Health facility management and primary health care performance in Uganda

Background

Primary health care is a critical foundation of high-quality health systems. Health facility management has been studied in high-income countries, but there are significant measurement gaps about facility management and primary health care performance in low and middle-income countries. A primary health care facility management evaluation tool (PRIME-Tool) was initially piloted in Ghana where better facility management was associated with higher performance on select primary health care outcomes such as essential drug availability, trust in providers, ease of following a provider’s advice, and overall patient-reported quality rating. In this study, we sought to understand health facility management within Uganda's decentralized primary health care system.

Methods

We administered and analyzed a cross-sectional household and health facility survey conducted in Uganda in 2019, assessing facility management using the PRIME-Tool.

Results

Better facility management was associated with better essential drug availability but not better performance on measures of stocking equipment. Facilities with better PRIME-Tool management scores trended towards better performance on a number of experiential quality measures. We found significant disparities in the management performance of primary health care facilities. In particular, patients with greater wealth and education and those living in urban areas sought care at facilities that performed better on management. Private facilities and hospitals performed better on the management index than public facilities and health centers and clinics.

Conclusions

These results suggest that investments in stronger facility management in Uganda may strengthen key aspects of facility readiness such as essential drug availability and potentially could affect experiential quality of care. Nevertheless, the stark disparities demonstrate that Uganda policymakers need to target investments strategically in order to improve primary health care equitably across socioeconomic status and geography. Moreover, other low and middle-income countries may benefit from the use of the PRIME-Tool to rapidly assess facility management with the goal of understanding and improving primary health care performance.

Predictors of patient-reported quality of care in low- and middle-income countries: a four-country survey of person-centered care

Background

Person-centeredness is a foundation of high-quality health systems but is poorly measured in low- and middle-income countries (LMICs). We piloted an online survey of four LMICs to identify the prevalence and correlates of excellent patient-reported quality of care (QOC).

Objective

The aims of this study were to investigate the examine people’s overall ratings of care quality in relation to their experiences seeking care in their respective health systems as well as individual-, provider- and facility-level predictors.

Methods

We administered a cross-sectional online survey using Random Domain Intercept Technology to collect a sample of random internet users across India, Kenya, Mexico and Nigeria in November 2016. The primary outcome was patient-reported QOC. Covariates included age, gender, level of education, urban/rural residence, person for whom care was sought, type of provider seen, public or private sector status of the health facility and type of facility. The exposure was an index of health system responsiveness based on a framework from the World Health Organization. We used descriptive statistics to determine the prevalence of excellent patient-reported QOC and multivariable Poisson regression to calculate adjusted prevalence ratios (aPRs) for predictors of excellent patient-reported quality.

Results

Fourteen thousand and eight people completed the survey (22.6% completion rate). Survey respondents tended to be young, male, well-educated and urban-dwelling, reflective of the demographic of the internet-using population. Four thousand one and ninety-one (29.9%) respondents sought care in the prior 6 months. Of those, 21.8% rated their QOC as excellent. The highest proportion of respondents gave the top rating for wait time (44.6%), while the lowest proportion gave the top rating for facility cleanliness (21.7%). In an adjusted analysis, people who experienced the highest level of health system responsiveness were significantly more likely to report excellent QOC compared to those who did not (aPR 8.61, 95% confidence interval [95% CI]: 7.50, 9.89). In the adjusted model, urban-dwelling individuals were less likely to report excellent quality compared to rural-dwelling individuals (aPR 0.88, 95% CI: 0.78, 0.99). People who saw community health workers (aPR 1.37, 95% CI: 1.12, 1.67) and specialists (aPR 1.30, 95% CI: 1.12, 1.50) were more likely to report excellent quality than those who saw primary care providers. High perceived respect from the provider or staff was most highly associated with excellent ratings of quality, while ratings of wait time corresponded the least.

Conclusion

Patient-reported QOC is low in four LMICs, even among a well-educated, young population of internet users. Better health system responsiveness may be associated with better ratings of care quality. Improving person-centered care will be an important component of building high-quality health systems in these LMICs.

