Examining Public Sector Availability and Supply Chain Management Practices for Malaria Commodities: Findings From Northern Nigeria.

BACKGROUND: Nigeria accounts for substantial proportions of global malaria infections and deaths, with children aged younger than 5 years being the most affected group. This suggests that access to lifesaving malaria interventions could be suboptimal, especially at public health facilities where most rural dwellers seek health care. We conducted this study to ascertain if public health facilities have the commodities and the robust supply chain management (SCM) system required to deliver malaria interventions to children younger than 5 years. METHOD: We conducted a cross-sectional survey in 1,858 health facilities across 7 states in Nigeria. Using structured questionnaires, we assessed the availability of selected malaria commodities required by children aged younger than 5 years. We also interviewed health workers to evaluate other core SCM activities. RESULT: More than 50% of health facilities in 5 states were stocked out of malaria rapid diagnostic tests (mRDTs), and stock-out rates for artemisinin-based combination therapies (ACTs) were over 50% for almost all assessed ACTs across all states. The percentage of health facilities that received malaria commodities within the recommended lead time was below average across most states (71%). States with a higher percentage of health workers who were aware of and placed orders following the national reporting timeline and those that delivered commodities to the last mile predominantly through third-party logistics service providers tended to have higher availability of mRDTs and artemether/lumefantrine combinations. The top 2 logistics challenges were insecurity and inadequate funding. CONCLUSION: The availability of lifesaving malaria commodities across the health facilities visited was suboptimal, possibly due to several SCM challenges. The results from this study underscore the urgent need to implement effective interventions to address the observed gaps. This will contribute to reducing malaria morbidity and mortality among children aged younger than 5 years in Nigeria.

Assessment of carcinogenic and non-carcinogenic risk of exposure to potentially toxic elements in tea infusions: Determination by ICP-OES and multivariate statistical data analysis.

BACKGROUND: The perennial evergreen tea (Camellia sinensis) plant is one of the most popular nonalcoholic drinks in the world. Fertilizers and industrial, agricultural, and municipal activities are the usual drivers of soil contamination, contaminating tea plants with potentially toxic elements (PTEs). These elements might potentially accumulate to larger amounts in the leaves of plants after being taken up from the soil. Thus, frequent monitoring of these elements is critically important. METHODS: The present study intended to determine PTEs (Al, Cr, Mn, Fe, Co, Ni, Cu, Zn, Cd, and Pb) in both tea leaves and infusions using ICP-OES. Various multivariate data analysis methods such as principal component analysis (PCA) and hierarchical cluster analysis (HCA) were employed to elucidate the potential sources of PTEs contamination, whether from anthropogenic activities or natural origins. Additionally, Pearson's correlation coefficient (PCC) was calculated to assess the relationships between the variables under study. RESULTS: The mean contents (mg/L) of all studied elements in tea infusions decreased in order Mn (150.59 ±â€¯1.66) > Fe (11.39 ±â€¯0.99) > Zn (6.62 ±â€¯0.89) > Cu (5.86 ±â€¯0.62) > Co (3.25 ±â€¯0.64) > Ni (1.69 ±â€¯0.23) > Pb (1.08 ±â€¯0.16) > Cr (0.57 ±â€¯0.09) > Cd (0.46 ±â€¯0.09) > Al (0.05 ±â€¯0.008), indicating that Mn exhibits the highest abundance. The mean concentration trend in tea leaf samples mirrored that of infusions, albeit with higher concentrations of PTEs in the former. The tolerable dietary intake (TDI) value for Ni and provisional tolerable monthly intake (PTMI) value for Cd surpassed the standards set by the WHO and EFSA. Calculated hazard index (HI < 1) and cumulative cancer risk (CCR) values suggest negligible exposure risk. CONCLUSION: Elevated levels of PTEs in commonly consumed tea products concern the public and regulatory agencies.

Intrinsic Room-Temperature Ferromagnetism in New Halide Perovskite AgCrX3 (X: F, Cl, Br, I) Using Ab Initio and Monte Carlo Simulations.

