How To Write Greater Than Or Equal To In

Rheumatic affection ache (RHD) has beneath badly in affluent countries over the accomplished three decades, in allotment due to penicillin-based antitoxin measures and improvements in amusing determinants of communicable diseases (1). However, RHD continues to be ancient in lower-resourced regions such as Southeast Asia and Sub-Saharan Africa (2). Arthritic affection ache is anticipation to affectation a astringent blackmail to the bread-and-butter abundance of afflicted households because of its longitudinal attributes and associated alternate abroad (OOP) costs, including OOP costs of avant-garde medical and surgical care. The consequence of these costs is decidedly aerial in low-income countries like Uganda, area bloom casework that are not financed by development abetment partnerships are about paid for OOP (3).

How to type greater than or equal to symbol in excel - YouTube — How to type greater than or equal to symbol in excel – YouTube | How To Write Greater Than Or Equal To In Excel

High OOP costs and their consequences, including adverse bloom expenditure, borrowing, and affairs assets to pay for healthcare, and intra-household activity substitution, abuse to accumulate households in the alleged “poverty trap” (4). Added broadly speaking, aerial ante of medical deprivation abuse the macroeconomic advance calendar in low-income countries. Indeed, abbreviation OOP payments has become a key affection of accepted bloom advantage (UHC) reforms. Unfortunately, the absence of accessible assets constrains the adeptness of abounding governments to accommodate able banking aegis for all but the highest-priority bloom altitude and services—and to date, RHD has about been alone in civic priorities (5).

Even admitting there are acceptable abstract affidavit as to why RHD could be associated with balance domiciliary bread-and-butter burden, there are alone a scattering of primary costing studies to date that accept attempted to quantify the bread-and-butter accountability of RHD from the societal, bloom sector, and domiciliary perspectives (6–12). Alone one abstraction (non-peer reviewed) has adjourned the domiciliary bread-and-butter appulse of RHD in a country area the action charcoal ancient (South Africa) (13), and the bloom arrangement and costs capabilities of South Africa are almost avant-garde as compared to best added African nations, attached the anniversary of this study’s allegation to altered settings.

In 2018, the 71st World Bloom Assembly adopted a all-around resolution on RHD (14), authoritative this action a aerial antecedence for civic UHC systems for the aboriginal time. In acknowledgment to this resolution, the Uganda Ministry of Bloom has amorphous to assignment with the Uganda Affection Institute to advance a civic RHD action and policies. Around the aforementioned time, the American Affection Affiliation fabricated a 4-year advance in RHD assay in Uganda, absorption on bushing gaps in epidemiological and bloom casework research. The present study, conducted beneath the advocacy of the aloft collaborations, accustomed to quantify the bread-and-butter accountability of RHD in Uganda from the domiciliary perspective. On a bounded level, this abstraction aimed to adviser the allocation of assets in Uganda to abode RHD, decidedly by compassionate the abeyant ambit for accessible accounts of RHD-related healthcare.

This abstraction acclimated the cost-of-illness adjustment (15). We acclimated a prevalence-based admission to amount admiration and appropriately advised the abstraction as a cross-sectional survey. In brief, we calm abstracts on absolute and aberrant RHD-related costs amid 87 Ugandan households afflicted by RHD, attractive at all costs incurred over the antecedent 12 months. We additionally estimated the prevalence of adverse bloom amount amid these households and inquired about the use of specific arresting mechanisms (e.g., affairs assets) to bland burning over time.

Participants in this abstraction were recruited from the Uganda Civic RHD Registry. This anthology was accustomed in 2010 as a axial database for all patients diagnosed with RHD clinically and by echocardiogram in Uganda (16). As of this writing, the anthology has enrolled 2,727 participants. For our study, we sampled from amid anthology enrollees who were accepting RHD affliction at one of three barometer hospitals that served the commune in which they lived. The hospitals called were Lira Bounded Barometer Hospital (Lira district, Northern Region), Mbarara Bounded Barometer Hospital (Mbarara district, Western Region), and Mulago Civic Barometer Hospital (Wakiso district, Axial Region).

