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The majority of adults with serious mental illness living in the community are parents, many of whom may be receiving services from State Mental Health Authorities. Innovative intervention approaches are available to improve outcomes for these parents and their children. An understanding of factors related to SMHA responsiveness to clients who are parents suggests strategies for policy and program development. Quantitative analyses of SMHA- and state-level data, and qualitative interviews of administrators, service providers, and consumers underscore the importance of organizational structure and philosophy, an advocacy presence, and available funding to SMHA efforts on behalf of parents and their families.
The majority of State Mental Health Authorities (SMHAs) are unaware of the parenting status of the adult clients receiving public sector mental health services (Nicholson, Geller, Fisher, & Dion, 1993). Findings from a national survey of SMHA Directors regarding programs and policies for mothers with mental illness indicate only 31 percent of SMHAs collected data on the parenting status of female clients, 20 percent had policies regarding pregnancy and parenting for women receiving services, and none had visitation policies for hospitalized mothers and their children (Nicholson et al.). Neglect of the parenting role may result in missed opportunities for promoting rehabilitation and recovery of adult clients, and may increase barriers to services for parents and children. Attention to the goals of adult clients with mental illness who are parents may contribute to positive outcomes for entire families. Knowledge regarding factors related to the responsiveness of SMHAs to the issues of clients who are parents could inform efforts of those in other states and systems interested in facilitating change to meet the needs of families living with mental illness.
Women and men living in the community who met criteria for serious and persistent mental illness in the previous 12 months are as likely or more likely to be parents than individuals not meeting criteria for any psychiatric disorder (Nicholson, Biebel, Williams, & Katz-Leavy, in press). In analyses of National Comorbidity Survey data, 68 percent of women meeting criteria for psychiatric disorder over their lifetime are mothers, and 55 percent of men meeting lifetime criteria are fathers, compared to 62 percent of women without psychiatric disorder who are mothers and 53 percent of men who are fathers (Nicholson et al., in press) Other studies corroborate the finding that adults with mental illness have the same fertility and pregnancy rates as those without psychiatric diagnoses (Apfel & Handel, 1993; Oyserman, Mowbray, & Zemencuk, 1994). Several studies drawing from state mental health case management records indicate that significant numbers of adults receiving public sector mental health services are parents. Analyses of New York State Office of Mental Health data suggest that almost half of women younger than 35 receiving intensive case management services are mothers (Blanch, Nicholson, & Purcell, 1994). Approximately nine percent of women receiving Massachusetts Department of Mental Health case management services in the early 1990s were caring for dependent children (White, Nicholson, Fisher, & Geller, 1995). These studies using public sector mental health service data may underestimate the rates of parenting among individuals with mental illness given the stringent eligibility requirements of SMHAs regarding functional impairment, illness duration, and severity (Nicholson et al., in press). In the only published study of fathers with mental illness, approximately 21 percent of male clients receiving services in a Massachusetts Department of Mental Health case management site were known by their clinicians to be fathers (Nicholson, Nason, Calabresi, & Yando, 1999).
Children receiving public sector mental health services are likely to have parents with their own psychiatric issues. Data from the SAMHSA National Evaluation of the Comprehensive Communities Mental Health Services for Children and their Families Program sites indicate that 45 percent of children with serious emotional disturbance have a history of family mental illness and 20 percent have a history of psychiatric hospitalization (Center for Mental Health Services, 1999). While there are no national data available on the number of children in the general population who have a parent or parents with mental illness, the numbers are likely to be in the millions, as women and men with mental illness bear children at the same rate as those without mental illness (Caton, Cournos, & Dominguez, 1999; Mowbray, Oyserman, & Ross, 1995b; Nicholson et al., in press; White et al., 1995).
Families living with parental mental illness have the generic needs of all families, as well as service needs specific to living with mental illness (Nicholson & Henry, in press). Mowbray and colleagues (2000) found that mothers worry about paying off debts, transportation, clothing, food, social activities, rent and utilities, and medical needs. In addition, a large number of women reported experiencing stressful life events including psychiatric crises, major money crises, the death of a close friend or relative, or periods of separation from their children (Mowbray et al., 2000). Marital discord is also common for parents with mental illness (Downey & Coyne, 1990; Quinton, Rutter, & Liddle, 1984). Mothers with mental illness, while acknowledging the challenges, identify motherhood as a primary motivating factor for treatment (Mowbray, Oyserman, & Ross, 1995a). Mothers say that not being able to parent their children compromises their well-being and impedes their progress toward recovery (Blanch et al., 1994; Nicholson, 1996).
