Spatio-temporal analysis of spatial accessibility to primary health care in Bhutan

© 2015 by the authors; licensee MDPI, Basel, Switzerland. Geographic information systems (GIS) can be effectively utilized to carry out spatio-temporal analysis of spatial accessibility to primary healthcare services. Spatial accessibility to primary healthcare services is commonly measured using floating catchment area models which are generally defined with three variables; namely, an attractiveness component of the service centre, travel time or distance between the locations of the service centre and the population, and population demand for healthcare services. The nearest-neighbour modified two-step floating catchment area (NN-M2SFCA) model is proposed for computing spatial accessibility indices for the entire country. Accessibility values from 2010 to 2013 for Bhutan were analysed both spatially and temporally by producing accessibility ranking maps, plotting Lorenz curves, and conducting spatial clustering analysis. The spatial accessibility indices of the 205 sub-districts show great disparities in healthcare accessibility in the country. The mean-and median-based classification results indicate that, in 2013, 24 percent of Bhutan's population have poor access to primary healthcare services, 66 percent of the population have medium-level access, and 10 percent have good access

Spatio-temporal modelling and analysis of spatial accessibility to primary health care: A case study of Bhutan

Both spatial and aspatial dimensions of healthcare system are important in strengthening the healthcare system of any country. Knowing the spatial aspects of healthcare accessibility can help develop proper health policies in planning equitable allocation of health resources across the country. This thesis deals with the modelling of population and spatial accessibility using GIS, and an analysis of spatial and temporal changes in accessibility to healthcare services in Bhutan

Spatial Patterns Associating Low Birth Weight with Environmental and Behavioral Factors

Low birth weight (LBW) is a significant public health problem in the world. It was estimated globally by the World Health Organization (WHO) that prevalence of LBW was 15% of all births. In Murung Raya district LBW cases remain high. This paper aimed to identify and discuss the relationship between environmental risk factors with LBW in Murung Raya.A spatial analysis was conducted with 150 women as the total participantswho were recruited through the incidence data in 2013-2014. The questionnaires, medical records, and geographic data were measured by Stata software, ArcGis, SatScan, and Geoda. The study results indicated there was significant correlation between health behavior and environmental variables with the strength of external neighborhood effect across LBW risk factors. More intense clustering of high values (hot spots) was found through the spatial analysis showing that most of the cases were located near the defined buffer zone. This research demonstrates that the spatial pattern analysis provided greater statistical power to detect an effect that was not apparent in the previous epidemiology studies