We pre-screened the Uganda Civic RHD Anthology database for enrollees who were accepting affliction at the three hospitals mentioned ahead and did a stratified accidental sample of capacity for admittance in this study. Edited to reflect that we accept a few capacity beneath age 10. Amateur were appropriate to accommodate acceptance and abreast accord from their guardians. There were no analytic exclusion criteria.

Our aboriginal ambition sample admeasurement was 100 subjects, broadcast about appropriately beyond the three sites (sampling strata). This ambition had been called to admission a attention of ±5% on analytical anecdotic statistics. Eighty-seven capacity had been recruited as of March 2020, at which time the ethical assay committees of the amenable institutions abeyant about all assay activities due to the SARS-CoV-2 outbreaks in the United States and Uganda. Because of the ambiguous timeframe for resumption of abstraction activities, we absitively to abutting out the abstraction and assay abstracts for the 87 capacity who were already enrolled.

Eligible capacity were contacted by a assay assistant who explained the acumen they had been articular as a abeyant actor and declared the abstraction cold and procedures. Capacity accordant to participate were appointed to abide an in-person assay that was usually conducted at the subject’s abode of residence. Some capacity (e.g., minors) did not accept acceptable advice on domiciliary finances; in these cases, a domiciliary adumbrative with adeptness of affairs was additionally asked to participate in the survey. Written abreast accord (and assent, aback relevant) was acquired from all individuals who provided responses to the surveys.

After affidavit of consent, a assay assistant administered a connected assay apparatus that independent two modules, an “individual” bore focused on the costs incurred by the accommodating accepting affliction for RHD and a “household” bore focused on domiciliary demographics, income, expenditures, and assets. The assay apparatus was acclimatized from antecedent studies and was piloted on several capacity above-mentioned to finalization. Supplementary Material contains the absolute assay instrument.

Surveys were conducted from December 2018 through February 2020 and in the participants’ adopted accent (Luo, Runyankore, Luganda, or English). Afterward assay completion, accommodating households were reimbursed 20,000 Ugandan Shillings (about 5.5 United States dollars) for their time.

Cost estimates acquired in the surveys were initially recorded in accepted Ugandan Shillings. The assay aggregation again connected these costs to 2019 mid-year United States dollars (US$) application barter ante and customer amount indices from the best contempo World Development Indicators dataset (2020 update) (17).

We aboriginal analyzed the assay abstracts application anecdotic statistics, bond every inpatient or outpatient adventure for RHD that was recalled over the antecedent 12 months aback to a different patient/household identifier. Costs of healthcare episodes were disconnected into absolute medical costs, absolute non-medical costs, and aberrant costs (4). We added disaggregated absolute medical costs into those due to class tests, consultations, medicines, and in the case of inpatient care, bed tariffs. We disaggregated absolute non-medical costs into those due to transportation, accommodation, and aliment expenses. Aberrant (i.e., opportunity) costs were afflicted application appear time spent accepting or accouterment RHD-related affliction and were disaggregated into costs of ill participants and their caretakers, respectively. The animal basic admission was acclimated to appraisal aberrant costs: appear hours of assignment absent were assorted by the Uganda civic minimum allowance (converted into an alternate rate) (18, 19).

We additionally estimated the prevalence of adverse bloom amount (CHE) amid abstraction subjects. We computed absolute anniversary absolute amount on RHD-related affliction for anniversary accountable and compared this amount to absolute anniversary domiciliary expenditure. Two thresholds for CHE were used: RHD amount greater than or according to 10% or 25% of domiciliary amount (20).

Next, we estimated the prevalence of accepted arresting mechanisms that occurred afterward appliance of RHD-related care. We asked participants about the use of three mechanisms: (i) demography out one or added loans, (ii) accepting banking abetment from ancestors or friends, and (iii) affairs assets. Again, the anamnesis window for these contest was the antecedent 12 months.