Herein, we present a detailed comparative study of the structural, elastic, electronic, and magnetic properties of a series of new halide perovskite AgCrX3 (X: F, Cl, Br, I) crystal structures using density functional theory, mean-field theory (MFT), and quantum Monte Carlo (MC) simulations. As demonstrated by the negative formation energy and Born-Huang stability criteria, the suggested perovskite compounds show potential stability in the cubic crystal structure. The materials are ductile because the Pugh's ratio is greater than 1.75, and the Cauchy pressure (C12-C44) is positive. The ground state magnetic moments of the compound were calculated as 3.70, 3.91, 3.92, and 3.91 µB for AgCrF3, AgCrCl3, AgCrBr3, and AgCrI3, respectively. The GGA + SOC computed spin-polarized electronic structures reveal ferromagnetism and confirm the metallic character in all of these compounds under consideration. These characteristics are robust under a ±3% strained lattice constant. Using relativistic pseudopotentials, the total energy is calculated, which yields that the single ion anisotropy is 0.004 meV and the z-axis is the hard-axis in the series of AgCrX3 (X: F, Cl, Br, and I) compounds. Further, to explore room-temperature intrinsic ferromagnetism, we considered ferromagnetic and antiferromagnetic interactions of the magnetic ions in the compounds by considering a supercell with 2 × 2 × 2 dimensions. The transition temperature is estimated by two models, namely, MFT and MC simulations. The calculated Curie temperatures using MC simulations are 518.35, 624.30, 517.94, and 497.28 K, with ±5% error for AgCrF3, AgCrCl3, AgCrBr3, and AgCrI3 compounds, respectively. Our results suggest that halide perovskite AgCrX3 compounds are promising materials for spintronic nanodevices at room temperature and provide new recommendations. For the first time, we report results for novel halide perovskite compounds based on Ag and Cr atoms.

A system dynamics simulation-based strategic analysis of integrated water resources utilization and management in Shenzhen city.

As one of the most rapidly developing cities in China, Shenzhen grapples with an increasing challenge in managing water resources due to escalating conflicts with its soaring water demand. This study established a system dynamics (SD) model based on a causal loop diagram to explore the intricate interconnections within the urban water resources system. Through simulating water supply and demand in Shenzhen from 2021 to 2035, the model identified key sensitive factors and examined various utilization scenarios for multiple water resources. Results indicated that water scarcity posed a significant obstacle to Shenzhen's development. To tackle this challenge, several effective measures should be implemented, including enhancing water conservation capabilities, developing seawater resources, promoting water reuse, optimizing the economic structure, and managing population growth. Prioritizing water conservation efforts and maximizing the utilization of seawater resources were regarded as the most impactful strategies in alleviating the water crisis. Furthermore, the relationship between water conservation capabilities and seawater utilization scale was analyzed using the SD model, contributing to the development of a comprehensive water resources management strategy. The findings from this study would provide insights into robust methods for allocating water resources, thereby enhancing sustainable water management strategies applicable to regions facing similar challenges.

Preparation and assessment of an optimized multichannel acellular nerve allograft for peripheral nerve regeneration.

Peripheral nerve regeneration after injury is still a clinical problem. The application of autologous nerve grafting, the gold standard treatment, is greatly restricted. Acellular nerve allografts (ANAs) are considered promising alternatives, but they are difficult to achieve satisfactory therapeutic outcomes, which may be attributed to their compact inherent ultrastructure and substantial loss of extracellular matrix (ECM) components. Regarding these deficiencies, this study developed an optimized multichannel ANA by a modified decellularization method. These innovative ANAs were demonstrated to retain more ECM bioactive molecules and regenerative factors, with effective elimination of cellular antigens. The presence of microchannels with larger pore size allowed ANAs to gain higher porosity and better swelling performance, which improves their internal ultrastructure. Their mechanical properties were more similar to those of native nerves. Moreover, the optimized ANAs exhibited good biocompatibility and possessed significant advantages in supporting the proliferation and migration of Schwann cells in vitro. The in vivo results further confirmed their superior capacity to promote axon regrowth and myelination as well as restore innervation of target muscles, leading to better functional recovery than the conventional ANAs. Overall, this study demonstrates that the optimized multichannel ANAs have great potential for clinical application and offer new insight into the further improvement of ANAs.

Assessment of halotolerant bacterial and fungal consortia for augmentation of wheat in saline soils.

