignment(amtAssignmentId: Int, hitId: String, assignmentId: String,
                         assignmentStart: Timestamp, assignmentEnd: Timestamp,
                         workerId: String, confirmationCode: String, completed: Boolean)

/**
 *
 */
class AMTAssignmentTable(tag: Tag) extends Table[AMTAssignment](tag, Some("sidewalk"), "amt_assignment") {
  def amtAssignmentId = column[Int]("amt_assignment_id", O.PrimaryKey, O.AutoInc)
  def hitId = column[String]("hit_id", O.NotNull)
  def assignmentId = column[String]("assignment_id", O.NotNull)
  def assignmentStart = column[Timestamp]("assignment_start", O.NotNull)
  def assignmentEnd = column[Timestamp]("assignment_end")
  def workerId = column[String]("turker_id", O.NotNull)
  def confirmationCode = column[String]("confirmation_code")
  def completed = column[Boolean]("completed", O.NotNull)

  def * = (amtAssignmentId, hitId, assignmentId, assignmentStart, assignmentEnd, workerId, confirmationCode, completed) <> ((AMTAssignment.apply _).tupled, AMTAssignment.unapply)
}

/**
 * Data access object for the amt_assignment table.
 */
object AMTAssignmentTable {
  val db = play.api.db.slick.DB
  val amtAssignments = TableQuery[AMTAssignmentTable]

  val TURKER_TUTORIAL_PAY: Double = 1.00D
  val TURKER_PAY_PER_MILE: Double = 5.00D
  val TURKER_PAY_PER_METER: Double = TURKER_PAY_PER_MILE / 1609.34D
  val TURKER_PAY_PER_LABEL_VALIDATION = 0.012D
  val VOLUNTEER_PAY: Double = 0.0D

  def save(asg: AMTAssignment): Int = db.withTransaction { implicit session =>
    val asgId: Int =
      (amtAssignments returning amtAssignments.map(_.amtAssignmentId)) += asg
    asgId
  }

  def getConfirmationCode(workerId: String, assignmentId: String): String = db.withTransaction { implicit session =>
    amtAssignments.filter(a => a.workerId === workerId && a.assignmentId === assignmentId).sortBy(_.assignmentStart.desc).map(_.confirmationCode).first
  }

  def getMostRecentAssignmentId(workerId: String): String = db.withTransaction { implicit session =>
    amtAssignments.filter(_.workerId === workerId).sortBy(_.assignmentStart.desc).map(_.assignmentId).first
  }

  def getMostRecentAMTAssignmentId(workerId: String): Int = db.withTransaction { implicit session =>
    amtAssignments.filter(_.workerId === workerId).sortBy(_.assignmentStart.desc).map(_.amtAssignmentId).first
  }

  def getMostRecentAsmtEnd(workerId: String): Option[Timestamp] = db.withSession { implicit session =>
    amtAssignments.filter(_.workerId === workerId).sortBy(_.assignmentStart.desc).map(_.assignmentEnd).firstOption
  }

  /**
    * Get the number of milliseconds between now and the end time of the worker's most recent assignment.
    */
  def getMsLeftOnMostRecentAsmt(workerId: String): Option[Long] = db.withSession { implicit session =>
    val now: Timestamp = new Timestamp(Instant.now.toEpochMilli)
    val endOption: Option[Timestamp] = getMostRecentAsmtEnd(workerId)
    endOption.map(end => end.getTime - now.getTime)
  }

  def getMostRecentConfirmationCode(workerId: String): Option[String] = db.withSession { implicit session =>
    amtAssignments.filter(_.workerId === workerId).sortBy(_.assignmentStart.desc).map(_.confirmationCode).firstOption
  }

  def getMostRecentAssignment(workerId: String): Option[AMTAssignment] = db.withSession { implicit session =>
    amtAssignments.filter(_.workerId === workerId).sortBy(_.assignmentStart.desc).firstOption
  }

  def getAssignment(workerId: String, assignmentId: String): Option[AMTAssignment] = db.withSession { implicit session =>
    amtAssignments.filter(a => a.workerId === workerId && a.assignmentId === assignmentId).firstOption
  }

  /**
    * Update the `completed` column of the specified amt_assignment row.
    */
  def updateCompleted(amtAssignmentId: Int, completed: Boolean): Int = db.withTransaction { implicit session =>
    val q = for { asg <- amtAssignments if asg.amtAssignmentId === amtAssignmentId } yield asg.completed
    q.update(completed)
  }
}

redpajama_set_name: RedPajamaGithub


text:
Q: Why does adding a Flex DateChooser component throw an index out of bounds error? I'm facing an issue with the flex Application I'm currently working on.
When I open a pop-up using the 'createPopUp' method, I've got this index out of bounds error message :