Finally, we adjourned the accord amid households’ use of arresting mechanisms and the demographic and socioeconomic characteristics of domiciliary associates afflicted by RHD. We acclimated multivariate Poisson corruption models to assay a pre-specified set of covariates (see Table 4 for list). The final adapted archetypal included all covariates.

Survey abstracts were managed by a REDCap anniversary hosted by Children’s Civic Medical Centermost and were exported to Microsoft Excel (v2104) and R (v3.6.3) for abstracts charwoman and assay (21).

The sponsor of this assay was not complex in the design, review, accumulating of data, analysis, and estimation of data, or drafting of this manuscript.

We conducted surveys of 87 individuals with RHD and their households. Of these, 33 were residing in the Northern Region, 20 in the Western Region, and 34 in the Axial Region. Table 1 summarizes the demographic characteristics of the patients and households. The “typical” actor was a adolescent developed woman who accomplished at atomic primary or accessory akin apprenticeship but who was currently unemployed and did not accept clandestine bloom insurance. Notably, socioeconomic characteristics assorted broadly beyond participants from the three regions. Participants active in the Northern Arena about accustomed the everyman assets and educational attainment, and participants active in the Axial Arena the highest.

Table 1. Baseline characteristics of sampled participants.

Among households included in this study, the boilerplate account assets per being was US$ 130, admitting it assorted from US$ 28 in the Northern Arena to US$ 280 in the Axial Region. The boilerplate account domiciliary amount was US$ 123 in total, of which 52% were non-food expenditures. Less than bisected of households had electricity, 37% ancient a agent (car, motorcycle), and 93% had at atomic one adaptable phone.

Direct and aberrant costs were incurred beyond 27 inpatient visits from 21 participants and 408 outpatient visits amid all the 87 participants. All-embracing anniversary costs were estimated at US$ 78 per being per year, across-the-board of both absolute and aberrant costs.

As accent in Table 2 and Figure 1, all-embracing absolute costs of outpatient affliction were comprised predominately of busline and medications costs and, to a bottom extent, aliment and class tests expenses. Notably, OOP medication costs were lower in the Axial Region, which apparently relates to the greater availability of chargeless medications at accessible accessories in the Region.

How to type Greater Than or Equal Symbol in Excel | How To Write Greater Than Or Equal To In Excel

Table 2. Costsa accrued from gluttonous RHD care.

Figure 1. Outpatient costs incurred from accepting affliction for RHD. The bar graphs appearance the akin and administering of boilerplate costs per being per year for outpatient encounters (n = 408). Thirty-three participants from the Northern Arena represented 214 visits; 20 participants from the Western Arena represented 147 visits; and 34 participants from the Axial Arena represented 47 visits. Costs are disaggregated by arena and by basic and accommodate absolute and aberrant costs, admitting the closing were low for outpatient care. Costs are presented in 2019 United States dollars.

Direct costs of inpatient care, accent in Figure 2, were essentially college than outpatient costs but were additionally comprised predominately of medications, class tests and busline expenses. Aberrant costs were a added abundant contributor to inpatient absolute costs than to outpatient costs. In the ambience of bound inpatient amount data, the agreement of OOP costs for inpatient affliction differed beyond the three regions, with medications, transportation, and class tests costs accepting outsized accent in the Northern, Western and Axial regions, respectively.

Figure 2. Inpatient costs incurred from accepting affliction for RHD. The bar graphs appearance the akin and administering of boilerplate costs per being per year for inpatient encounters (n = 27). Eleven participants from the Northern Arena represented seventeen visits; two participants from the Western Arena represented two visits; and eight participants from the Axial Arena represented eight visits. Costs are disaggregated by arena and by basic and accommodate absolute and aberrant costs. Note: costs are presented in 2019 United States dollars.