An emerging evidence base and the identification of promising practices offer SMHAs solutions to the problem of unmet service needs for parents with mental illness and their families (Hinden, Biebel, Nicholson, Henry, & Stier, 2002). Solutions do not always require the development of specialized services or the expenditure of new money. Exemplary models have been identified, many of which employ well-known psychosocial rehabilitation strategies to improve parenting skills, and access and modify existing resources (Nicholson & Henry, in press). Recommendations have been made to expand on well-documented, tested, and widely-used models, such as Assertive Community Treatment or Family Psychoeducation, to include a focus on the adult client's goals as parent and family members' need for information about mental illness. Guidelines for practice have been developed in other countries (Australian Infant, Child, Adolescent and Family Mental Health Association, 2003).
Innovative interventions are being tested in the field, and are available for adoption by SMHAs and adaptation by service providers. Beardslee and colleagues developed a psychoeducational intervention to educate parents about the potential impact of their illness on children, ages eight to 15, and to enhance communication between parents and children about mental illness (Beardslee et al., 1996, 1997a, 1997b). Longitudinal follow-up indicates that parents and children report improved knowledge and communication about mental illness; parents report increased marital support and understanding of each other's feelings; and children are reported to be functioning better (Beardslee et al., 1997b). This intervention is currently being tested in various community settings (Podorefsky, McDonald-Dowdell, & Beardslee, 2001). Nicholson and colleagues (2001), in partnership with parents with mental illness, their family members and service providers, developed a rehabilitation approach to improving the skills of parents with mental illness either individually or in groups. Components of this intervention are currently being tested in several settings, including with special populations, e.g., homeless mothers (Weinreb & Nicholson, presentation). The "Nurturing Families Affected by Substance Abuse, Mental Illness and Trauma" curriculum, developed by the Institute for Health and Recovery in Cambridge, MA, involves both one-on-one mentoring and intensive skill building, as well as a group intervention (Moore, Buchan, Finkelstein, & Thomas, 2002).
Research on the development of mental health policy in general reveals that it is not a linear process, but rather an interaction of a multiplicity of decision points, ideologies, technologies, and incentives (financial and otherwise), with political, economic and organizational frameworks of care (Rochefort, 1989). In addition, mental health policy must be considered in the context of the policy structure of the United States, the policy-making process, and changing conceptions of mental health and illness (Miller, 1991).
Factors related to SMHA performance in general have been studied in previous research, and are potentially related to SMHA "responsiveness" to adult clients who are parents and their families, that is, the development of policies and programs for parents with mental illness. Torrey and Wolfe (1986), in their controversial ranking of SMHAs, identify indicators of "best" public mental health systems performance reflecting fiscal characteristics and organizational structure, including: flexible fiscal systems, decentralization of authority to states or counties, and good leadership within the SMHA and by the governor and legislature. These authors also highlight the importance of a strong advocacy presence, the significance of which is underscored in later research by Geller and colleagues (1998). The presence of empowered consumers in the public mental health system can be influential in SMHAs policies and practices. States with larger populations were found to have SMHAs with greater consumer involvement (Geller at al).
Analyzing the same data as Torrey and Wolfe, Hudson (1987) identifies additional variables significant in determining a state's mental health performance, including population characteristics. States with greater population densities, that is, more urban than rural, had higher-rated community mental health systems (Hudson). States with greater population densities had increased socioeconomic development, facilitated by economies of scale that allow for more cost-effective community programming. In contrast, rural communities struggled to meet the minimum needs of a geographically dispersed population. SMHAs in smaller states may be better able than those in larger states, however, to maintain a higher degree of accountability for lesser costs, as they have closer contact with providers (Frank & Gaynor, 1994).