RangeError: The supplied index is out of bounds.  at
  mx.core::FTETextField/getLineMetrics()[E:\dev\4.y\frameworks\projects\spark\src\mx\core\FTETextField.as:2169]
    at mx.core::UIFTETextField/get
  baselinePosition()[E:\dev\4.y\frameworks\projects\spark\src\mx\core\UIFTETextField.as:784]
    at mx.controls::DateChooser/get
  baselinePosition()[E:\dev\4.y\frameworks\projects\mx\src\mx\controls\DateChooser.as:994]
    at spark.components::Group/get
  baselinePosition()[E:\dev\4.y\frameworks\projects\spark\src\spark\components\Group.as:282]
    at
  spark.layouts::ConstraintLayout/parseElementConstraints()[E:\dev\4.y\frameworks\projects\spark\src\spark\layouts\ConstraintLayout.as:1818]
    at
  spark.layouts::ConstraintLayout/parseConstraints()[E:\dev\4.y\frameworks\projects\spark\src\spark\layouts\ConstraintLayout.as:1632]
    at
  spark.layouts::ConstraintLayout/measure()[E:\dev\4.y\frameworks\projects\spark\src\spark\layouts\ConstraintLayout.as:414]
    at
  spark.components.supportClasses::GroupBase/measure()[E:\dev\4.y\frameworks\projects\spark\src\spark\components\supportClasses\GroupBase.as:1148]
    at
  mx.core::UIComponent/http://www.adobe.com/2006/flex/mx/internal::measureSizes()[E:\dev\4.y\frameworks\projects\framework\src\mx\core\UIComponent.as:8506]
    at
  mx.core::UIComponent/validateSize()[E:\dev\4.y\frameworks\projects\framework\src\mx\core\UIComponent.as:8430]
    at
  spark.components::Group/validateSize()[E:\dev\4.y\frameworks\projects\spark\src\spark\components\Group.as:1012]
    at
  mx.managers::LayoutManager/validateClient()[E:\dev\4.y\frameworks\projects\framework\src\mx\managers\LayoutManager.as:987]
    at
  mx.managers::PopUpManagerImpl/addPopUp()[E:\dev\4.y\frameworks\projects\framework\src\mx\managers\PopUpManagerImpl.as:382]
    at
  mx.managers::PopUpManagerImpl/createPopUp()[E:\dev\4.y\frameworks\projects\framework\src\mx\managers\PopUpManagerImpl.as:232]
    at
  mx.managers::PopUpManager$/createPopUp()[E:\dev\4.y\frameworks\projects\framework\src\mx\managers\PopUpManager.as:139]    at
  views::AddProjects/loadAddProjectPopUp()[C:\Users\Laura\Web\spidermak\spidermak\src\views\AddProjects.mxml:184]
    at
  views::AddProjects/___AddProjects_Button1_click()[C:\Users\Laura\Web\spidermak\spidermak\src\views\AddProjects.mxml:838]

It seems that this error is caused by a "dateChooser" component in my popup :
<mx:DateChooser id="endDate"/>

When I comment this line, the error is no longer thrown and the popup loads correctly.
It's really weird because I didn't have this issue until this morning. All I did in the meantime was changing some layout-related stuff, but I don't see what is would have to do with this problem.
I don't get it...
Does anyone have a clue about how to fix this ? I need my DateChooser !
Thanks !
Laura

*

*EDIT -

It seems that the problem is not caused by the DateChooser itself, but by the FormItem around it. Here's what my code looks like :
<Form width="100%">
[...]
    <s:HGroup width="100%">
        <s:FormItem label="Date de début">
            <mx:DateChooser id="startDate"
                    firstDayOfWeek="1"/>
        </s:FormItem>

        <s:FormItem label="Date de fin">
            <mx:DateChooser id="endDate"
                    firstDayOfWeek="1"/>
        </s:FormItem>
    </s:HGroup>
</Form>

If I remove the two FormItems, it works. Could anyone explain me why? Thanks !

A: Try wrapping the component in a <s:Group> element, i.e.
<s:FormItem label="Start date">
    <s:Group>
        <mx:DateChooser id="startDate"
            firstDayOfWeek="1" />
    </s:Group>
</s:FormItem>

Apparently, it's something to do with the composition of Spark components. lolFlex.
(I had exactly the same problem, and couldn't find any solution on the interwebs either!)

A: I think you should upgrade to the latest TLF. This reminds me of a bug in TLF 1.x. Try 2.x.


text:
Basel El-Garbawi –en árabe, باسل الغرباوي– (Trípoli, 10 de abril de 1977) es un deportista egipcio que compitió en judo. Ganó dos medallas en los Juegos Panafricanos de 1999, y once medallas en el Campeonato Africano de Judo entre los años 1996 y 2006.