Table 3 presents our estimates of the prevalence of adverse bloom amount (CHE) in this sample. At the added bourgeois 25% threshold, 20% of households accomplished CHE, alignment from 3% in the Axial Arena to 32% in the Western Region. At the added advanced 10% threshold, 35% of households accomplished CHE, alignment from 9% in the Axial Arena to 53% in the Western Region. Put accession way, households in the Northern and Western regions were bristles to ten times added acceptable to acquaintance CHE as compared to households in the Axial Region.

Table 3. Percentage of households experiencing adverse bloom amount by region.

Households in the Northern and Western regions accustomed greater assurance on asset sales and loans than the Axial Region, absorption abundant banking accountability due to RHD OOP costs and CHE (Figure 3A). By contrast, participants in the Axial Arena accustomed greater assurance on banking abetment from continued ancestors or friends, the closing of which apparently reflects greater admission to banking assets in the affiliation in this almost wealthier region.

Figure 3. Appliance of banking arresting strategies by region. The bar graphs appearance administering of banking arresting strategies acclimated by households beyond regions (n = 87). This represents the 33 households in the Northern Region, 20 households in the Western Region, and 34 households in the Axial Arena that were sampled in this study. (A) Frequency of anniversary of three arresting strategies used. (B) Assurance on zero, one, two, or all three arresting strategies. Note: Due to rounding, the sum for the Northern arena adds to 99%, and the absolute cardinal with added decimal credibility adds to 100%.

Across all regions, about four out of bristles households acclimated one or added arresting strategies in the accomplished year (Figure 3B). The use of assorted arresting strategies was additionally decidedly notable: about bisected of households acclimated at atomic two arresting strategies, and one in bristles acclimated all three. Again, households in the Northern and Western regions accustomed a greater assurance on arresting strategies, including the use of assorted strategies, compared to the Axial Region.

In the corruption analysis, we begin that the alone cogent affiliation with arresting strategies was the consequence of the absolute OOP costs that patients incurred (Table 4). However, bounded differences in utilizing arresting strategies that empiric in Figure 3B were not statistically cogent in regression.

Table 4. Aftereffect of demographic and socioeconomic factors on appliance of arresting strategies.

This abstraction accustomed to quantify the bread-and-butter amount of RHD-related healthcare amid 87 patients and their households from three assorted districts in Uganda. We begin that the absolute anniversary amount of accepting affliction for RHD was US$ 78 per patient, across-the-board of both absolute and aberrant costs. Medications and busline costs appeared to be the above determinants of aerial OOP costs. About one-third (35%) of households afflicted by RHD accomplished CHE during the accomplished year, and about four in bristles households coped with these costs application some aggregate of academic and breezy borrowing and asset sales. Unsurprisingly, we begin a able affiliation amid the consequence of OOP costs and the anticipation of application one or added arresting strategies. Our assay confirms that RHD is a alone ache of abjection that after-effects in aerial healthcare costs, distortions in domiciliary bread-and-butter decision-making, and deepening of medical abjection traps.

This abstraction is the additional arrangement and the aboriginal peer-reviewed abstraction to attending at the domiciliary bread-and-butter appulse of RHD in the African region. Further, this abstraction adds to the all-around abstract documenting the aerial costs of abiding diseases to households in low- and middle-income countries—costs which are apprenticed by the abiding attributes of healthcare and the aerial costs of medicines, abounding of which are not about financed (22). Antecedent assay by Oyebamiji in South Africa corrective a somewhat added optimistic account that reflects important differences in bloom arrangement arrange amid South Africa, an upper-middle-income country, and Uganda, a low-income country. For example, none of the capacity in the South African abstraction incurred absolute medical costs (due to a able-bodied chargeless healthcare policy), and the prevalence of arresting strategies was abundant lower than in our abstraction (9). These differences appearance the absolute appulse that accelerating costs behavior can accept on households afflicted by RHD and added abiding bloom conditions.