In addition, some research suggests that behavioral managed care has the potential to address the needs of the unserved and underserved better (McGovern, Lyons, & Pomp, 1990). However, behavioral managed care systems often ignore many of the primary concerns faced by public mental health service consumers (VanLeit, 1996), and may not have the necessary social commitment to serve traditionally underserved populations (Ross, 2000). Scallet (1996) warns that the most vulnerable populations will be ill-served by a behavioral managed care system.
Parental mental illness is a significant issue for SMHAs addressing the mental health service needs of adults and children in the public sector. Innovative interventions and modifications to well-established treatment approaches offer solutions. An understanding of the factors contributing to SMHA "responsiveness" to clients who are parents or their children would suggest strategies for policy and program development in other states and systems committed to improving the lives of families living with parental mental illness. The objectives of this study are three-fold: (1) to determine the "responsiveness" of SMHAs to the issues of parents with mental illness and their families, i.e., the extent to which SMHAs have relevant policies and programs; (2) to determine the relationship between selected state characteristics and SMHA "responsiveness;" and (3) to explore factors and strategies contributing to SMHA developments related to parental mental illness.
This study was conducted in three phases to address the three study objectives. In Phase 1, primary survey data were collected and analyzed to explore SMHA responses to the needs of adult clients as parents. In Phase 2, secondary quantitative data were analyzed to determine the relationship between selected state characteristics and SMHA development of policies and programs specific to parents with mental illness. Phase 3 involved a qualitative case study component to elaborate factors and strategies related to SMHA developments.
In Phase 1, SMHA Directors in all 50 states and the District of Columbia (N=51) were surveyed regarding policies and programs for parents with mental illness using a 142-item questionnaire developed as part of a SAMHSA-funded project. Survey items were reviewed by eight experts in the field, including researchers, SMHA policy makers, providers and consumers, for feedback on validity and ease of administration, prior to its distribution to SMHAs. From this survey, 25 questions were selected to reflect information on SMHA activities in three broad categories: the identification of adult clients as parents and assessment of clients' parental functioning (five items); specific programs and services designed for SMHA clients who are parents (10 items); and specific policies and written guidelines for SMHA clients who are parents (10 items). Program and policy activities were examined across 10 service types including: acute inpatient; continuing inpatient; emergency mental health; community residential; community rehabilitation; employment/vocational; clubhouse; day treatment; outpatient; and other. The SMHA Director or Commissioner, or his or her designee, typically the director of adult mental health services, completed the survey. Response rate for the survey was 100 percent. The survey was reviewed and approved by the University of Massachusetts Medical School (UMMS) Institutional Review Board (IRB).
Data for the quantitative component of Phase 2 were obtained from the National Association of State Mental Health Program Directors Research Institute, Inc.(NRI) and United States Census Bureau (USCB) databases, and the United States Advisory Commission on Intergovernmental Relations' Index of Fiscal Comfort (IFC). The NRI database includes information provided by SMHAs about the fiscal characteristics, organizational structure, policies, and service offerings in the states and the District of Columbia. The USCB database contains demographic and economic information gathered at county, state, and national levels regarding population characteristics, expenditures, and growth. The United States Advisory Commission on Intergovernmental Relations Index of Fiscal Comfort is a measure of states' capacities to raise revenue relative to the cost of delivering services (Tannenwald, 1999).
In Phase 3, four states were selected for case studies using data generated from Phase 1. These states represented a range of SMHA responsiveness to the parental role of adult clients. Selected states varied in size from mid-sized to large, and all had county-run mental health systems. Original SMHA survey respondents identified an initial set of stakeholders for interviewing; a snowball sampling strategy was used to generate the larger sample for the qualitative component of the study. Stakeholders from each state included two administrators/policy-makers, two consumers/advocates, and two service providers involved with the issues of parents with mental illness and their families. Telephone interviews were conducted with six stakeholders from each state using a semi-structured protocol. A total of 25 stakeholders were interviewed, as one state yielded three consumer/advocate respondents. Interviews were audio-taped and lasted approximately one hour. Respondents were paid $50 for participating, if allowed to accept compensation by their agencies or organizations. The UMMS IRB approved the semi-structured protocol and consent form; completed consent forms were received from all respondents.