Palmarés internacional

Referencias

Judokas de Egipto
Judokas en los Juegos Olímpicos de Atenas 2004
Deportistas de Egipto en los Juegos Olímpicos de Atenas 2004
Nacidos en Trípoli

redpajama_set_name: RedPajamaWikipedia


text:
Q: In this example, how columnar database is faster compared to RDBMS In this example, how is a columnar database like Vertica better than an rdbmsw.r.t speed?
I am assuming that Symbol and date are primary key w.r.t rdbms

From the example I am following, the projection looks like the following but I can't figure out why the no. of reads is less

A: If tickstore only has the three columns you are using in your example (and practically only then), the row-oriented DBMS might be faster - especially if you have symbol and date indexed.
But in any other case: each column in a columnar database (and Vertica was the first widely known one) boils down to a file by itself. So , in the case of 103 columns in the table, the row-oriented DBMS reads 100 columns too many from disk, while Vertica reads only 3; the row-oriented DBMS needs to navigate through the complete read row to find the starts of each column needed in the query; and Vertica can rely on the fact that each column-file contains exactly one data type, and can optimise both reading and writing processes to take advantage of that knowledge.
Plus there are encoding algorithms for column-oriented data that would blow up the space of this answer to go into detail for here.
To sum it up: the only thing a column oriented database does not like is a SELECT * of a 100-plus column table.


text:
Premier League Previews: Brighton & Hove Albion
What are you most excited about heading into the new season?
The promise of attacking football is what's exciting most of us Albion fans. As much as we adored Chris Hughton, the second half of last season was turgid. And that's being generous.
Graham Potter has arrived on the coast with a very different CV from many managers. He's a bit of a maverick. His methods are unconventional and that suits the fabric of the club, and the city it represents.
I'm looking forward to seeing Trossard and Maupay up front, and hope Glenn Murray can inch towards the all-time club goalscoring record.
What worries you ahead of the new season?
I hope we don't go on a bad run which results in Potter's reactionary sacking. It's an element of the game that turns my stomach at times. His methods are a bit out there so I'm fascinated by what he could achieve.
It's a cliché, but he might require a smidgen longer than many bosses to bed in. This summer's new signings need to perform drastically better than those from the corresponding period last year.
What have you made of your club's transfer activity this summer?
Paying £20million – twice – for Championship players highlights just how utterly nuts the football landscape is. Trossard, a league-title-winning captain from Gent, has certainly looked the part in pre-season, and is another leader on the pitch. Something we've lacked.
Teenager Taylor Richards is an intriguing acquisition from Manchester City. The attacking midfielder shone in Premier League 2 in 2018/19, and is chomping at the bit for a shot at first-team action…
Become part of the moment. COPA90's Players Collection: shop now.
What unpopular opinion do you have about your team going into the season?
I'd like to see some of our talented youngsters given a chance this year. Apart from Solly March and Lewis Dunk, who made his debut at our former temporary athletics track home, we've not had a single academy graduate make an impact in the first team. Irish striker Aaron Connolly could shatter that stat in 2019/20.
Who would win if your squad had a WWE Royal Rumble style fight?
The Albion have had their fair share of big old units over the years. Guy Butters would have beaten – and eaten – all comers. In today's hyper healthy football environment, players take their conditioning much more seriously than their predecessors.
My money would be on Shane Duffy though. He could headbutt himself out of any situation. As an outside bet, I'd bung a fiver on Maty Ryan. Our Aussie keeper looks tiny on the pitch but is deceptively large. He wouldn't stand a chance against Butters, though.
Where do you think your team will realistically finish in the Premier League?
I've bet on Albion to win their respective division twice in my life – both times we finished 23rd out of 24 clubs. My blue-and-white tinted spectacles predict a forthcoming campaign of free-flowing football, an avalanche of intricate goals, envious glances from boardrooms across the nation, a spirited run to a cup final, and an outside possibility of Europa League qualification.
Or perhaps we may finish 15th.
See also: Premier League article Brighton & Hove Albion


Mallard Pond, one of Ridgefield's most distinguished country estates, set on 5.71 pastoral acres complete with scenic pond in prime equestrian area with nearby stables and riding trails. Custom built in 2006, the majestic architecture combines classical and symmetrical design elements of Colonial, English, Georgian, and Jeffersonian styles influenced by five late 18th and early 19th century Virginia plantation homes still standing today. Total 10,986 sf, 5 BR, 5/2 BA; 7 fireplaces; 2nd floor "Oak Room" bar; separate "meditation" pavilion/studio; and full apartment in lower level w/pvt entry. Features hand made red brick construction; balustrade-capped porticoes/balconies; colonnaded piazza; arched covered arcade; formal courtyards and gardens; groin and barrel vaulted ceilings; grand stairways, moldings, trim, and hand plastered walls by Italian artisans. While expressing the grandeur of a bygone era, this sophisticated home is designed for today's high tech lifestyle w/automated entry gates; state of the art A/V system controlled by 8 iPads (Elan, Spotify, Sonos); 68 zone sprinkler system; security system with 11 exterior cameras; 600 amps electrical, generator; and 10 authentic period gas lamps lit at the touch of a switch. The vast acreage includes stone walls, meadows and pastures; meandering brooks; 50′ heated saltwater lap pool and spa with electronic pool cover; and the picturesque natural stock pond, home to the dabbling Mallard ducks for which this estate was named.