ALL Metrics
-
Views
-
Downloads
Get PDF
Get XML
Cite
Export
Track
Research Article
Revised

Investigate the efficiency of primary care facilities in emergency situations by application of geographical and demographic standards using GIS

[version 3; peer review: 2 approved, 2 approved with reservations]
PUBLISHED 23 Dec 2024
Author details Author details
OPEN PEER REVIEW
REVIEWER STATUS

Abstract

Background

This study applied geographical standards (coverage distance) and demographic standards to investigate the capabilities of primary healthcare facilities to cover the largest area of the study area and the service area that can be accessed. This study was conducted to find out the sufficient number of primary healthcare (PHC) centers required to provide healthcare services to the entire community.

Methods

Data was obtained by applying geographic information system (GIS) techniques to analyze primary care facilities using the demographic and geographic standards for primary care facilities.

Results

PHC centers cover 79% of the study area according to the geographical standard. The study area needs 41 additional centers to cover the shortfall in service provision per the demographic and geographic standards.

Conclusions

A significant deficiency in the number of primary care centers found in the study area compared to the large population at the geographical and demographic standards level.

Keywords

Primary health care, emergencies, geographical standard, demographic standard, GIS, Coverage

Revised Amendments from Version 2

Title: The title remains unchanged.
Abstract: No modifications were made to the abstract.
Figures No modifications were made to the Figures. 
Tables No modifications were made to the Tables
Introduction: Additional citations were included to further substantiate the background and context of our study based on the reviewer. 
Methods:  Expanding this section to increase replicability, providing more comprehensive descriptions of the GIS techniques based on the reviewer.
Results: Clarifications were added based on the reviewer.
Discussion and Recommendations: The discussion was enhanced to explore the implications of findings in greater depth, particularly regarding underserved areas. New recommendations added based on the reviewer.

See the authors' detailed response to the review by Ayed Taran
See the authors' detailed response to the review by Hanifa Denny

Introduction

The pre-disaster phase of the disaster management (DM) process is based on examining the current readiness of facilities and services related to disaster risk reduction and identifying and addressing deficiencies and weaknesses for providing the needs and requirements for the success of the DM process.1 The spatial evaluation process for the sites of services and facilities needed for DM examines readiness in the study area using geographic information system (GIS) techniques and spatial analysis.24

Geographical standards (coverage distance) and demographic standards show the capabilities of primary health center facilities to cover the largest area of the study area and the service area. In addition, we analyze the population’s suitability with the number of facilities available in the study area to find out if it is sufficient to provide services to the entire community according to the standards required.58

Planning standards for primary care centers

Primary health care (PHC) is a crucial component of health systems and communities’ social and economic development.911 PHC is responsible for providing health services and responding to emergencies at each sub-region level.1116 There are 26 centers in Sleman District, Indonesia, distributed over 17 sub-regions.12

The study utilized demographic and geographic Standards as variables, gathering data from the District Health Office. It adhered to the Ministry of Health’s regulations to assess their applicability within the study area.

Methods

Study area

The study was conducted in Sleman District, Yogyakarta City, Indonesia, which comprises 26 Primary Health Care (PHC) centers distributed across 17 sub-regions. Sleman District has the highest disaster risk index in Yogyakarta, with a score of 97.17 This study utilized ArcGIS 10.5 to analyze the distribution and accessibility of PHC facilities based on demographic and geographic standards, aiming to identify shortages, assess needs, and propose solutions and recommendations.1821

The GIS-based analytical approaches employed in this study depend on the availability of spatial and non-spatial data.2224 According to the geographical standard, each sub-district should have one PHC, and urban facilities should have a service scope within specific distances: 5 km for hospitals, 2.5 km for schools, and 2 km for markets. Non-spatial data, such as population demographics, were also considered to estimate healthcare demand.25,26

Furthermore, the study utilized statistical data to measure the need for new PHC centers based on the population data. The Ministry of Health set the standard where each PHC has to provide services for 20,000 people.27

Data collection and preparation

Astronomical location

Sleman District is located between 110° 13′ 00″ to 110° 33′ 00″ east longitude and 7° 34′ 51″ to 7° 47′ 03″ south latitude (see Figure 1).