Results from Phase 1 and 2, examination of the on-line databases, review of the literature and previous research, and existing interview instruments informed the development of the semi-structured protocol. Questions were clustered into three categories reflecting (1) the process of responding to the needs of parents and their families (e.g., "Describe your role in the public sector mental health system or services in your state."); (2) interests, influences, and obstacles to responding (e.g., "What made it difficult to generate interest in the issue of parents with mental illness?"); and (3) the potential for greater response (e.g., "To what extent do you think your state's efforts with regards to parents with mental illness can be replicated?").
The dependent variables for Phase 1 and Phase 2 analyses are SMHA responsiveness and breadth of responsiveness. SMHA responsiveness is a dichotomous variable (responsive vs. non-responsive) created from survey responses. SMHAs providing "Yes" responses to at least one of the 25 questions regarding parents, programs and policies were designated as responsive. SMHAs with "No" responses to all 25 questions were designated as non-responsive. Breadth of responsiveness is a continuous dependent variable; a summary score was created by adding strength and diversity scores. Strength scores reflected the number of affirmative responses. SMHAs were given a diversity score of zero if there were no affirmative responses, 100 if all affirmative responses appeared in only one category of questions, 200 if affirmative responses appeared in any two categories of questions, and 300 if affirmative responses appeared in each of the three categories of questions. Diversity scores were weighted more heavily than strength scores because responsiveness across several domains demonstrates a greater incorporation of the issues of parents at multiple levels. The resulting breadth of responsiveness scores were transposed to reflect their rank within the 51 subject slots (i.e., 51 states) with higher scores representing greater responsiveness by SMHAs to parental mental illness.
For Phase 2 analyses, 11 independent variables, theorized to be influential with respect to program and policy development, were generated from data in the NRI and USCB databases and the IFC, and grouped into five categories: fiscal characteristics, organizational structure, advocacy presence, population characteristics and managed care. (see Table 1) Fiscal characteristics are measured by three continuous independent variables: per capita mental health expenditures, per capita income, and fiscal comfort. Characteristics of SMHA organizational structure are reflected in three independent variables: organizational layer (continuous), independent SMHA (dichotomous), and SMHA services (dichotomous). Advocacy presence is represented by two dichotomous independent variables: voluntary consumer involvement and mandated consumer involvement. Two continuous independent variables measure state-level demographic characteristics: population per square mile and estimated population. One dichotomous independent variable, managed care, reflects the presence of managed behavioral health services in each state. For one of the subjects, data were Windsorized to control for extreme outlying values on per capita mental health expenditures and population per square mile.
Responses to each of the 25 SMHA survey questions were examined through descriptive statistics in Phase 1. Descriptive statistics were calculated for responses to individual questions, as well as for items grouped into the three categories of questions. Survey data were internally cross-checked for consistency and analyzed for links between response patterns and respondents.
Relationships among independent and dependent variables were analyzed using multivariate techniques to address Phase 2 research goals. Characteristics contributing to SMHA responsiveness were modeled using regression techniques – logistic regression for the dichotomous dependent variable and multiple regression for the continuous dependent variable. For non-dichotomous independent variables, the modal category was used as the reference category.
For the Phase 3 state case study component, qualitative data from interview transcripts were content analyzed after coding for themes derived from the interview protocol and the results of analyses conducted in the first phase of the project. A hierarchical map of relationships among factors was used to identify major themes. Themes were summarized and compared across states and across type of stakeholders, to elaborate factors and strategies related to SMHA developments.
Fifty-three percent (n=27) of the SMHAs were responsive to the parental role of adult clients, i.e., answered "Yes" to at least one of the 25 questions regarding the identification of adult clients as parents and assessment of clients' parental functioning, specific programs and services designed for SMHA clients who are parents, and specific policies and written guidelines for SMHA clients who are parents. The number of affirmative responses ranged from two to 16, with the majority of SMHAs reporting six or less affirmative responses. SMHAs were most likely to identify adult clients as parents and/or assess clients' parental functioning (n=25); next likely to have specific programs and services for clients who are parents (n=14); and least likely to have specific policies and written guidelines for clients who are parents (n=4).
None of the independent variables in the logistic regression models were significant predictors of SMHA responsiveness. In multiple regression models, two variables from the organizational structure category, independent SMHA and SMHA services, were identified as significant positive predictors of breadth of responsiveness. (see Table 2) Fiscal characteristics, the variable organizational layer within the organizational structure category, advocacy presence, population characteristics, and managed care were not identified as significant predictors of breadth of responsiveness.