Studies on the epidemiology and control of rabies in Bhutan

Rabies, a fatal and neglected zoonotic disease, is reported mainly from the southern parts of Bhutan bordering India, but sporadic occurrences have been reported in other, previously free areas. Domestic dogs play a principal role in the transmission of rabies and no wildlife rabies cases have been reported so far in Bhutan. Although rabies has been endemic and causes substantial financial losses, no detailed studies have been conducted to understand the epidemiology of rabies in Bhutan. The overall objective of this research was to better understand the epidemiology of animal and human rabies and estimate the cost of various rabies intervention measures in humans and animals. This was the first epidemiologic research on rabies ever conducted in Bhutan. Rabies surveillance data (1996 to 2009) and field surveys were used for this epidemiologic research. The spatial and temporal distribution of animal rabies cases was examined by using a Geographic Information System and time series analysis approaches. The study showed that 59 of the 205 sub-districts in Bhutan reported animal rabies from 1996 to 2009 with increased incidences in the four districts in southern parts of Bhutan. Significant (P<0.05) clusters of cases were observed in south central and south west Bhutan. More cases were reported in cattle (n=447) and domestic dogs (n=317) and a significant cross correlation between the number of reported cases in dogs and other domestic animals was demonstrated, wherein the report of cases in dogs predicted cases in other domestic animals. Rabies cases were reported throughout the year with more reports during spring and summer months, likely to be associated with the breeding season of dogs. The annual patterns of cases were relatively stable until 2005, but increased in 2006 and 2008. This increased incidence was associated with re-emergence of rabies in eastern and south west Bhutan between 2005 and 2008, areas that had been previously free from rabies. This major rabies outbreak in eastern Bhutan resulted in one human and 256 domestic animal deaths while the outbreak in south west Bhutan resulted in 97 animal deaths; both outbreaks caused serious financial losses to society. During these outbreaks, large numbers of people (~2000) were directly or indirectly exposed to either suspected rabid animals or animal products derived from rabid animals and were given post-exposure prophylaxis. The outbreak in eastern Bhutan was believed to have been due to an incursion from across the border while local spread from the endemic areas or an incursion was hypothesized in the south-west Bhutan outbreak. The high densities and movements of stray dogs with inadequate control measures were responsible for the rapid spread and persistence of the infection for about two years (from May 2005 to November 2007) in eastern Bhutan. In contrast, the outbreak in south west Bhutan during 2008 was controlled within six months by culling of stray dogs, mass dog vaccination, and impounding of dogs. Anthropogenic factors − including human population characteristics and its movement, road network accessibility, and high dog density − played a major role in the spread of disease during both of these outbreaks. The assessment of risk factors for the occurrence of rabies at the sub-district level identified the socio-demographic and anthropogenic factors significantly associated with reporting of rabies in domestic animals in Bhutan. Sharing a common border with India was found to be the most important individual predictor of the overall distribution of rabies occurrence in Bhutan (odds ratio 10.43; 95% CI: 4.42–24.64; P<0.001). Of the 59 sub-districts that reported rabies in Bhutan, 43 (73%) shared a border with India. The trans-border movement or translocation of stray dogs and an inadequate control program may be responsible for the maintenance of rabies endemicity and transmission among the stray dog population in these border areas. Molecular and phylogenetic analyses further demonstrated that Bhutanese rabies virus isolates were found to be closely related to Indian rabies virus strain and belong to Arctic-like-1 viruses which are widely circulating in the Indian sub-continent. This study suggests that the rabies viruses spreading in southern parts of Bhutan have originated from a common ancestor. However, more sampling is needed from Bhutan-India border areas to understand the transmission dynamic of rabies virus in the region. In humans, rabies cases were found to be sporadic, mainly reported in the canine rabies endemic areas of southern Bhutan. A total of 15 human rabies deaths was reported between January 2006 and July 2011 (with 5 deaths reported in 2011 alone), equivalent to a cumulative incidence of 2.14 per 100000 population (annual incidence of 0.28 per 100000 people). Although the number of human rabies deaths was sporadic, there were increased number of dog bite incidents and post-exposure prophylaxis (PEP) administration to the patients. In order to understand the use and distribution of rabies PEP in humans, PEP data for the period from 2005 to 2008 were retrieved from the hospital medical database and analysed. The study showed that PEP was provided to the patients free of charge by the medical hospitals in Bhutan, and followed the 5-dose Essen intramuscular regimen. A significant (P<0.001) difference in gender and age groups receiving PEP was observed: males received more PEP than females across all age groups. Children − particularly 5–9 years of age − received more PEP than other age groups, indicating children and males are more at risk of rabies exposure in Bhutan. PEP was provided throughout the year with a higher number of doses administered during the winter and spring months, and was given to both animal bite and non-bite exposures. The study also identified a lack of patient compliance to complete the course of PEP: some 40% (n = 3360) of the patients received an incomplete course of vaccine (less than the required course of 5-doses). However, the results suggest that patients with animal bite injury were less likely to receive an incomplete vaccine course than non-bite recipients. Secondly, patients presented to hospitals in rabies endemic or outbreak areas were less likely