9da9a2c4-358a-4044-a1be-79c1ff2138e9_figure1.gif

Figure 1. Astronomical site of Sleman district.

Population

Sleman had a population of 1,206,714, comprising 608,968 males and 597,746 females, within an area of 574.82 km2. The population density was 2,099 people per km2. Notably dense districts include Depok (5,359 people per km2), Mlati (4,049 people per km2), Gamping (3,771 people per km2), and Ngaglik (3,194 people per km2) in 2018.28

Data collection, processing, and analysis

Proximity Analysis: Assessed the accessibility of PHC facilities by measuring distances or travel times from specific locations, considering transportation networks and road conditions to determine ease of access during emergencies.

Spatial Overlay: Combined spatial data layers to identify relationships and patterns, such as overlaying facility locations with demographic data to pinpoint areas with a critical need for primary care. This overlay identified gaps by linking population data to service coverage zones, helping to pinpoint critical need areas. Additional overlays for schools and markets (within 2.5 km and 2 km, respectively) were also applied to measure secondary accessibility standards.

Network Analysis: Optimized routes and travel times using transportation networks, aiding in the identification of efficient emergency service routes and areas requiring improved infrastructure or additional facilities. Routes were calculated considering road types, traffic patterns, and transportation networks, which enabled the identification of underserved areas and assessment of infrastructure improvement needs.29,30

The correctness of facilities’ locations were verified through maps using Google Earth and WorldWindEarthExplorer. Using the ArcGIS 10.5 program and Arc Analysis tools, the study area is derived based on arial images, identified by comparing it with the arial images obtained from Indonesian Disaster Management Agency. The extracted data sets were then transferred to Microsoft Excel 2013, using the network analysis in Arc GIS 10.5 (open source alternative: QGIS) to analyze and determine the scope of service of PHC. Spatial analysis of the location regarding PHC needed in the study area depended on geographical standard and demographic standards. By applying these standards, we can inquire about PHC capabilities to cover the study field and the service area that could be accessed. In addition to analyzing the population’s suitability with the number of PHCs available in the study area, is it sufficient to provide primary healthcare services to all, at the time and standard required? The analysis started by obtaining the map of 26 PHC centres distributed over 17 sub-regions as shown in Figure 2.

9da9a2c4-358a-4044-a1be-79c1ff2138e9_figure2.gif

Figure 2. Primary healthcare center distribution in Sleman district.

Results

Geographical standard (coverage distance)

According to the geographical standard, each sub-district must have one PHC and urban facilities, including a scope of service within 5 km, a school within 2.5 km, a market within 2 km, and a hospital within 5 km.31 The service area of PHCs in the study area, based on these geographical standards, is illustrated below:

Geographical standard, availability of hospital within 5 km

The PHC service areas in the study area are defined by a 5 km radius from hospitals. Figure 3 shows the availability of hospitals within this radius. It was found that 24 health centers met the specified standard in the presence of a hospital (represented in green), while two health centers did not meet the standard (represented in red).

9da9a2c4-358a-4044-a1be-79c1ff2138e9_figure3.gif

Figure 3. Illustrates the service area of primary healthcare (PHC) in the study area, based on a geographical standard of 5 km from the hospitals.

The scope of service within 5 km

The PHC service area based on a 5 km radius is further detailed in Figure 4. According to the Indonesian Ministry of Health standards, health centers are required to provide services within a 5 km distance. The 5 km radius for healthcare service coverage is chosen to enhance accessibility and equity, ensuring patients can reach healthcare within a manageable distance, especially in rural and semi-urban areas (Regulation of the Minister of Health of the Republic of Indonesia Number 43 Year 2019 Concerning Public Health Centers, 2019).

In Sleman District, health centers cover an area of 454.10 km2 out of 574.25 km2, serving approximately 79% of the study area. The unserved area totals 120.15 km2, primarily in the northern (Cangkringan, Pakem, Turi, Tempel) and southern (Prambanan, Berbah, Gamping) districts. Detailed coverage for each district is provided below:

  • Cangkringan District: One PHC covers 24.24 km2 out of 44.72 km2 (45% unserved).