Adaptations of green technologies to counter abiotic stress, including salinity for crops like wheat by using halotolerant microbes, is a promising approach. The current study investigated 17 salt-affected agroecological zones from the Punjab and Sindh provinces of Pakistan to explore the potential of indigenous microbial flora, with their multiple biochemical characteristics in addition to plant growth promoting (PGP) traits, for enhanced wheat production in saline areas. Initially, 297 isolated pure bacterial colonies were screened for salt tolerance, biochemical, and PGP traits. Three bacterial strains belonging to Pantoea spp. and Erwinia rhaphontici with possession of multiple characteristics were selected for the development of the halotolerant bacterial consortium. Inoculation of two local wheat varieties, Faisalabad 2008 and Galaxy 2013, with the consortium for in vitro seed germination assay and sand microcosm experiments exhibited significant improvement of selected plant growth parameters like germination percentage and root structure. Two previously reported PGP fungal strains of Trichoderma harzianum and T. viridae were also used as fungal consortium separately for pot experiments and field trials. The pot experiments exhibited a positive correlation of consortia with metabolic viz. catalase, peroxidase, and proline and agronomical parameters including shoot length, dry weight, number of spikes, spike length, and 100 grain weight. To evaluate their performance under natural environmental conditions, field trials were conducted at three salt-affected sites. Agronomical attributes including days of flowering and maturity, flag leaf weight, length and width, shoot length, number of spikes, spike length, spike weight, number of seeds spike-1, 1,000 grain weight, and plot yield indicated the efficiency of these microbes to enhance wheat growth. Concisely, the bacterial consortium showed better performance and Faisalabad 2008 was a more resistant variety as compared to Galaxy 2013. Initial promising results indicate that further extensive research on indigenous microbes might lead to the development of Pakistan's first saline-specific biofertilizers and sustainable eco-friendly agriculture practices.

Assessment of essential and toxic elemental concentrations in tumor and non-tumor tissues with risk of colorectal carcinoma in Pakistan.

BACKGROUND: Colorectal tumor is a major cause of cancer morbidity and mortality both in USA and around the globe. Exposure to environmental toxicants such as toxic trace elements has been implicated in colorectal malignancy. However, data linking them to this cancer are generally lacking. METHODS: Accordingly, the current study was to investigate the distribution, correlation and chemometric evaluation of 20 elements (Ca, Na, Mg, K, Zn, Fe, Ag, Co, Pb, Sn, Ni, Cr, Sr, Mn, Li, Se, Cd, Cu, Hg and As) in the tumor tissues (n = 147) and adjacent non tumor tissues (n = 147) of same colorectal patients which were analyzed by flame atomic absorption spectrophometry employing nitric acid-perchloric acid based wet digestion method. RESULTS: On the average, Zn (p < 0.05), Ag (p < 0.001), Pb (p < 0.001), Ni (p < 0.01), Cr (p < 0.005) and Cd (p < 0.001) showed significantly higher levels in the tumor tissues compared with the non tumor tissues of patients, whereas mean levels of Ca (p < 0.01), Na (p < 0.05), Mg (p < 0.001), Fe (p < 0.001), Sn (p < 0.05) and Se (p < 0.01), were significantly elevated in the non tumor tissues than the tissues of tumor patients. Most of the elements revealed markedly disparities in their elemental levels based on food (vegetarian/nonvegetarian) habits and smoking (smoker/nonsmoker) habits of donor groups. The correlation study and multivariate statistical analyses demonstrated some significantly divergent associations and apportionment of the elements in the tumor tissues and non tumor tissues of donors. Noticeably, variations in the elemental levels were also noted for colorectal tumor types (lymphoma, carcinoids tumor and adenocarcinoma) and stages (I, II, III, & IV) in patients. CONCLUSION: Overall, the study revealed that disproportions in essential and toxic elemental concentrations in the tissues are involved in pathogenesis of the malignancy. These findings provide the data base that helps to oncologist for diagnosis and prognosis of colorectal malignant patients.

The dynamic change trends and internal driving factors of green development efficiency: robust evidence from resource-based Yellow River Basin cities.