to receive an incomplete course than in rabies free interior Bhutan, thus reducing the chances of vaccination failures. The study also showed that the PEP was provided to patients that have low or no risk of rabies exposure. Therefore, a thorough assessment of each individual case based on the WHO guidelines would reduce unnecessary use of PEP, and therefore costs in Bhutan. The main reason for providing PEP was found to be due to dog bites. To better understand the dog bites incidents in humans, a hospital-based survey was conducted at the three hospitals in Western and Southern Bhutan (Thimphu, Phuentsholing and Gelephu) for a period of nine months. The study revealed that dog bites in human are common in the survey areas and showed significant (P<0.001) gender and age differences in bite incidents. Males were more at risk of dog bites than females, and the children aged 5–9 years were bitten more than other age groups, which substantiate our earlier findings of more use of PEP in males and children. The majority of victims were bitten by stray dogs, and the most common anatomical bite sites were on the legs. Using data on the anatomical location of dog bites in humans and a probability of dying from rabies, a decision tree model was constructed to estimate human deaths from rabies in two rabies endemic areas of southern Bhutan. Based on the official reported cases of rabies in two hospital areas (Gelephu and Phuentsholing) in southern Bhutan, the average number of human rabies death was 1.5 (95% CI: 0.75–3.00) per year, equivalent to an annual incidence of 3.14 (95% CI: 1.57–6.29) per 100,000 population. The decision tree model predicted 2.23 (95% CI: 1.20−3.59) human deaths from rabies per year, equivalent to an annual incidence of 4.67 (95% CI: 2.53–7.53) deaths per 100,000 populations. This indicated that no major underreporting of human rabies deaths has occurred, unlike in other rabies endemic countries, although some underreporting of dog bites is possible. In the absence of post-exposure prophylaxis, the model predicted 19.24 (95% CI: 13.69–25.14) deaths per year, equivalent to an annual incidence of 40.31 (95% CI: 28.70–52.68) per 100,000 population, suggesting post-exposure prophylaxis is important to prevent human rabies deaths. Since both dog bite incidents and the use of PEP were high in Bhutan, a cross-sectional study was conducted at Gelephu (south central Bhutan), an area endemic for rabies, to understand people’s level of knowledge and awareness about rabies. The study showed that a majority of the interviewed respondents had heard of rabies, and had a positive attitude towards the prevention and control of rabies. About 84 to 92% of the respondents also mentioned that they would report to the hospital for treatment if bitten by dogs and other animals, indicating good health seeking behaviours of the people. The respondents also had a positive attitude towards prevention and control of rabies in dogs by vaccination. However, these findings also indicated the existence of some knowledge gaps (knowledge about rabies and its transmission and importance of wound washing) which could be filled by creating awareness education programmes on: the danger of rabies and mode of transmission to humans and importance washing animal bite wound and visiting a hospital for post-exposure prophylaxis. Since rabies causes substantial financial losses to society, understanding the cost-benefit or cost-effectiveness of the intervention programme is important. Quantification of the financial cost of rabies intervention in Bhutan suggested that the average direct medical cost of human PEP (using rabies vaccine only) was approximately Bhutanese Ngultrum (Nu) 1615 (US$35.65) per 5-dose Essen regimen per patient. The cost would increase to Nu. 2497 (US$ 55.13) and Nu. 19633 (US$433.41) per patient, if one dose of either equine rabies immunoglobulin (ERIG) or human rabies immunoglobulin (HRIG) was administered, respectively. The societal cost (public plus private cost) per patient was estimated to be Nu. 2019 (US$ 45), Nu. 2901 (US$64), and Nu. 20037 (US$ 442) using vaccine alone, vaccine with ERIG and vaccine with HRIG, respectively. The average cost per dog vaccination was estimated to be Nu. 75 (US$1.66) and the cost per dog sterilization was estimated to be Nu. 288 (US$ 6.52). The total direct medical cost due to rabies (including surveillance and livestock loss cost, PEP in human and dog vaccination and sterilization) between 2001 and 2008 was estimated to be Nu. 48.54 million (US$ 1.07 million). The analysis also showed that mass dog vaccination would be more cost-effective than intensified post-exposure prophylaxis in human alone. The above findings suggest that an area bordering India in the south were at higher risk of reporting rabies than the interior of Bhutan. More resources for rabies control programs and surveillance should be targeted and focussed in the highly endemic ‘hot spot’ areas of southern Bhutan. Mass vaccination of dogs in the border areas in the south would create an immune buffer (cordon sanitaire) and prevent incursion of rabies into interior Bhutan. A One-Health approach for rabies control in Bhutan should be implemented towards elimination of rabies through creation of effective partnership focussing on coordinating research, operational activities and pooling of resources between public health and veterinary services. Elimination of rabies through mass dog vaccination would reduce the recurrent cost of intensified PEP in humans and will produce economic savings in the long run by preventing human and livestock deaths and by discontinuing the intensified use of PEP in humans and rabies control programmes. Public awareness education is necessary and should include: the risk of rabies exposure; importance of preventing dog bites and wound washing and visiting health centres following dog bites and exposure to suspected rabid animals. Epidemiological surveillance of rabies should be improved by the laboratory confirmation of all suspected cases, including human, and the data so generated should be shared between the public health and veterinary sectors and also relevant international organizations. International collaboration is necessary for technical and financial support for sustaining rabies control in Bhutan