Strengthening data collection and use for quality improvement in primary care: the case of Costa Rica

Costa Rica is a bright spot of primary healthcare (PHC) performance, providing first-contact accessibility and continuous, comprehensive, coordinated, and patient-centered care to its citizens. Previous research hypothesized that strong data collection and use for quality improvement are central to Costa Rica's success. Using qualitative data from 40 interviews with stakeholders across the Costa Rican healthcare system, this paper maps the various data streams at the PHC level and delineates how these data are used to make decisions around insuring and improving the quality of PHC delivery. We describe four main types of PHC data: individual patient data, population health data, national healthcare delivery data, and local supplementary healthcare delivery data. In particular, we find that the Healthcare Delivery Performance Index-a ranking of the nation's 106 Health Areas using 15 quality indicators-is utilized by Health Area Directors to create quality improvement initiatives, ranging from education and coaching to optimization of care delivery and coordination. By ranking Health Areas, the Index harnesses providers' intrinsic motivation to stimulate improvement without financial incentives. We detail how a strong culture of valuing data as a tool for improving population health and robust training for personnel have enabled effective data collection and use. However, we also find that the country's complex data systems create unnecessary duplication and can inhibit efficient data use. Costa Rica's experience with data collection, analysis, and use for quality improvement hold important lessons for PHC in other public sector systems.

Implementing sustainable primary healthcare reforms: strategies from Costa Rica

As the world strives to achieve universal health coverage by 2030, countries must build robust healthcare systems founded on strong primary healthcare (PHC). In order to strengthen PHC, country governments need actionable guidance about how to implement health reform. Costa Rica is an example of a country that has taken concrete steps towards successfully improving PHC over the last two decades. In the 1990s, Costa Rica implemented three key reforms: governance restructuring, geographic empanelment, and multidisciplinary teams. To understand how Costa Rica implemented these reforms, we conducted a process evaluation based on a validated implementation science framework. We interviewed 39 key informants from across Costa Rica's healthcare system in order to understand how these reforms were implemented. Using the Exploration Preparation Implementation Sustainment (EPIS) framework, we coded the results to identify Costa Rica's key implementation strategies and explore underlying reasons for Costa Rica's success as well as ongoing challenges. We found that Costa Rica implemented PHC reforms through strong leadership, a compelling vision and deliberate implementation strategies such as building on existing knowledge, resources and infrastructure; bringing together key stakeholders and engaging deeply with communities. These reforms have led to dramatic improvements in health outcomes in the past 25 years. Our in-depth analysis of Costa Rica's specific implementation strategies offers tangible lessons and examples for other countries as they navigate the important but difficult work of strengthening PHC.

Towards patient-centred care in Ghana: health system responsiveness, self-rated health and experiential quality in a nationally representative survey

Introduction

Person-centredness, including patient experience and satisfaction, is a foundational element of quality of care. Evidence indicates that poor experience and satisfaction are drivers of underutilisation of healthcare services, which in turn is a major driver of avoidable mortality. However, there is limited information about patient experience of care at the population level, particularly in low-income and middle-income countries.

Methods

A multistage cluster sample design was used to obtain a nationally representative sample of women of reproductive age in Ghana. Women were interviewed in their homes regarding their demographic characteristics, recent care-seeking characteristics, satisfaction with care, patient-reported outcomes, and—using questions from the World Health Survey Responsiveness Module—the seven domains of responsiveness of outpatient care to assess patient experience. Using Poisson regression with log link, we assessed the relationship between responsiveness and satisfaction, as well as patient-reported outcomes.

Results

Women who reported more responsive care were more likely to be more educated, have good access to care and have received care at a private facility. Controlling for respondent and visit characteristics, women who reported the highest responsiveness levels were significantly more likely to report that care was excellent at meeting their needs (prevalence ratio (PR)=13.0), excellent quality of care (PR=20.8), being very likely to recommend the facility to others (PR=1.4), excellent self-rated health (PR=4.0) and excellent self-rated mental health (PR=5.1) as women who reported the lowest responsiveness levels.

Discussion

These findings support the emerging global consensus that responsiveness and patient experience of care are not luxuries but essential components of high-performing health systems, and highlight the need for more nuanced and systematic measurement of these areas to inform priority setting and improvement efforts.