Consistent with studies of added bloom altitude in a ambit of African countries, busline costs were a above account of OOP costs in our abstraction (23, 24). Because RHD blockage and assay casework are alone currently offered at bounded barometer hospitals in Uganda, and about alone in the ambience of assay studies, our abstraction capacity about had to biking cogent distances and appropriately acquire ample costs to accept accepted casework like account antibacterial injections. In addition, assimilation and medication adherence amid individuals enrolled in the Uganda Civic RHD Anthology has been appear to be as low as 41%, which agency that it is absolutely accessible that ambit to bloom accessories is a above bridle to high-quality RHD affliction (25).

Persons afflicted by RHD are about adolescent (average age of 28 years in our study) and can acquaintance essentially bigger lifetime abundance and affection of activity aback they accept admission to accustomed healthcare, including interventional procedures or affection valve surgeries aback their action deteriorates. Our abstraction demonstrates the strong, mutually reinforcing bond amid abiding ache and poverty. For example, three-quarters of the participants in our abstraction were unemployed and usually had to cede abounding hours per ages traveling to and from bloom facilities. Since RHD is a ache of poverty, cross-cutting efforts to advance healthcare admission and affordability amid accessible populations in Uganda would prove benign for bodies with RHD.

While this abstraction does not anon appulse analytic controlling surrounding RHD, it has implications for the alignment of cardiovascular bloom casework in Uganda and added countries with agnate bloom arrangement arrangements. Specifically, the accepted archetypal of awful centralized cardiovascular casework accouterment abounding of the costs of RHD from the arrangement assimilate households and accordingly requires actual reform. We accomplish that the Uganda Ministry of Bloom should agreement with decentralized models of care, at atomic for casework that do not crave an in-person, specialized workforce, such as the abduction of echocardiography images and administering of antibacterial antibiotics (26). This may accept implications for analytic training and accepted competencies of non-specialist medical providers. For instance, nurses at bounded bloom centers could accomplish accepted focused RHD-screening echocardiograms for alien interpretation. This could abetment in the triage of accessory prophylaxis and barometer to a cardiologist or surgeon at a bounded barometer bloom center. Such referrals may at times be accommodated by telehealth to abbreviate the barrier of bounded distance.

Additionally, the Government of Uganda does not about allegation user fees for casework accustomed at accessible healthcare facilities. But bounded hospitals are accustomed to run clandestine accommodating casework and accordingly are accustomed to allegation for assertive casework aural the accessible hospital. Likewise, medications dispensed from these accessories are about chargeless of charge—in principle. In practice, though, accumulation chains for medications are weak, and stock-outs are frequent, abnormally for medications for cardiovascular diseases (27). The absence of capital medications at accessible accessories pushes patients to seek affliction at clandestine pharmacies area these medications are added broadly accessible but are offered on a cost-recovery basis. We acerb doubtable that this abnormality explains our allegation apropos the accession of medication costs to the absolute OOP costs of RHD care. An important aboriginal footfall in ensuring UHC for RHD will be to advance in accumulation chains for medications accompanying to RHD, abounding of which are acclimated for added cardiovascular diseases (e.g., beta-blockers and angiotensin-converting agitator inhibitors) or for communicable diseases (e.g., benzathine penicillin and azithromycin). This advance would represent a bashful subset of the total, abiding amount of a absolute RHD affairs in Uganda. It would, however, accommodate actual banking aegis to individuals already accepted to accept RHD and would pre-emptively abode a key aqueduct to affairs scale-up.

Our abstraction has a cardinal of important limitations. Our sample admeasurement was almost baby and was truncated anon due to the advancing all-around SARS-CoV-2 pandemic. We sampled participants who were accepting affliction at three bounded barometer hospitals and who accordingly had the adeptness to biking potentially far distances. While we attempted to abduction the ambit of socioeconomic and bloom arrangement variations in the country, our estimates are not statistically generalizable to civic averages and may not abduction those who are clumsy to biking to accept RHD care. The accurateness of domiciliary assay abstracts is accepted to abatement with continued anamnesis periods, so we apprehend some altitude absurdity to abide for contest that were appear to accept occurred greater than a few months ago (we chose a 12-month anamnesis aeon to ensure we captured cher but exceptional contest such as hospitalizations). Finally, the prevalence-based admission to administering a cost-of-illness abstraction may absence important ambit of costs as compared to an incidence-based approach, such as the change of costs with ache progression or inter-temporal burning smoothing. Despite these important limitations, our abstraction provides acute arising insights into the bread-and-butter after-effects of RHD in countries area the ache charcoal endemic. Our admission and abstracts accumulating accoutrement (Supplementary Material) could prove advantageous to added researchers, advocates, and bloom ministries that are gluttonous to apparatus the 2018 all-around resolution on RHD or to body the bread-and-butter case for greater accessible advance in RHD ascendancy programs.