Spatial Analyses of Low Birth Weight Incidence, Indonesia

The etiology of Low Birth Weight (LBW) in Murung Raya is still unclear. This study aimed to find out the relationship between environmental and health behavior risk factors of LBW in Murung Raya. 150 women were recruited through the incidence data 2013- 2014, and the questionnaires, medical records, and geographic data were measured by McNemar, ANOVA, logistic, IRR, MI, z (Gi), and NNI tests. Bivariate analysis showed significant correlation of LBW with TBA care OR= 10, drinking popa OR= 5, smoking OR= 6.1, and accessibility OR = 2.3, with adjusted OR for TBA care OR= 32.78, ANC OR= 27.52 revealing trend lines with ANOVA F=49, and clustering RR=7, MI >0 (four clusters), z (Gi) >1 (two high clusters), and NNI>1 (two high clusters). The spatial analysis provided greater statistical power to detect an effect that was not apparent in the case-control study. This study suggests that preventions, interventions and treatment for LBW not only be conducted by the current epidemiology approach but also by new modern geographic positioning analysis

Studies on the epidemiology and control of rabies in Bhutan

Rabies, a fatal and neglected zoonotic disease, is reported mainly from the southern parts of Bhutan bordering India, but sporadic occurrences have been reported in other, previously free areas. Domestic dogs play a principal role in the transmission of rabies and no wildlife rabies cases have been reported so far in Bhutan. Although rabies has been endemic and causes substantial financial losses, no detailed studies have been conducted to understand the epidemiology of rabies in Bhutan. The overall objective of this research was to better understand the epidemiology of animal and human rabies and estimate the cost of various rabies intervention measures in humans and animals. This was the first epidemiologic research on rabies ever conducted in Bhutan. Rabies surveillance data (1996 to 2009) and field surveys were used for this epidemiologic research. The spatial and temporal distribution of animal rabies cases was examined by using a Geographic Information System and time series analysis approaches. The study showed that 59 of the 205 sub-districts in Bhutan reported animal rabies from 1996 to 2009 with increased incidences in the four districts in southern parts of Bhutan. Significant (P<0.05) clusters of cases were observed in south central and south west Bhutan. More cases were reported in cattle (n=447) and domestic dogs (n=317) and a significant cross correlation between the number of reported cases in dogs and other domestic animals was demonstrated, wherein the report of cases in dogs predicted cases in other domestic animals. Rabies cases were reported throughout the year with more reports during spring and summer months, likely to be associated with the breeding season of dogs. The annual patterns of cases were relatively stable until 2005, but increased in 2006 and 2008. This increased incidence was associated with re-emergence of rabies in eastern and south west Bhutan between 2005 and 2008, areas that had been previously free from rabies. This major rabies outbreak in eastern Bhutan resulted in one human and 256 domestic animal deaths while the outbreak in south west Bhutan resulted in 97 animal deaths; both outbreaks caused serious financial losses to society. During these outbreaks, large numbers of people (~2000) were directly or indirectly exposed to either suspected rabid animals or animal products derived from rabid animals and were given post-exposure prophylaxis. The outbreak in eastern Bhutan was believed to have been due to an incursion from across the border while local spread from the endemic areas or an incursion was hypothesized in the south-west Bhutan outbreak. The high densities and movements of stray dogs with inadequate control measures were responsible for the rapid spread and persistence of the infection for about two years (from May 2005 to November 2007) in eastern Bhutan. In contrast, the outbreak in south west Bhutan during 2008 was controlled within six months by culling of stray dogs, mass dog vaccination, and impounding of dogs. Anthropogenic factors − including human population characteristics and its movement, road network accessibility, and high dog density − played a major role in the spread of disease during both of these outbreaks. The assessment of risk factors for the occurrence of rabies at the sub-district level identified the socio-demographic and anthropogenic factors significantly associated with reporting of rabies