National Response to COVID-19 in the Republic of Korea and Lessons Learned for Other Countries

In the first two months of the COVID-19 pandemic, the Republic of Korea (South Korea) had the second highest number of cases globally yet was able to dramatically lower the incidence of new cases and sustain a low mortality rate, making it a promising example of strong national response. We describe the main strategies undertaken and selected facilitators and challenges in order to identify transferable lessons for other countries working to control the spread and impact of COVID-19. Identified strategies included early recognition of the threat and rapid activation of national response protocols led by national leadership; rapid establishment of diagnostic capacity; scale-up of measures for preventing community transmission; and redesigning the triage and treatment systems, mobilizing the necessary resources for clinical care. Facilitators included existing hospital capacity, the epidemiology of the COVID-19 outbreak, and strong national leadership despite political changes and population sensitization due to the 2015 Middle East respiratory syndrome-related coronavirus (MERS-CoV) epidemic. Challenges included sustaining adequate human resources and supplies in high-caseload areas. Key recommendations include (1) recognize the problem, (2) establish diagnostic capacity, (3) implement aggressive measures to prevent community transmission, (4) redesign and reallocate clinical resources for the new environment, and (5) work to limit economic impact through and while prioritizing controlling the spread and impact of COVID-19. South Korea's strategies to prevent, detect, and respond to the pandemic represent applicable knowledge that can be adopted by other countries and the global community facing the enormous COVID-19 challenges ahead.

Preliminary validation of the PRImary care facility Management Evaluation tool (PRIME-Tool), a national facility management survey implemented in Ghana

Background

The management quality of healthcare facilities has consistently been linked to facility performance, but available tools to measure management are costly to implement, often hospital-specific, not designed for low- and middle-income countries (LMICs), nor widely deployed. We addressed this gap by developing the PRImary care facility Management Evaluation Tool (PRIME-Tool), a primary health care facility management survey for integration into routine national surveys in LMICs. We present an analysis of the tool’s psychometric properties and suggest directions for future improvements.

Methods

The PRIME-Tool assesses performance in five core management domains: Target setting, Operations, Human resources, Monitoring, and Community engagement. We evaluated two versions of the PRIME-Tool. We surveyed 142 primary health care (PHC) facilities in Ghana in 2016 using the first version (27 items) and 148 facilities in 2017 using the second version (34 items). We calculated floor and ceiling effects for each item and conducted exploratory factor analyses to examine the factor structure for each year and version of the tool. We developed a revised management framework and PRIME-tool as informed by these exploratory results, further review of management theory literature, and co-author consensus.

Results

The majority (17 items in 2016, 23 items in 2017) of PRIME-Tool items exhibited ceiling effects, but only three (2 items in 2016, 3 items in 2017) showed floor effects. Solutions suggested by factor analyses did not fully fit our initial hypothesized management domains. We found five groupings of items that consistently loaded together across each analysis and named these revised domains as Supportive supervision and target setting, Active monitoring and review, Community engagement, Client feedback for improvement, and Operations and financing.

Conclusion

The revised version of the PRIME-Tool captures a range of important and actionable information on the management of PHC facilities in LMIC contexts. We recommend its use by other investigators and practitioners to further validate its utility in PHC settings. We will continue to refine the PRIME-Tool to arrive at a parsimonious tool for tracking PHC facility management quality. Better understanding the functional components of PHC facility management can help policymakers and frontline managers drive evidence-based improvements in performance.

Empanelment: A foundational component of primary health care

Empanelment is a foundational strategy for building or improving primary health care systems and a critical pathway for achieving effective universal health coverage. However, there is little international guidance for defining empanelment or understanding how to implement empanelment systems in low- and middle-income countries. To fill this gap, a multi-country collaborative within the Joint Learning Network for Universal Health Coverage developed this empanelment overview, proposing a people-centered definition of empanelment that reflects the responsibility to proactively deliver primary care services to all individuals in a target population. This document, building on existing literature on empanelment and representing input from 10 countries, establishes standard concepts of empanelment and describes why and how empanelment is used. Finally, it identifies key domains that may influence effective empanelment and that must be considered in deciding how empanelment can be implemented. This document is designed to be a useful resource for health policymakers, planners and decision-makers in ministries of health, as well as front line providers of primary care service delivery who are working to ensure quality people-centered primary care to everyone everywhere.