Stakeholders identified 33 factors or strategies contributing to the development of policies and programs for parents with mental illness and their families within SMHAs. These cluster into eight theme categories.
Identify and collaborate with key stakeholders, particularly those in leadership positions, from other agencies and systems. One mental health provider noted, "Coordinate locally. People may not have money but may have resources and can be partners with you."
Embrace a family-centered orientation in which both adult and child clients are viewed as family members. According to one policy-maker, "Counties that have embraced (thinking about families) have moved towards very family-oriented, family-friendly services. This lends itself to thinking about parenting."
Articulate a vision of the challenges facing parents with mental illness and the solutions. In some states, considerable change has resulted from the dedication and commitment of one visionary person, dedicated to serving families. One policy-maker suggested, "You have to have a person who can organize the thoughts and put them on the table and talk about what you want to do to get a clean, coherent picture of what it is all about."
Prevalence data regarding the number of families living with parental mental illness are useful in making policy, planning and development decisions, and advocating for change. As one policy-maker noted, "The first step is knowing your population, and knowing who you need to serve."
The personal stories of individuals affected by parental mental illness are very powerful in demonstrating need and recommending solutions. A provider related, "What really opened my eyes was actually being in a room with people who were in that situation, parents who had a mental illness and hearing their stories. It was very compelling to me and I knew it would be compelling to others as well. That information, those testimonies, were very, very, very powerful."
Individuals, agencies or systems that have been willing to embrace new issues, service delivery models or treatment strategies are more responsive to the needs of parents with mental illness and their families. One policy-maker suggested, "We had buy-in from the top and support from the very beginning. There was a very clear statement to everybody in our organization that (serving families) is how we are going to do business."
Interest in and efforts to respond to the challenges of parental illness can come from both inside and outside the mental health system, and benefit from the support of "top-down" and "bottom-up" approaches within agencies and organizations. According to one consumer, "It's not just top-down or bottom-up. It's a combined effort of local need advocating strong and hard and people at the top saying this is important and you need to respond to it."
Funding targeted to early intervention and prevention service for infants, young children and their parents has been useful in developing services and supports for families living with parental mental illness. A policy-maker noted, "The adult system doesn't have a funding stream like Early and Periodic Screening, Diagnostic, and Treatment. There are no prevention dollars available for adults."
Results suggest that approximately half of SMHAs are responsive to the parental role of adult clients in some way. These SMHAs are identifying the parental status of adult clients, assessing parental functioning, offering specific programs or services for parents or providing specific guidelines or written policies for parents. Almost half are not ostensibly responding to the needs of parents with mental illness even though the prevalence of parenthood is high, the risk to children and families is significant, and parenting is an issue identified as important to mental health consumers. SMHAs may be genuinely unaware of the prevalence of adult clients who are parents. Especially given the high rates of custody loss, many SMHA clients who are parents may not be the primary caregivers for their children. Issues concerning parenting have traditionally been the responsibility of other systems or agencies such as child welfare or public health, or, within an SMHA, the purview of the children's mental health division. Finally, most SMHAs have service delivery and funding mechanisms designed to serve individual clients rather than families. SMHAs may not have the mandate or the resources to meet the needs of the children of adult SMHA clients, or conversely, to address the issues of parents of child SMHA clients with serious emotional disturbance, many of whom are living with mental illness themselves.
Interestingly, fiscal variables were identified only in relation to supporting early intervention and prevention programs. And while a lack of financial resources is frequently cited as a barrier to serving SMHA clients, results suggest that the availability of funding is just one of many factors that are important when developing new programs and policies.
Organizational structure of an SMHA, specifically whether a SMHA was independent and whether a SMHA administers only mental health services, was also identified as significant in relation to program and policy development for parents with mental illness. It may be the case that independent SMHAs not located within other agencies may be more autonomous, and be able to develop their own agendas better without having to include the priorities and interests of other departments located under the same umbrella agency. Independent SMHAs may also be more capable of establishing their own areas of interest, and may have an easier time developing new initiatives and priorities if they are not part of a larger agency that needs to be involved in the decision-making process. SMHAs that administer only mental health services may be better able to concentrate their efforts on specific populations of interest within the mental health arena, e.g., parents with mental illness.