in domestic animals in Bhutan. Sharing a common border with India was found to be the most important individual predictor of the overall distribution of rabies occurrence in Bhutan (odds ratio 10.43; 95% CI: 4.42–24.64; P<0.001). Of the 59 sub-districts that reported rabies in Bhutan, 43 (73%) shared a border with India. The trans-border movement or translocation of stray dogs and an inadequate control program may be responsible for the maintenance of rabies endemicity and transmission among the stray dog population in these border areas. Molecular and phylogenetic analyses further demonstrated that Bhutanese rabies virus isolates were found to be closely related to Indian rabies virus strain and belong to Arctic-like-1 viruses which are widely circulating in the Indian sub-continent. This study suggests that the rabies viruses spreading in southern parts of Bhutan have originated from a common ancestor. However, more sampling is needed from Bhutan-India border areas to understand the transmission dynamic of rabies virus in the region. In humans, rabies cases were found to be sporadic, mainly reported in the canine rabies endemic areas of southern Bhutan. A total of 15 human rabies deaths was reported between January 2006 and July 2011 (with 5 deaths reported in 2011 alone), equivalent to a cumulative incidence of 2.14 per 100000 population (annual incidence of 0.28 per 100000 people). Although the number of human rabies deaths was sporadic, there were increased number of dog bite incidents and post-exposure prophylaxis (PEP) administration to the patients. In order to understand the use and distribution of rabies PEP in humans, PEP data for the period from 2005 to 2008 were retrieved from the hospital medical database and analysed. The study showed that PEP was provided to the patients free of charge by the medical hospitals in Bhutan, and followed the 5-dose Essen intramuscular regimen. A significant (P<0.001) difference in gender and age groups receiving PEP was observed: males received more PEP than females across all age groups. Children − particularly 5–9 years of age − received more PEP than other age groups, indicating children and males are more at risk of rabies exposure in Bhutan. PEP was provided throughout the year with a higher number of doses administered during the winter and spring months, and was given to both animal bite and non-bite exposures. The study also identified a lack of patient compliance to complete the course of PEP: some 40% (n = 3360) of the patients received an incomplete course of vaccine (less than the required course of 5-doses). However, the results suggest that patients with animal bite injury were less likely to receive an incomplete vaccine course than non-bite recipients. Secondly, patients presented to hospitals in rabies endemic or outbreak areas were less likely to receive an incomplete course than in rabies free interior Bhutan, thus reducing the chances of vaccination failures. The study also showed that the PEP was provided to patients that have low or no risk of rabies exposure. Therefore, a thorough assessment of each individual case based on the WHO guidelines would reduce unnecessary use of PEP, and therefore costs in Bhutan. The main reason for providing PEP was found to be due to dog bites. To better understand the dog bites incidents in humans, a hospital-based survey was conducted at the three hospitals in Western and Southern Bhutan (Thimphu, Phuentsholing and Gelephu) for a period of nine months. The study revealed that dog bites in human are common in the survey areas and showed significant (P<0.001) gender and age differences in bite incidents. Males were more at risk of dog bites than females, and the children aged 5–9 years were bitten more than other age groups, which substantiate our earlier findings of more use of PEP in males and children. The majority of victims were bitten by stray dogs, and the most common anatomical bite sites were on the legs. Using data on the anatomical location of dog bites in humans and a probability of dying from rabies, a decision tree model was constructed to estimate human deaths from rabies in two rabies endemic areas of southern Bhutan. Based on the official reported cases of rabies in two hospital areas (Gelephu and Phuentsholing) in southern Bhutan, the average number of human rabies death was 1.5 (95% CI: 0.75–3.00) per year, equivalent to an annual incidence of 3.14 (95% CI: 1.57–6.29) per 100,000 population. The decision tree model predicted 2.23 (95% CI: 1.20−3.59) human deaths from rabies per year, equivalent to an