PHC Progression Model: a novel mixed-methods tool for measuring primary health care system capacity

High-performing primary health care (PHC) is essential for achieving universal health coverage. However, in many countries, PHC is weak and unable to deliver on its potential. Improvement is often limited by a lack of actionable data to inform policies and set priorities. To address this gap, the Primary Health Care Performance Initiative (PHCPI) was formed to strengthen measurement of PHC in low-income and middle-income countries in order to accelerate improvement. PHCPI’s Vital Signs Profile was designed to provide a comprehensive snapshot of the performance of a country’s PHC system, yet quantitative information about PHC systems’ capacity to deliver high-quality, effective care was limited by the scarcity of existing data sources and metrics. To systematically measure the capacity of PHC systems, PHCPI developed the PHC Progression Model, a rubric-based mixed-methods assessment tool. The PHC Progression Model is completed through a participatory process by in-country teams and subsequently reviewed by PHCPI to validate results and ensure consistency across countries. In 2018, PHCPI partnered with five countries to pilot the tool and found that it was feasible to implement with fidelity, produced valid results, and was highly acceptable and useful to stakeholders. Pilot results showed that both the participatory assessment process and resulting findings yielded novel and actionable insights into PHC strengths and weaknesses. Based on these positive early results, PHCPI will support expansion of the PHC Progression Model to additional countries to systematically and comprehensively measure PHC system capacity in order to identify and prioritise targeted improvement efforts.

Facility management associated with improved primary health care outcomes in Ghana

Background

Strong primary health care (PHC) is essential for achieving universal health coverage, but in many low- and middle-income countries (LMICs) PHC services are of poor quality. Facility management is hypothesized to be critical for improving PHC performance, but evidence about management performance and its associations with PHC in LMICs remains limited.

Methods

We quantified management performance of PHC facilities in Ghana and assessed the experiences of women who sought care at sampled facilities. Using multi-level models, we examined associations of facility management with five process outcomes and eight experiential outcomes.

Findings

On a scale of 0 to 1, the average overall management score in Ghana was 0·76 (IQR = 0·68–0·85). Facility management was significantly associated with one process outcome and three experiential outcomes. Controlling for facility characteristics, facilities with management scores at the 90^th percentile (management score = 0·90) had 22% more essential drugs compared to facilities with management scores at the 10^th percentile (0·60) (p = 0·002). Positive statistically non-significant associations were also seen with three additional process outcomes—integration of family planning services (p = 0·054), family planning types provided (p = 0·067), and essential equipment availability (p = 0·104). Compared to women who sought care at facilities with management scores at the 10^th percentile, women who sought care at facilities at the 90^th percentile reported 8% higher ratings of trust in providers (p = 0·028), 15% higher ratings of ease of following provider’s advice (p = 0·030), and 16% higher quality rating (p = 0·020). However, women who sought care in the 90^th percentile facilities rated their waiting times as worse (22% lower, p = 0·039).

Interpretation

Higher management scores were associated with higher scores for some process and experiential outcomes. Large variations in management performance indicate the need to strengthen management practices to help realize the full potential of PHC in improving health outcomes.

Primary Health Care That Works: The Costa Rican Experience

Long considered a paragon among low- and middle-income countries in its provision of primary health care, Costa Rica reformed its primary health care system in 1994 using a model that, despite its success, has been generally understudied: basic integrated health care teams. This case study provides a detailed description of Costa Rica's innovative implementation of four critical service delivery reforms and explains how those reforms supported the provision of the four essential functions of primary health care: first-contact access, coordination, continuity, and comprehensiveness. As countries around the world pursue high-quality universal health coverage to attain the Sustainable Development Goals, Costa Rica's experiences provide valuable lessons about both the types of primary health care reforms needed and potential mechanisms through which these reforms can be successfully implemented.

Jeopardizing quality at the frontline of healthcare: prevalence and risk factors for disrespect and abuse during facility-based childbirth in Ethiopia

Disrespect and abuse (D&A) experienced by women during facility-based childbirth has gained global recognition as a threat to eliminating preventable maternal mortality and morbidity. This study explored the frequency and associated factors of D&A in four rural health centres in Ethiopia. Experiences of women who delivered in these facilities were captured by direct observation of client-provider interaction (N = 193) and exit interview at time of discharge (N = 204). Incidence of D&A was observed in each facility, with failure to ask woman for preferred birth position most commonly observed [n = 162, 83.9%, 95% confidence interval (95% CI) 78.0-88.5%]. During exit interviews, 21.1% (n = 43, 95% CI 15.4-26.7%) of respondents reported at least one occurrence of D&A. Bivariate models using client characteristics and index birth experience showed that women's reporting of D&A was significantly associated with childbirth complications [odds ratio (OR) = 7.98, 95% CI 3.70, 17.22], weekend delivery (OR = 0.17, 95% CI 0.05, 0.63) and no previous delivery at the facility (OR = 3.20, 95% CI 1.27, 8.05). Facility-level fixed-effect models found that experience of complications (OR = 15.51, 95% CI 4.38, 54.94) and weekend delivery (OR = 0.05, 95% CI 0.01-0.32) remained significantly and most strongly associated with self-reported D&A. These data suggest that addressing D&A in health centres in Ethiopia will require a sustained effort to improve infrastructure, support the health workforce in rural settings, enforce professional standards and target interventions to improve women's experiences as part of quality of care initiatives.