  • Pakem District: One PHC covers 25.98 km2 out of 52.70 km2 (50.7% unserved).

  • Turi District: One PHC covers 22.90 km2 out of 40.50 km2 (43.4% unserved).

  • Tempel District: Two PHCs cover 28.45 km2 out of 32.33 km2 (12% unserved).

  • Prambanan District: One PHC covers 14.25 km2 out of 40.62 km2 (64.9% unserved).

  • Berbah District: One PHC covers 17.0 km2 out of 25.85 km2 (24.2% unserved).

9da9a2c4-358a-4044-a1be-79c1ff2138e9_figure4.gif

Figure 4. The service area of PHC in the study area based on the geographical standard (5 km).

In conclusion, the study area has a service coverage deficiency of 21%. This highlights the need for additional primary healthcare centers (PHCs) in districts that face shortages. These districts have high population densities and are also located in close proximity to natural disaster sources, such as volcanoes, floods, and landslides.

Geographical standards, availability of schools with 2.5 km

The service area of the PHC center is defined as a 2.5 km radius from the schools. Figure 5 illustrates the availability of schools within this 2.5 km radius. A service scope within 2.5 km of the primary care centers has been implemented. In Figure 5, 26 PHC centers met the specified standard in the presence of a school, indicated by the green color.

9da9a2c4-358a-4044-a1be-79c1ff2138e9_figure5.gif

Figure 5. The service area of the PHC centre (2.5 km from the schools).

Geographical standards, availability of market within 2 km

The service area based on a 2 km radius from markets is shown in Figure 6. Out of 26 PHCs, 23 met the standard (indicated in green), while three did not (indicated in red). Three PHC centers did not meet the specified standard in the presence of a market, indicated by the red color.

9da9a2c4-358a-4044-a1be-79c1ff2138e9_figure6.gif

Figure 6. The service area of the PHC centre in the study area based on the geographical standard (2 km from the market).

Demographic standard

Table 1 provides an explanation of the individuals who receive services and those who do not receive services through the PHC center in Sleman District, based on the demographic standard. The location of the PHC center is determined by the population distribution in the region, following the demographic standard set by the Indonesian Ministry of Health, which specifies serving a population of 20,000 people per PHC.32 After applying the demographic standards, the study yielded the following findings. The total population of the Sleman district is 1,206,714 people. Out of 26 PHCs, 520,000 individuals are receiving services in accordance with the prescribed criteria. The population without access to services amounts to approximately 686,714 people. According to the demographic standard, a larger percentage of the population should have access to PHC services. The shortage in health centers represents approximately 41 PHC centers. Statistical data indicates that the highest number of individuals lacking services in PHCs is found in the Depok region, with a shortage of 130,526 people. The construction of seven additional PHC facilities is necessary. In contrast, the percentage of individuals lacking access to PHC services in Cangkringan District is relatively small, necessitating the establishment of one new PHC.

Table 1. Number of people who receive services and who do not receive services through PHC centre according to the demographic standard in Sleman District.

No. Sub-District Population (2018) No. of PHCs Served population Unserved population PHCs needed
1Berbah59,943120,00039,9432
2Cankringan29,592120,0009,9521
3Depok190,526360,000130,5266-7
4Gamping110,288240,00070,2883-4
5Dodean72,286240,00032,2861-2
6Kalasan88,110120,00068,1103-4
7Minggir29,929120,00099291
8Mlati115,466240,00075,4663-4
9Moyudan31,536120,00011,5361
10Ngaglik123,039240,00083,0394
11Ngemplak66,899240,00026,8991-2
12Pakem38,658120,00018,6581
13Prambanan48,734120,00028,7341-2
14Seyegan47,355120,00027,3551-2
15Sleman68,480240,00028,4801-2
16Tempel50,844240,00010,8441
17Turi34,489120,00014,4891
Total171,206,71426520,000686,714

Discussion

In this study, the researchers set a geographical standard to determine the service area of Primary Health Care (PHC) centers in the study area. The standard was based on a 5 km radius from the hospitals.25 According to the findings presented in the study, it was observed that 24 health centers met the specified standard for service area coverage in the presence of a hospital. This discrepancy between compliant and non-compliant health centers may have important implications for healthcare accessibility in the region. The availability of PHC services within a 5 km radius from hospitals could significantly impact the ease of access to healthcare for the population living in those areas. The PHC centers that fall within the service area are better positioned to serve their communities effectively, ensuring that a larger population has access to essential healthcare services. Factors such as distance, transportation infrastructure, and population density could play a role in determining the feasibility of establishing PHC centers in those regions.33 Policymakers and healthcare administrators may need to consider additional measures to address the accessibility challenges faced by these areas, potentially by improving transportation options or establishing additional health facilities to fill the service gap.