Promoting the green development of resource-based cities is an essential way to achieve sustainable regional economic development. Based on 2009-2019 panel data of the Yellow River Basin cities, this study adopts the super-directional distance function model to measure the green development efficiency of these selected cities. Furthermore, based on the Malmquist-Luenberger index, this paper focuses on the dynamic change trend of green development efficiency and internal driving factors. Furthermore, the Tobit model is used to specifically explore the influencing factors affecting the green development of cities. The findings suggested that the green development efficiency of selected cities falls in the middle to high range and that the efficiency varies among all cities in the Yellow River Basin. Likewise, technical efficiency improvements and technological progress drive development efficiency, and the former contributes more to green development. However, financial development, energy structure adjustments, and environmental regulation can strongly contribute to the green development of cities, and each influencing factor has obvious temporal and regional differences. This paper proposes appropriate policy suggestions to promote the coordinated development of the economic development and environmental protection of the Yellow River Basin.

Assessment of potentially toxic metal(loid)s contamination in soil near the industrial landfill and impact on human health: an evaluation of risk.

The generation of solid waste is increasing with each passing day due to rapid urbanization and industrialization and has become a matter of concern for the international community. Leachate leakages from landfills pollute the soil and can potentially harm the human health. In this paper, inductively coupled plasma-optical emission spectrometric studies were employed to assess and analyze the composition of metals (Ba, Cd, Pb, Hg, Cu, Cr and Mn) and metalloid (As) in soil samples. Results of Cr, Mn, Cu, As, Ba, Cd, Pb and Hg from CRM (certified reference material, SRM 2709a) of San Joaquin soil were evaluated and reported in terms of percent recoveries which were in the range of 97.6-102.9% and show outstanding extraction efficiency. Other than copper, where the permitted limit set by the EU is specified as 50-140 mg/kg in soil, the average amount of all the metals in soil was found within the permissible limits provided by WHO, the European Community (EU) and US EPA. Soil contaminated with Hg (PERI = 100) and Cd (PERI = 145.50) posed an ecological risk significantly. Pollution load index (PLI) value is greater than 1, while degree of contamination (Cdeg) value is less than 32 which indicated that the soil is polluted and considerably contaminated with metals and metalloid, respectively. In terms of the average daily dosage (ADD) of soil, children received the highest doses of all metals (ADDing = 1.315 × 10-7 - 2.470 × 10-3 and ADDderm = 9.939 × 10-7 - 5.292 × 10-11), whereas ADDing (1.409 × 10-8 - 2.646 × 10-4) was found greater in adults. For all metals except for Ba, the hazard quotient (HQ) trend in both children and adults was observed to be HQing > HQderm > HQinh of soil. Children who are at the lower edge of cancer risk had a lifetime cancer risk (LCR) of 2.039 × 10-4 for Cr from various paths of soil exposure.

A comparative study based on performance and techno-economic analysis of different strategies for PV-Electrolyzer (green) hydrogen fueling incinerator system.

The integration of hydrogen in the primary energy mix requires a major technological shift in virtually every energy-related application. This study has attempted to investigate the techno-economic solar photovoltaic (PV) integrated water electrolysis and waste incineration system. Three different strategies, i.e., (i) PV + Battery(Hybrid mode with required batteries); (ii) auto-ignition (Direct coupling); and (iii) PV + Secondary-Electrolyzer(Direct coupling assisted with secondary electrolyzer), have been envisioned. The 'PV + Battery' consume 42.42 % and 15.07 % less energy than the auto-ignition and 'PV + Secondary-Electrolyzer' methods. However, the capital cost of 'PV + Battery' has been calculated to be 15.4 % and 11.8 % more than auto-ignition and 'PV + Secondary-Electrolyzer, respectively.The energy consumption relative to waste input, the 'PV + Battery' method used 80 % less energy, while auto-ignition and 'PV + Secondary-Electrolyzer' showed 70.5 % and 77.5 % less energy, respectively. Furthermore, these approaches showed a vast difference in cost-benefit for the longer run. 'PV + Battery' was forecasted to be 73.3 % and 23.3 % more expensive than auto-ignition and 'PV + Secondary-Electrolyzer' methods, respectively, for 30 years. Overall, this study can benefit from using either of these methods depending on the application, usage scale, and climatic conditions.

Modified matrix solid phase dispersion-HPLC method for determination of pesticide residue in vegetables and their impact on human health: A risk assessment.