annual incidence of 4.67 (95% CI: 2.53–7.53) deaths per 100,000 populations. This indicated that no major underreporting of human rabies deaths has occurred, unlike in other rabies endemic countries, although some underreporting of dog bites is possible. In the absence of post-exposure prophylaxis, the model predicted 19.24 (95% CI: 13.69–25.14) deaths per year, equivalent to an annual incidence of 40.31 (95% CI: 28.70–52.68) per 100,000 population, suggesting post-exposure prophylaxis is important to prevent human rabies deaths. Since both dog bite incidents and the use of PEP were high in Bhutan, a cross-sectional study was conducted at Gelephu (south central Bhutan), an area endemic for rabies, to understand people’s level of knowledge and awareness about rabies. The study showed that a majority of the interviewed respondents had heard of rabies, and had a positive attitude towards the prevention and control of rabies. About 84 to 92% of the respondents also mentioned that they would report to the hospital for treatment if bitten by dogs and other animals, indicating good health seeking behaviours of the people. The respondents also had a positive attitude towards prevention and control of rabies in dogs by vaccination. However, these findings also indicated the existence of some knowledge gaps (knowledge about rabies and its transmission and importance of wound washing) which could be filled by creating awareness education programmes on: the danger of rabies and mode of transmission to humans and importance washing animal bite wound and visiting a hospital for post-exposure prophylaxis. Since rabies causes substantial financial losses to society, understanding the cost-benefit or cost-effectiveness of the intervention programme is important. Quantification of the financial cost of rabies intervention in Bhutan suggested that the average direct medical cost of human PEP (using rabies vaccine only) was approximately Bhutanese Ngultrum (Nu) 1615 (US$35.65) per 5-dose Essen regimen per patient. The cost would increase to Nu. 2497 (US$ 55.13) and Nu. 19633 (US$433.41) per patient, if one dose of either equine rabies immunoglobulin (ERIG) or human rabies immunoglobulin (HRIG) was administered, respectively. The societal cost (public plus private cost) per patient was estimated to be Nu. 2019 (US$ 45), Nu. 2901 (US$64), and Nu. 20037 (US$ 442) using vaccine alone, vaccine with ERIG and vaccine with HRIG, respectively. The average cost per dog vaccination was estimated to be Nu. 75 (US$1.66) and the cost per dog sterilization was estimated to be Nu. 288 (US$ 6.52). The total direct medical cost due to rabies (including surveillance and livestock loss cost, PEP in human and dog vaccination and sterilization) between 2001 and 2008 was estimated to be Nu. 48.54 million (US$ 1.07 million). The analysis also showed that mass dog vaccination would be more cost-effective than intensified post-exposure prophylaxis in human alone. The above findings suggest that an area bordering India in the south were at higher risk of reporting rabies than the interior of Bhutan. More resources for rabies control programs and surveillance should be targeted and focussed in the highly endemic ‘hot spot’ areas of southern Bhutan. Mass vaccination of dogs in the border areas in the south would create an immune buffer (cordon sanitaire) and prevent incursion of rabies into interior Bhutan. A One-Health approach for rabies control in Bhutan should be implemented towards elimination of rabies through creation of effective partnership focussing on coordinating research, operational activities and pooling of resources between public health and veterinary services. Elimination of rabies through mass dog vaccination would reduce the recurrent cost of intensified PEP in humans and will produce economic savings in the long run by preventing human and livestock deaths and by discontinuing the intensified use of PEP in humans and rabies control programmes. Public awareness education is necessary and should include: the risk of rabies exposure; importance of preventing dog bites and wound washing and visiting health centres following dog bites and exposure to suspected rabid animals. Epidemiological surveillance of rabies should be improved by the laboratory confirmation of all suspected cases, including human, and the data so generated should be shared between the public health and veterinary sectors and also relevant international organizations. International collaboration is necessary for technical and financial support for sustaining rabies control in Bhutan