Overall, this study provides valuable insights into the distribution of PHC services based on geographical standards in the study area. The findings can serve as a foundation for healthcare planning and resource allocation, aiming to enhance healthcare accessibility and ultimately improve the overall health outcomes for the population in the region. However, further research and collaboration between various stakeholders, including government agencies, healthcare providers, and community representatives, will be necessary to address the challenges highlighted by the study and ensure equitable access to healthcare services for all residents.

The variations in PHC coverage across different sub-districts signify the importance of localized and targeted healthcare planning and resource allocation. It is evident that certain areas are more underserved than others, requiring specific attention and efforts to improve healthcare accessibility in those regions.

The study’s findings can serve as a foundation for evidence-based decision-making in healthcare planning and policy development. By identifying the areas with the greatest need for additional healthcare resources, policymakers can prioritize their interventions to achieve more equitable healthcare distribution and improve the health outcomes of the population in the study area. The implementation of a service scope based on a 2.5 km radius from schools is a commendable step towards improving healthcare accessibility and promoting the well-being of the school community.

It also encourages early intervention and preventive healthcare practices, which can contribute to better health outcomes among the school community.

The implementation of a service scope based on a 2 km radius from markets is a promising initiative to enhance healthcare accessibility in the study area.25 The findings in Figure 6 underscore the importance of such approaches in healthcare planning. However, it is crucial to continue evaluating and refining the service area to ensure that healthcare services effectively reach all populations, particularly those residing near markets. By addressing the challenges and disparities identified in the evaluation process, healthcare providers and policymakers can work together to build a more inclusive and accessible healthcare system, ultimately contributing to the improvement of community health and well-being.

The study highlights the importance of adhering to demographic standards to ensure that a larger percentage of the population has access to PHC services. There is a shortage of 41 PHC centers, based on the demographic standard of 20,000 people per PHC. This shortage of health centers directly affects the number of individuals who lack access to healthcare services in the region. Moreover, shortfalls indicate that a considerable portion of the population lacks timely access to essential healthcare, potentially leading to adverse health outcomes such as delays in medical interventions, and overall diminished quality of care. The underserved populations are especially vulnerable in emergencies, where delays in accessing healthcare can exacerbate injury or illness outcomes.

The study’s results have significant implications for healthcare planning and resource allocation in Sleman District. Policymakers and healthcare authorities need to take into account the demographic standards and the actual healthcare needs of the population when planning the distribution and establishment of PHC centers.

The study identifies significant gaps in healthcare access for a substantial portion of the population. Addressing these disparities requires careful planning, resource allocation, and the establishment of new PHC centers, particularly in regions with the greatest need. By addressing the shortages and expanding healthcare infrastructure, policymakers can work towards achieving a more equitable healthcare system that caters to the healthcare needs of all individuals in the district.

Conclusion

In conclusion, there is a significant deficiency in the number of PHCs in the study area compared to the large population, both at the geographical and demographic standards level. The region is in urgent need of filling these gaps by establishing new PHC centers to meet the population’s needs and provide high-quality PHC services in line with international standards. This will also help alleviate the burden on central hospitals in the region.

Recommendations

Policymakers should consider expanding infrastructure by establishing additional PHC centers in densely populated, underserved areas, thus improving service reach. Additionally, enhancing community engagement through health education and preventive care programs can lower disease incidence, helping to manage healthcare demand in high-need areas. Improving transportation routes to PHCs would further facilitate access for those in distant regions. Finally, adopting a data-driven approach to resource allocation, utilizing GIS data, will ensure that health infrastructure evolves to meet population changes and emerging needs, creating a resilient and equitable healthcare system.