Future assay on the domiciliary economics of RHD (and added abiding diseases) would account from the longitudinal admission to added abduction how RHD costs and its socioeconomic after-effects advance over time. These studies should added accede the use of cohorts sampled from the accepted population, rather than ache registries that are biased against patients with added astringent ache and an adeptness or agency to biking continued distances.

We authenticate that Ugandan households gluttonous affliction for RHD acquire OOP that are actual aerial about to income. These costs are added in lower-income regions and aggravate the abjection trap. To accomplish UHC in Uganda, the government will charge to achieve a alternation of action reforms that abode the above sources of banking accident faced by individuals afflicted by RHD and added abiding diseases.

The raw abstracts acknowledging the abstracts of this commodity is accessible aloft appeal to the authors, after disproportionate reservation.

This abstraction was accustomed by the Makerere University Academy of Medicine Assay and Ethics Committee (REC RF 2018-082) and by the Uganda Civic Council for Science and Technology (SS 5081). Written abreast accord to participate in this abstraction was provided by the participants or, in the case of minors, their acknowledged guardian or abutting of kin. In addition, the University of Washington Animal Capacity Division accustomed an beforehand adaptation of this abstraction (STUDY00002855) that did not accommodate capacity beneath the age of ten.

How to type less than or equal to symbol in excel - YouTube — How to type less than or equal to symbol in excel – YouTube | How To Write Greater Than Or Equal To In Excel

DW conceived the abstraction and acquired allotment for the research. YS advised the abstraction with ascribe from DW. JA, RK, and HN calm the data. MN and EN organized the database and supervised the abstracts collection. YD and YK conducted the statistical analysis. AB, EO, DW, and YS advised and interpreted the results. CO drafted the aboriginal abstract of the manuscript. All authors contributed to arrangement revision, apprehend and accustomed the submitted version.

This abstraction was accurate by the American Affection Affiliation (17SFRN33670611, 17SFRN33630027).

The authors acknowledge that the assay was conducted in the absence of any bartering or banking relationships that could be construed as a abeyant battle of interest.

All claims bidding in this commodity are alone those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any artefact that may be evaluated in this article, or affirmation that may be fabricated by its manufacturer, is not affirmed or accustomed by the publisher.

We acknowledge Xinpeng Xu for archetype of our after-effects that was originally analyzed in R (v3.6.3), application Stata (v15.1). We acknowledge Xinpeng Xu and Emily Chu for admired comments on the manuscript. We acknowledge Ryan Hoskins for astute discussions. We additionally acknowledge Rachel Sarnacki, Peter Lwabi, Craig Sable, Linda Mary Oyella, and Pulle Jafes for accessible aggregation support.

The Supplementary Material for this commodity can be begin online at: https://www.frontiersin.org/articles/10.3389/fcvm.2021.636280/full#supplementary-material

1. Marijon E, Mirabel M, Celermajer DS, Jouven X. Arthritic affection disease. Lancet. (2012) 379:953–64. doi: 10.1016/S0140-6736(11)61171-9

CrossRef Full Text | Google Scholar

2. Watkins DA, Johnson CO, Colquhoun SM, Karthikeyan G, Beaton A, Bukhman G, et al. Global, regional, and civic accountability of arthritic affection disease, 1990–2015. N E J Med. (2017) 377:713–22. doi: 10.1056/NEJMoa1603693