Responsive SMHAs appear to embrace a particular organizational philosophy, or way of doing business that facilitates serving parents with mental illness and their children. This organizational philosophy involves working collaboratively within and across agencies and service systems, moving away from more traditional ideas about delivering and designing mental health services for individual "identified clients" and focusing on the needs of families and children, and a willingness to design and implement innovative services and policies. These concepts support Hasenfeld's (1983) notion that flexible internal structures are critical to adopting novel organizational goals. These strategies are potentially enhanced by SMHAs with organizational structures that are independent, and administer only mental health services, as autonomy and the ability to have a more narrow focus contribute to a more innovative and collaborative organizational philosophy and the flexibility to make change. High-level support (usually at the county level) from systems, agencies and boards was crucial to the ability to be responsive to parents with mental illness and their children.
Advocacy and the role of advocates are important in SMHAs' efforts to be responsive to the parental role of adult clients. Strategies used by advocates focused on what information was effective in making change happen (i.e., collecting and using personal experiences and prevalence data) as well as how to use this information within service systems (i.e., adopting multiple approaches). Stories of mental illness, whether of being a parent with a mental illness, being the child of a parent with mental illness, or working with parents with mental illness and their families, were powerful and effective in generating interest in parental mental illness. Prevalence data lend validity to the stories of consumers, family members and advocates, and prevent the dismissal of parental mental illness as a rare and uncommon occurrence. These data convey that parental mental illness is not something that affects only a small number of adults and their children; the prevalence is great and the issue is pervasive. Advocates then used these experiences and data to tackle the mental health system with both top-down and bottom-up approaches, while also working from within and outside of the mental health system. This decreases the reliance on one individual, and encourages involvement of persons from different systems, and from different levels within systems, in facilitating change. These types of advocacy may differ from the advocacy efforts often seen in SMHAs including consumer involvement in policy making, advisory boards and statewide planning efforts. The data suggest that how advocates choose to move forward with an issue, as well as their relationships relative to an SMHA matter when promoting systems change.
Some methodological limitations should be considered when reviewing these findings. First, the lack of previous research on parents with mental illness, as well as the dichotomous nature of the response categories for many of the survey questions, limit the sophistication of the methodology. Second, the identity of the SMHA survey respondents could be a confounding variable, as individuals in different administrative positions may vary in their knowledge of how the SMHA responds to the needs of adult clients who are parents and their families. Third, the reliability and validity of the SMHA survey have not been demonstrated. Therefore, how well the survey questions capture how a particular SMHA responds to parents with mental illness is unknown. Fourth, the selection of independent variables is limited by the NRI database. Since NRI is the only nationwide database committed to issues concerning SMHAs, data available for analysis are determined by NRI. However, data from the NRI and USCB databases and the Index of Fiscal Comfort (Tannenwald, 1999) are widely used, and researchers have accepted their reliability and validity. Fifth, the reliability and validity of the semi-structured protocol for the qualitative component of the study are also unknown. As there were no existing protocols to explore factors and strategies contributing to SMHA development related to parental mental illness, questions were generated through review of previous research, the literature and existing interview instruments. Finally, linear statistical models may be ill-suited to address complex, multiply-determined relationships such as program and policy decision-making. Setting mental health priorities is often an irrational and illogical process, influenced by a variety of factors including the values of the times, cultural forces and interest groups (Callahan, 1994). SMHAs are extremely complex entities; decisions regarding policy and program development may not be based on a step-wise, rational model.
Parenthood is extremely prevalent among adults with serious mental illness. There are many opportunities for SMHAs to attend to the needs of both adults and children living with parental mental illness. Findings from this study suggest that over half of SMHAs respond in some way to the needs of these families. Quantitative analyses indicate that organizational structure, specifically autonomous structure and providing only mental health services are positively related to SMHA responsiveness. Stakeholders suggest a variety of factors and strategies related to change including organizational philosophy, advocacy presence, and funding. These results should encourage SMHA administrators and providers interested in strategies that facilitate systems change.