Primary Health Care as a Foundation for Strengthening Health Systems in Low- and Middle-Income Countries

Primary health care (PHC) has been recognized as a core component of effective health systems since the early part of the twentieth century. However, despite notable progress, there remains a large gap between what individuals and communities need, and the quality and effectiveness of care delivered. The Primary Health Care Performance Initiative (PHCPI) was established by an international consortium to catalyze improvements in PHC delivery and outcomes in low- and middle-income countries through better measurement and sharing of effective models and practices. PHCPI has developed a framework to illustrate the relationship between key financing, workforce, and supply inputs, and core primary health care functions of first-contact accessibility, comprehensiveness, coordination, continuity, and person-centeredness. The framework provides guidance for more effective assessment of current strengths and gaps in PHC delivery through a core set of 25 key indicators ("Vital Signs"). Emerging best practices that foster high-performing PHC system development are being codified and shared around low- and high-income countries. These measurement and improvement approaches provide countries and implementers with tools to assess the current state of their PHC delivery system and to identify where cross-country learning can accelerate improvements in PHC quality and effectiveness.

Applying a participatory approach to the promotion of a culture of respect during childbirth

Disrespect and abuse (D&A) during facility-based childbirth is a topic of growing concern and attention globally. Several recent studies have sought to quantify the prevalence of D&A, however little evidence exists about effective interventions to mitigate disrespect and abuse, and promote respectful maternity care. In an accompanying article, we describe the process of selecting, implementing, and evaluating a package of interventions designed to prevent and reduce disrespect and abuse in a large urban hospital in Tanzania. Though that study was not powered to detect a definitive impact on reducing D&A, the results showed important changes in intermediate outcomes associated with this goal. In this commentary, we describe the factors that enabled this effect, especially the participatory approach we adopted to engage key stakeholders throughout the planning and implementation of the program. Based on our experience and findings, we conclude that a visible, sustained, and participatory intervention process; committed facility leadership; management support; and staff engagement throughout the project contributed to a marked change in the culture of the hospital to one that values and promotes respectful maternity care. For these changes to translate into dignified care during childbirth for all women in a sustainable fashion, institutional commitment to providing the necessary resources and staff will be needed.

Mitigating disrespect and abuse during childbirth in Tanzania: an exploratory study of the effects of two facility-based interventions in a large public hospital

Background

There is emerging evidence that disrespect and abuse (D&A) during facility-based childbirth is prevalent in countries throughout the world and a barrier to achieving good maternal health outcomes. However, much work remains in the identification of effective interventions to prevent and eliminate D&A during facility-based childbirth. This paper describes an exploratory study conducted in a large referral hospital in Dar es Salaam, Tanzania that sought to measure D&A, introduce a package of interventions to reduce its incidence, and evaluate their effectiveness.

Methods

After extensive consultation with critical constituencies, two discrete interventions were implemented: (1) Open Birth Days (OBD), a birth preparedness and antenatal care education program, and (2) a workshop for healthcare providers based on the Health Workers for Change curriculum. Each intervention was designed to increase knowledge of patient rights and birth preparedness; increase and improve patient-provider and provider-administrator communication; and improve women’s experience and provider attitudes. The effects of the interventions were assessed using a pre-post design and a range of tools: pre-post questionnaires for OBD participants and pre-post questionnaires for workshop participants; structured interviews with healthcare providers and administrators; structured interviews with women who gave birth at the study facility; and direct observations of patient-provider interactions during labor and delivery.

Results

Comparisons before and after the interventions showed an increase in patient and provider knowledge of user rights across multiple dimensions, as well as women’s knowledge of the labor and delivery process. Women reported feeling better prepared for delivery and provider attitudes towards them improved, with providers reporting higher levels of empathy for the women they serve and better interpersonal relationships. Patients and providers reported improved communication, which direct observations confirmed. Additionally, women reported feeling more empowered and confident during delivery. Provider job satisfaction increased substantially from baseline levels, as did user reports of satisfaction and perceptions of care quality.

Conclusions

Collectively, the outcomes of this study indicate that the tested interventions have the potential to be successful in promoting outcomes that are prerequisite to reducing disrespect and abuse. However, a more rigorous evaluation is needed to determine the full impact of these interventions.