The use of pesticides is unavoidable in agricultural practices. This class of chemicals is highly toxic for the environment as well as for humans. The present work was carried out to assess the presence of some pesticides (diafenthiuron, lufenuron, azoxystrobin, difenoconazole, and chlorothalonil) residues in five of the very commonly used vegetables (eggplant, capsicum, apple gourd, cauliflower, and sponge gourd). Matrix solid phase dispersion (MSPD) technique was used to extract the pesticides and subsequently their quantification was performed through high performance liquid chromatography (HPLC) coupled to ultraviolet-visible (UV-Vis) detector. The elution was accomplished at wavelength of 254 nm by injecting 20 µL of standards or samples into chromatographic system. The mobile phase consisted of acetonitrile and water (80:20 v/v), where the flow rate was adjusted at 1.0 ml/min. The linearity was good (R 2 ≥ 0.994) over a concentration range from 20 to 100 µg/ml for the investigated pesticides. The low detection limits showed a quite appreciable potential of the method to detect (1.12-1.61 µg/L) and quantify (3.73-5.36 µg/ml) the pesticides under study. The accuracy was demonstrated in terms of percent recovery which ranged between 88.5% and 116.9% for all the pesticides under investigation. These results justify the suitability of the technique for the intended purpose. The concentration of difenoconazole in apple gourd (20.97 mg/kg), cauliflower (10.28 mg/kg), and sponge gourd (40.32 mg/kg) whereas diafenthiuron in cauliflower (0.66 mg/kg) exceeded the maximum residue level (MRLs) as defined by Food and Agriculture Organization of the United Nations and the World Health Organization (FAO/WHO). Target hazard quotient (THQ) values of difenoconazole and diafenthiuron (except for adults) were more than one which indicates the significant effect on human health on consumption of apple gourd, cauliflower, and sponge gourd.

A Brief Assessment on Recent Developments in Efficient Electrocatalytic Nitrogen Reduction with 2D Non-Metallic Nanomaterials.

In recent years, the synthesis of ammonia (NH3) has been developed by electrocatalytic technology that is a potential way to effectively replace the Haber-Bosch process, which is an industrial synthesis of NH3. Industrial ammonia has caused a series of problems for the population and environment. In the face of sustainable green synthesis methods, the advantages of electrocatalytic nitrogen reduction for synthesis of NH3 in aqueous media have attracted a great amount of attention from researchers. This review summarizes the recent progress on the highly efficient electrocatalysts based on 2D non-metallic nanomaterial and provides a brief overview of the synthesis principle of electrocatalysis and the performance measurement indicators of electrocatalysts. Moreover, the current development of N2 reduction reaction (NRR) electrocatalyst is discussed and prospected.

Morphological, physiological and molecular assessment of cotton for drought tolerance under field conditions.

Climate change could be an existential threat to many crops. Drought and heat stress are becoming harder for cultivated crops. Cotton in Pakistan is grown under natural high temperature and low moisture, could be used as a source of heat and drought tolerance. Therefore, the study was conducted to morphological, physiological and molecular characterization of cotton genotypes under field conditions. A total of 25 cotton genotypes were selected from the gene pool of Pakistan based on tolerance to heat and drought stress. In field trail, the stress related traits like boll retention percentage, plant height, number of nodes and inter-nodal distance were recorded. In physiological assessment, traits such as photosynthesis rate, stomatal conductance, transpiration rate, leaf temperature, relative water content and excised leaf water loss were observed. At molecular level, a set of 19 important transcription factors, controlling drought/heat stress tolerance (HSPCB, GHSP26, HSFA2, HSP101, HSP3, DREB1A, DREB2A, TPS, GhNAC2, GbMYB5, GhWRKY41, GhMKK3, GhMPK17, GhMKK1, GhMPK2, APX1, HSC70, ANNAT8, and GhPP2A1) were analyzed from all genotypes. Data analyses depicted that boll retention percentage, photosynthesis, stomatal conductance, relative water content under the stress conditions were associated with the presence of important drought & heat TF/genes which depicts high genetic potential of Pakistani cotton varieties against abiotic stress. The variety MNH-886 appeared in medium plant height, high boll retention percentage, high relative water content, photosynthesis rate, stomatal conductance, transpiration rate and with maximum number transcription factors under study. The variety may be used as source material for heat and drought tolerant cotton breeding. The results of this study may be useful for the cotton breeders to develop genotype adoptable to environmental stresses under climate change scenario.

COVID-19 and inequalities: the need for inclusive policy response.