This research was supported by a grant from the National Institute of Mental Health (R03 MH061026-01A1) and a contract from the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration (98M00263101R). Data from this article were presented at the Baltimore meeting of the NASMHPD Research Institute 13th Annual Conference on State Mental Health Agencies Services Research, Program Evaluation, and Policy in February 2003. We are grateful to Jim Callahan and Doreen Cavanaugh from the Heller School for Social Policy and Management for their consultation and assistance with this study. We thank our colleagues from the UMMS Center for Mental Health Services Research, Bill Fisher, Steve Banks, Alexis Henry and Valerie Williams for their comments on earlier drafts.
PubMed Central Canada is a service of the Canadian Institutes of Health Research (CIHR) working in partnership with the National Research Council's national science library in cooperation with the National Center for Biotechnology Information at the U.S. National Library of Medicine(NCBI/NLM). It includes content provided to the PubMed Central International archive by participating publishers.


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ATLANTA (AFP) – President Barack Obama issued a global call to action to fight West Africa's Ebola epidemic on Tuesday, warning the deadly outbreak was unprecedented and "spiraling out of control," threatening hundreds of thousands of people.
Speaking as he unveiled a major new US initiative which will see 3,000 US military personnel deployed to West Africa to combat the growing health crisis, Obama said the outbreak was spreading "exponentially."
"Here's the hard truth. In West Africa, Ebola is now an epidemic of the likes that we have not seen before," Obama said.
"It's spiraling out of control. It is getting worse. It's spreading faster and exponentially. Today, thousands of people in West Africa are infected. That number could rapidly grow to tens of thousands.
"And if the outbreak is not stopped now, we could be looking at hundreds of thousands of people infected with profound political and economic and security implications for all of us."
President Obama participates in a briefing on efforts to control the Ebola virus, at the Centres for Disease Control and Prevention in Atlanta, Georgia – REUTERS
As well as the military deployment, the US will also set up a command and control centre in the capital of Liberia, the hardest-hit country, build new treatment centres and train health workers.
The Ebola epidemic has killed more than 2,400 people in Guinea, Liberia, Nigeria and Sierra Leone this year.
The virus can fell its victims within days, causing severe fever and muscle pain, weakness, vomiting and diarrhoea – in some cases shutting down organs and causing unstoppable bleeding.
No licenced vaccine or treatment exists.
The United Nations Security Council is poised to adopt a resolution on Thursday exhorting countries to provide more field hospitals and urgent aid to the crisis-stricken region.
Likely passage of the resolution marks only the third time that the Security Council will vote on a public health crisis after resolutions on AIDS in 2000 and 2011.
"This has gone beyond health issues," UN Secretary General Ban Ki-moon said.
"It has gone to areas affecting social and economic situations. It may even affect political stability if not properly contained and treated."
The United Nations said nearly one billion dollars would be needed to beat back the worst-ever outbreak of the disease, which is on track to infect 20,000 people by the end of the year.
The world body has set a goal of stopping the spread of Ebola within six to nine months but aid agencies are complaining that help has been too slow.
Ban is planning a "high-level event" on the sidelines of the UN General Assembly next week to draw attention to the crisis.

subset: commoncrawl


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Group advocating for people with disabilities files against CATS
by: Holly Maynard Updated:
A group that advocates for people with disabilities in Monroe County has filed a formal complaint with the federal government, saying Charlotte's transportation authority is lacking in the quality of service it provides for them.
Elaine Elston uses a wheelchair to get around. So when she needs to go somewhere, she often calls to book a "Special Transportation Services" bus. However, she doesn't like to.
"When you get treated like a child, it makes you angry," she said.
Elston and several others say there's a lack of respect among the drivers. One reason: she says it's mandatory for them to give people with disabilities assistance with things like buckling their seat belts even if they don't need it.
"There's some things that you can do yourself. And the more that we can do, the more we do feel independent and in charge of our own lives," Elston said.
That's just one of several issues mentioned in a formal complaint filed by a council representing people with disabilities in Mecklenburg County. The complaint was filed Wednesday. It's against the paratransit system in Mecklenburg County, which complements CATS.
Teri Saltzman is blind. She told Channel 9 about another issue several people have complained about. It involves how to book their buses.