Comments on this article Comments (0)

Version 3
VERSION 3 PUBLISHED 13 Dec 2023
Comment
Author details Author details
Competing interests
Grant information
Copyright
Download
 
Export To
metrics
Views Downloads
F1000Research - -
PubMed Central
Data from PMC are received and updated monthly.
- -
Citations
CITE
how to cite this article
Jarghon AEM, Damayanti NA, Dhamanti I and Awad AMM. Investigate the efficiency of primary care facilities in emergency situations by application of geographical and demographic standards using GIS [version 3; peer review: 2 approved, 2 approved with reservations]. F1000Research 2024, 12:1579 (https://doi.org/10.12688/f1000research.140107.3)
NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article.
track
receive updates on this article
Track an article to receive email alerts on any updates to this article.

Open Peer Review

Current Reviewer Status: ?
Key to Reviewer Statuses VIEW
ApprovedThe paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approvedFundamental flaws in the paper seriously undermine the findings and conclusions
Version 3
VERSION 3
PUBLISHED 23 Dec 2024
Revised
Views
17
Cite
Reviewer Report 11 Jan 2025
Pankaj Roy, Central University of Karnataka, Kalaburagi, India 
Approved with Reservations
VIEWS 17
Critical Review of the Article: "Investigate the Efficiency of Primary Care Facilities in Emergency Situations by Application of Geographical and Demographic Standards Using GIS"

1. Title Evaluation: The title reflects the core focus of the study, emphasising both ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Roy P. Reviewer Report For: Investigate the efficiency of primary care facilities in emergency situations by application of geographical and demographic standards using GIS [version 3; peer review: 2 approved, 2 approved with reservations]. F1000Research 2024, 12:1579 (https://doi.org/10.5256/f1000research.174054.r356660)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Views
9
Cite
Reviewer Report 28 Dec 2024
Hanifa Denny, Public Health, Universitas Diponegoro, Semarang, Central Java, Indonesia 
Approved
VIEWS 9
Dear authors,

Thank you for your thorough and thoughtful revisions. I have reviewed your responses and the updated manuscript, and I find that you have sufficiently addressed all the comments and suggestions provided. The additional citations, methodological ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Denny H. Reviewer Report For: Investigate the efficiency of primary care facilities in emergency situations by application of geographical and demographic standards using GIS [version 3; peer review: 2 approved, 2 approved with reservations]. F1000Research 2024, 12:1579 (https://doi.org/10.5256/f1000research.174054.r351971)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 2
VERSION 2
PUBLISHED 05 Jul 2024
Revised
Views
14
Cite
Reviewer Report 28 Oct 2024
Jianwei Li, Northwest University, Xi'an, Shaanxi, China 
Approved with Reservations
VIEWS 14
The manuscript, based on demographic data and utilizing GIS spatial network analysis, effectively reveals the spatial alignment between the service coverage of primary healthcare (PHC) centers in the Sleman region of Indonesia and the local population's medical needs. This provides ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Li J. Reviewer Report For: Investigate the efficiency of primary care facilities in emergency situations by application of geographical and demographic standards using GIS [version 3; peer review: 2 approved, 2 approved with reservations]. F1000Research 2024, 12:1579 (https://doi.org/10.5256/f1000research.168658.r328429)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Views
26
Cite
Reviewer Report 10 Oct 2024
Hanifa Denny, Public Health, Universitas Diponegoro, Semarang, Central Java, Indonesia 
Approved with Reservations
VIEWS 26
1. Clarity and Accuracy of Presentation and Literature Citations
The manuscript is generally well-written, and the topic is clearly defined. It focuses on primary healthcare (PHC) center distribution in Sleman District, Indonesia. The research is relevant, especially in public ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Denny H. Reviewer Report For: Investigate the efficiency of primary care facilities in emergency situations by application of geographical and demographic standards using GIS [version 3; peer review: 2 approved, 2 approved with reservations]. F1000Research 2024, 12:1579 (https://doi.org/10.5256/f1000research.168658.r325253)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 12 Nov 2024
    Ali Jarghon, Faculty of Public Health, Airlangga University, Surabaya, 60114, Indonesia
    12 Nov 2024
    Author Response
    Thank you so much for your comments and suggests.
     