Spatial Patterns Associating Low Birth Weight with Environmental and Behavioral Factors

Low birth weight (LBW) is a significant public health problem in the world. It was estimated globally by the World Health Organization (WHO) that prevalence of LBW was 15% of all births. In Murung Raya district LBW cases remain high. This paper aimed to identify and discuss the relationship between environmental risk factors with LBW in Murung Raya.A spatial analysis was conducted with 150 women as the total participantswho were recruited through the incidence data in 2013-2014. The questionnaires, medical records, and geographic data were measured by Stata software, ArcGis, SatScan, and Geoda. The study results indicated there was significant correlation between health behavior and environmental variables with the strength of external neighborhood effect across LBW risk factors. More intense clustering of high values (hot spots) was found through the spatial analysis showing that most of the cases were located near the defined buffer zone. This research demonstrates that the spatial pattern analysis provided greater statistical power to detect an effect that was not apparent in the previous epidemiology studies

Assessment of primary healthcare accessibility and inequality in north-eastern Kazakhstan

Out of the many aspects of health care, the concept of physical accessibility is a priority that not only encompasses availability of health care resources, but also requires that they are easily accessible for all. To assess this factor as expressed in terms of the number of available physicians in the north-eastern part of Kazakhstan, we used the enhanced two-step float catchment area in a geographic information system approach. The Gini index and the Lorentz curve were used to evaluate the economic inequality within this region. Based on the data obtained, we developed models to increase the availability of health care considering allocation of additional primary health care resources. A low to zero index was found to be typical for most rural settlements, which currently make up less than 15% of the total population. We also identified a correlation between the index of accessibility and that of inequality, which indicates that areas with high accessibility show a more equitable distribution of resources. The developed location/ allocation models of additional primary health care resources can be useful in implementing government initiatives to improve the availability of primary health care in rural areas.info:eu-repo/semantics/publishedVersio

Capturing time in space : Dynamic analysis of accessibility and mobility to support spatial planning with open data and tools

Understanding the spatial patterns of accessibility and mobility are a key (factor) to comprehend the functioning of our societies. Hence, their analysis has become increasingly important for both scientific research and spatial planning. Spatial accessibility and mobility are closely related concepts, as accessibility describes the potential to move by modeling, whereas spatial mobility describes the realized movements of individuals. While both spatial accessibility and mobility have been widely studied, the understanding of how time and temporal change affects accessibility and mobility has been rather limited this far. In the era of ‘big data’, the wealth of temporally sensitive spatial data has made it possible, better than ever, to capture and understand the temporal realities of spatial accessibility and mobility, and hence start to understand better the dynamics of our societies and complex living environment. In this thesis, I aim to develop novel approaches and methods to study the spatio-temporal realities of our living environments via concepts of accessibility and mobility: How people can access places, how they actually move, and how they use space. I inspect these dynamics on several temporal granularities, covering hourly, daily, monthly, and yearly observations and analyses. With novel big data sources, the methodological development and careful assessment of the information extracted from them is extremely important as they are increasingly used to guide decision-making. Hence, I investigate the opportunities and pitfalls of different data sources and methodological approaches in this work. Contextually, I aim to reveal the role of time and the mode of transportation in relation to spatial accessibility and mobility, in both urban and rural environments, and discuss their role in spatial planning. I base my findings on five scientific articles on studies carried out in: Peruvian Amazonia; national parks of South Africa and Finland; Tallinn, Estonia; and Helsinki metropolitan area, Finland. I use and combine data from various sources to extract knowledge from them, including GPS devices; transportation schedules; mobile phones; social media; statistics; land-use data; and surveys. My results demonstrate that spatial accessibility and mobility are highly dependent on time, having clear diurnal and seasonal changes. Hence, it is important to consider temporality when analyzing accessibility, as people, transport and activities all fluctuate as a function of time that affects e.g. the spatial equality of reaching services. In addition, different transport modes should be considered as there are clear differences between them. Furthermore, I show that, in addition to the observed spatial population dynamics, also nature’s own dynamism affects accessibility and mobility on a regional level due to the seasonal variation in river-levels. Also, the visitation patterns in national parks vary significantly over time, as can be observed from social media. Methodologically, this work demonstrates that with a sophisticated fusion of methods and data, it is possible to assess; enrich; harmonize; and increase the spatial and temporal accuracy of data that can be used to better inform spatial planning and decision-making. Finally, I wish to emphasize the importance of bringing scientific knowledge and tools into practice. Hence, all the tools, analytical workflows, and data are openly available for everyone whenever possible. This approach has helped to bring the knowledge and tools into practice with relevant stakeholders in relation to spatial planning