Intramural coronary arteriosclerosis of normal and dwarfed swine

Dwarfing of swine maintained in large groups with relatively little space per animal may be attributed to psychosocial factors. Intramural coronary arteriosclerosis developed at approximately the same rate in dwarfed and normally developing animals. Lesions in arteries of the left posterior papillary muscle were more advanced than in the left anterior papillary muscle of the same animal, irrespective of its growth rate, and often were more advanced than in swine twice as old.

Coronary, aortic and cerebral atherosclerosis in swine of 3 age-groups: implications

CORONARY, AORTIC AND INTERCRANIAL ATHEROSCLEROSIS HAS BEEN COMPARED IN SWINE MAINTAINED UNDER THE FOLLOWING CONDITIONS: (1) adequate food and housing but animals held in test social situations for 1 year; postmortem examination at ages of 13 to 15 months; (2) food and management designed for high productivity; postmortem examination at ages of 6 to 9 years; (3) an outdoor system of husbandry and a cooked garbage diet; postmortem examination at ages of 8 to 14 years.Extramural coronary, aortic and intracranial atherosclerosis was most advanced in swine that were fed garbage. Cerebral infarction (cerebromalacia) also was most advanced in these swine but developed in swine of the younger groups in which it was associated with atherosclerosis of small intracranial extracerebral arteries rather than with stenosis of the larger intracranial extracerebral arteries as in the oldest swine. The lesions of atherosclerosis in swine of these 3 age-groups form a continuous series and are morphologically identical with corresponding stages of atherosclerosis of man.It is concluded that swine can replace non-human primates as subjects for studies of atherosclerotic vascular disease, and that experimental designs must allow for age and behaviour patterns of the species.

Enzootic toxoplasmosis in caged squirrel monkeys Saimiri sciureus

An enzootic of toxoplasmosis occurred in caged squirrel monkeys ( Saimiri sciureus, a New World primate) which resulted in 9 deaths during an interval of 22 months. Diagnosis was based on morphology of the organism, character and distribution of the lesions, and laboratory history of the monkeys. The character of the lesions was essentially necrotic. The chronological incidence of the disease and distribution of lesions and organisms are tabulated. Trypanosoma cruzi which causes Chaga's disease is differentiated morphologically from toxoplasma. Incidence and lesions of the enzootic suggest 5 factors to be considered in the pathogenesis of toxoplasmosis in squirrel monkeys. They are: (1) lack of protective immunity, (2) local concentration of toxin and/or catabolites of reproduction of the organism, (3) individual tissue susceptibility to the organism, (4) capillary thrombosis, and (5) ability of the individual to adapt to its environment.

Arteriosclerotic stenosis of the intramural coronary arteries of chickens: further evidence of a relation to social factors

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Coronary arterial lesions in chickens: origin and rates of development in relation to sex and social factors

Single-comb, Hy-line white leghorns were hatched in one lot, brooded in one flock through 7 weeks, then assigned randomly to cages in one large room with 15 hours of light per day. The birds were studied in the following situations: a) separately caged cocks and hens, b) paired cocks and hens, and c) 3 cock-3 hen groups and 6 cock-6 hen groups. Basic space allowance was 2 square ft per bird which was increased to 8 square ft for some of the larger groups. Commercial rations and water were supplied ad libitum. Stenosing lesions of the intramural coronary arteries began development in cocks and hens before age 7 weeks (10 to 12 weeks before sexual maturity) and progressed with age. Progress, as measured by heart scores, was not influenced by space allowance but was related to social situation. The rate for separately caged cocks was significantly higher than for other birds. Cocks of the larger groups and cocks of the pairs were next in order, while heart scores for cocks of the smaller groups were third but not significantly higher than for grouped hens. Heart scores of grouped hens sometimes exceeded heart scores for cocks of corresponding groups.

High mean heart scores for grouped cocks correlated with high mean heart scores for hens of their groups, and low heart scores for grouped cocks with low scores for hens of their groups.

Neoplastic Disease of the Pancreas of Snakes (Serpentes)

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Familial occurrence of renal carcinoma in rhesus monkeys (Macaca mulatta)

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Spontaneous tumors in two colonies of rats of the Wistar Institute of Anatomy and Biology

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Studies on the Pathogenesis of Erythroleucosis

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Tumors in Captive Primates: Report of Two Cases

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