    1. Reviewer comment:
    Expand the citation of relevant literature, particularly recent studies on GIS in healthcare and disaster management.
    Author ... Continue reading
COMMENTS ON THIS REPORT
  • Author Response 12 Nov 2024
    Ali Jarghon, Faculty of Public Health, Airlangga University, Surabaya, 60114, Indonesia
    12 Nov 2024
    Author Response
    Thank you so much for your comments and suggests.
     
    1. Reviewer comment:
    Expand the citation of relevant literature, particularly recent studies on GIS in healthcare and disaster management.
    Author ... Continue reading
Views
8
Cite
Reviewer Report 24 Jul 2024
Ayed Taran, Al al-Bayt University, Al-Mafraq, Jordan 
Approved
VIEWS 8
No or only minor changes are required. This means that the aims and research methods are adequate; ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Taran A. Reviewer Report For: Investigate the efficiency of primary care facilities in emergency situations by application of geographical and demographic standards using GIS [version 3; peer review: 2 approved, 2 approved with reservations]. F1000Research 2024, 12:1579 (https://doi.org/10.5256/f1000research.168658.r299981)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
Version 1
VERSION 1
PUBLISHED 13 Dec 2023
Views
24
Cite
Reviewer Report 27 Jun 2024
Ayed Taran, Al al-Bayt University, Al-Mafraq, Jordan 
Approved with Reservations
VIEWS 24
1. The paper addresses geographical and demographic criteria to verify the ability of primary health care facilities to cover the largest area of ​​the study area and accessible service area use GIS, The study found that there is a significant shortage ... Continue reading
CITE
CITE
HOW TO CITE THIS REPORT
Taran A. Reviewer Report For: Investigate the efficiency of primary care facilities in emergency situations by application of geographical and demographic standards using GIS [version 3; peer review: 2 approved, 2 approved with reservations]. F1000Research 2024, 12:1579 (https://doi.org/10.5256/f1000research.153436.r253431)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
  • Author Response 05 Jul 2024
    Ali Jarghon, Faculty of Public Health, Airlangga University, Surabaya, 60114, Indonesia
    05 Jul 2024
    Author Response
    Response to Reviewer 
    Thank you for your comments.

    1. Thank you for your insightful comment. We have thoroughly addressed the geographical and demographic criteria to evaluate the coverage of ... Continue reading
  • Author Response 23 Jul 2024
    Ali Jarghon, Faculty of Public Health, Airlangga University, Surabaya, 60114, Indonesia
    23 Jul 2024
    Author Response
    Author response: 
    Thank you for your insightful comments and expertise.
    Competing Interests: No competing interests to disclose
COMMENTS ON THIS REPORT
  • Author Response 05 Jul 2024
    Ali Jarghon, Faculty of Public Health, Airlangga University, Surabaya, 60114, Indonesia
    05 Jul 2024
    Author Response
    Response to Reviewer 
    Thank you for your comments.

    1. Thank you for your insightful comment. We have thoroughly addressed the geographical and demographic criteria to evaluate the coverage of ... Continue reading
  • Author Response 23 Jul 2024
    Ali Jarghon, Faculty of Public Health, Airlangga University, Surabaya, 60114, Indonesia
    23 Jul 2024
    Author Response
    Author response: 
    Thank you for your insightful comments and expertise.
    Competing Interests: No competing interests to disclose

Comments on this article Comments (0)

Version 3
VERSION 3 PUBLISHED 13 Dec 2023
Comment
Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
Sign In
If you've forgotten your password, please enter your email address below and we'll send you instructions on how to reset your password.

The email address should be the one you originally registered with F1000.

Email address not valid, please try again

You registered with F1000 via Google, so we cannot reset your password.

To sign in, please click here.

If you still need help with your Google account password, please click here.

You registered with F1000 via Facebook, so we cannot reset your password.

To sign in, please click here.

If you still need help with your Facebook account password, please click here.

Code not correct, please try again
Email us for further assistance.
Server error, please try again.