Measuring Accessibility to Medical Centers in Isfahan City Using 2SFCA Method

AbstractOne of the most important challenges facing policymakers and urban planners in recent decades is the issue of accessibility to a variety of urban services. The main purpose of this study was thecalculation of the accessibility of census blocks to medical centers using the Two-Step Floating Catchment Area (2SFCA) method in Isfahan City. In the present study, according to the conditions with and without the limitations of the accessibility radii, different types of distance decay functions were used. The results showed that the 2SFCA method with the use of the cumulative opportunity negative linear function had the highest average of correlation for calculating accessibility to medical centers in comparison with other functions. Calculation of average accessibility in the 15 main regions of Isfahan City showed that the central regions (3, 1, and 5) had the highest decrease and the marginal regions (9, 8, and 11) had the highest increase in the unlimited compared to the limited mode. In general, based on the obtained results of 2SFCA method and the calculated Gini index, the level of inequality in accessibility of census blocks to health services was high in Isfahan City and this inequality increased in terms of accessibility to both hospitals and clinics. Since the extended 2SFCA method has a high capability for assessing supply and demand, as well as catchment area, application of this method can provide a great help for managers and planners in theassessment of the population’s access to a variety of services, such as emergency services and healthcare.Keywords: spatial accessibility, 2SFCA method, distance decay function, medical centers, Isfahan IntroductionOne of the most important challenges faced by policymakers and urban planners in recent decades has been the subjct of access to a variety of urban services. Hospital and clinic centers as the most important urban facilities play an important role in serving people. handeling access to healthcare requires examining the factors, such as spatial distribution of services and demands. Distribution of healthcare centers can affect ease of accessibility for applicants. As health is the basis of social, economic, political, and cultural developments of human societies, identifying deprived areas in terms of accessibility and planning for equitable accessibility to health services for all members of society are essential. MethodologyIn the present study, the Two-Step Floating Catchment Area Method (2SFCA) was employed to calculate the access of census blocks to medical centers (hospitals and clinics) in the city of Isfahan for limited and unlimited accessibility radii. To define the most appropriate distance decay function in the 2SFCA method, the average of Pearson’s correlation coefficient between the accessibility values ​​obtained from different distance decay functions was used. The distance decay function with the highest mean correlation of accessibility values compared to other functions was determined as the most appropriate function in the 2SFCA method. Also, the Lorenz curve and Gini coefficient were applied to compare inequalities of access to medical centers in Isfahan. Results and DiscussionThe results showed that the use of the negative linear cumulative opportunity distance decay function had the highest average correlation in the accessibility values compared to other functions. In the case of limited accessibility radius, the central regions and some northwest and east areas had the highest accessibility to hospitals. In the case of unlimited radius, the central areas had the most accessibility, while accessibility decreased as the distance from these areas increased. Calculation of the average accessibility in the 15 main regions of Isfahan showed that the central (3, 1 and 5) and marginal (9, 8, and 11) regions had the highest decrease and increase in the unlimited compared to the limited mode, respectively. Also, the sensitivity analysis of accessibility to hospitals showed that Al-Zahra and Hazrat Zahra hospitals in Districts 5 and 14 had the greatest impacts on the accessibility of cesus blocks to hospital services in Isfahan City. Comparing the accessibility of census blocks to both hospitals and clinics with accessibility only to hospitals showed an increase in accessibility in the central areas of the city due to the greater concentration of clinics in those areas. However, in the case of combination of hospitals and clinics, the Gini coefficient was equal to 0.60, which showed an increase of 0.04 compared to the case of accessibility only to hospitals, which indicated that inequality was higher in the combinatorial case. ConclusionConsidering the supply and demand simultaneously, the 2SFCA method can provide a more realistic assessment of the accessibility status of census blocks to medical services. 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