In this essay, the authors analyze the COVID-19 pandemic from the perspective of inequalities and socio-economic vulnerabilities. We argue that the current pandemic has been looked at mainly through the lens of biology, leaving sociological blind spots in the response to this pandemic that have had adverse effects. We conclude with the suggestion that apart from recommendations from health sciences, policy makers must also take into account local societal structures in order to design effective policies to control the contagion.

Fixation of distal radius fractures using wide-awake local anaesthesia with no tourniquet (WALANT) technique: A randomized control trial of a cost-effective and resource-friendly procedure.

AIMS: We hypothesized that the wide-awake local anaesthesia with no tourniquet (WALANT) technique is cost-effective, easy to use, safe, and reproducible, with a low learning curve towards mastery, having a high patient satisfaction rate. Furthermore, WALANT would be a suitable alternative for the austere and developing nation environments where lack of funds and resources are a common issue. METHODS: This was a randomized control trial of 169 patients who required surgery for closed isolated distal radius fractures. The study was performed between March 2016 and April 2019 at a public sector level 1 trauma centre. General anaesthesia was used in 56 patients, Bier's block in 58 patients, and WALANT in 55 patients. Data were collected on pre-, peri-, and postoperative parameters, clinical outcome, hospital costs, and patient satisfaction. One-way analysis of variance (ANOVA) was used with a p-value of 0.05 being significant. RESULTS: Operations with WALANT proceeded sooner, and patients recovered faster, resulting in mean fewer missed working days (7.8 (SD 1.67)) compared with general anaesthesia (20.1 (SD 7.37)) or Bier's block (14.1 (SD 7.65)) (p < 0.001). The WALANT patients did not develop complications, while the other patients did (p < 0.04). Clinical outcomes did not differ, nor did surgeon qualification affect clinical outcomes. Mean hospital costs were lower for WALANT ($428.50 (SD 77.71)) than for general anaesthesia ($630.63 (SD 114.77)) or Bier's block ($734.00 (SD 37.54)) (p < 0.001). Patient satisfaction was also higher (p < 0.001). CONCLUSION: WALANT for distal radius fractures results in a faster recovery, is more cost-effective, has similar clinical outcomes, and has fewer complications than general anaesthesia or Bier's block. This makes WALANT an attractive technique in any setting, but especially in middle- and low-income countries.Cite this article: Bone Joint Res 2020;9(7):429-439.

Efficient pyrolysis of ginkgo biloba leaf residue and pharmaceutical sludge (mixture) with high production of clean energy: Process optimization by particle swarm optimization and gradient boosting decision tree algorithm.

Production of sustainable clean energy can be achieved by co-pyrolysis of agricultural residues and wastewater sludge. Herein, non-additive thermal behaviour of co-pyrolysis of pharmaceutical sludge and ginkgo biloba leaf residues was investigated. Synergistic effect of co-pyrolysis was not obvious at elevated temperatures. Further, kinetics of co-pyrolysis was studied by fitting Coats-Redfern integration method to thermogravimetric (TG) curve. The change of heat and mass transfer in the reactor caused the change of dynamic parameters. Moreover, hybrid particle swarm optimization and gradient boosting decision tree (PSO-GBDT) algorithm was designed to boost the energy production at full-scale pyrolysis plant by monitoring TG curves. PSO-GBDT model well predicts mass loss rate of the mixture at different heating rates confirming that co-pyrolysis of PS and GBLR can results in high energy production by increasing PS pyrolysis. Designing PSO-GBDT model help to reduced waste production by resourceful treatment of waste in to energy.

Doctors' Interactions with Pharmaceutical Sales Representatives: Modelling Doctors Prescription Behaviour.

Using theory of planned behaviour, this study seeks to examine the effect of health practitioner's interaction with pharmaceutical sales representatives on their prescription behaviour. Data was collected from 248 health practitioners working in the city of Attock and from five Tehsils of Attock District through questionnaires with a net response rate of 82%. The hypothesis was tested by PLS Path Modelling. The major findings of the study were that physicians' interactions with pharmaceutical sales representatives in terms of market knowledge, product knowledge, corporate reputation and tangible rewards affect the prescription behaviour of physicians directly as well as through the mediating effect of the attitudinal component. The findings of the study would be helpful for the pharmaceutical industry as well as for drug regulatory authorities and health policy makers towards unethical practices in the medical field. Study provided practical implications for policy makers and health practitioners. Moreover, future directions for research were also provided.