"I was told when I would call that I had to call five days in advance. The law is that you have to be able to call the day before," she said.
The complaint also alleges that many riders are left waiting one to two hours after their scheduled pick up time.
"It's always sad when we have to take it to the enforcement agencies," said Julia Sain, from Disability Rights and Resources, Fighting For Justice and Advancing Independence.
She said the transit system also promises certain riders further out in the county that they can be picked up, but they actually don't have the resources to do so.
"It breaks my heart for the folks who think that they're just waiting and waiting and waiting for a ride to the doctor or somewhere and they're never going to get it," she said.
Sain said the agency has tried to formally work things out with the city since February 2011 but not much has changed.
Eyewitness News contacted CATS about the complaint.
It responded with a statement that read, "The Charlotte Area Transit System has just received a copy of the complaint and we are prepared to assist the federal agencies that review these complaints."
The Federal Transit Administration did receive its copy of the complaint on Wednesday. It's up to the agency to decide if there should be any changes. There's no word yet on how long that could take.
Group advocating for people with disabilities files against CATS
42-year-old bicyclist killed in hit-and-run crash in Lancaster Co.
WATCH: Vacationing Charlotte family finds gator in Oak Island surf
Total solar eclipse 1st in 99 years to sweep width of US
Suicide bomber blows himself up as Saudis foil Mecca plot


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1 E-COMMERCE INFRASTRUCTURE FOR THE DEVELOPMENT OF TECHNOLOGY Tryambak Hiwarkar* AND COMMUNICATION Abstract: Intend of this study is to recognize the desirable infrastructure for e-commerce and trade with technology and communication infrastructure mainly. Also we are going to cram whether technology and communication foundation is one of emotional obstacles in creation and development of e-commerce, among other communications of e-commerce. Information systems rely on infrastructure in sharing data and information. Here we focus on IT infrastructure and discuss what skills and knowledge is needed in development of e - commerce infrastructure for the company. The paper aims at to presenting the infrastructure for e- commerce and its impact on the current trends of economy. Keywords: Research Model, E-Commerce *Ph.D. Scholar, Dept. of Business Management, RTM, Nagpur University, Nagpur, (MS) Vol. 2 No. 4 April IJARMSS 84
2 I. Introduction: During the humane past some innovations have occurred that have caused great changes and have had wide cost. Innovations such as combustion discovery, language creation, and money creation have twisted surprising effects in human life. In the new two centuries, the creation of steam engine resulted in industrial revolt era and this new discovery augmented human welfare. Also in the 20 th century plenty of innovations happened. One these vital innovations was utilizing computer networks and lastly internet in business and trade affaires. This change and growth in information technology and communications caused the appearance of information era in which information about computer to use computer networks seems necessary and vital. E-commerce also is the consequence of information technology development which is keenly welcomed in today's business world. Although e- commerce was shaped in the developed countries, it is accepted as a medium of exchange in rising countries, too. But as there are customary infrastructure and business tools in these countries, they are not ready to carry out the novel economics (digital economics). Thus, companies are forced to recognize and supply the needed infrastructure in order to use e- commerce [1]. 1.1 Objectives Our objective was to explore e-commerce connected concepts, infrastructure and socioeconomic, as they relate to China as a mounting country with a government that has taken a individual interest in technical capabilities of its population. We knew from direct experience that, in malice of lately increased governmental efforts and investments,the telecommunication and e-commerce infrastructure was not as developed in China as they were in U.S., Europe, or as would be in any developing country, and we predictable to find technical and infrastructural limitations to be important obstruction. Therefore, we focused on the societal issues and particularly wanted to recognize and explore the influence of culture on receipt and use e-commerce in this developing country. Vol. 2 No. 4 April IJARMSS 85
3 II. LITERATURE REVIEW Billy and Lowrence [2] originate out in their studies that innovations and inventions in the pasture of information technology has cause an increase in the difficulty for technologies useful in the industry and has shaped competitions in service industries especially in a worldwide measure. Thus, countries seek those new technologies in order to advance their optimization level which is directly related to the increases in reasonable growth [3]. Pohjola and Javala (2007) found out that the reason for the development in economic status in America in 1990s which was about 2.3 percent was owing to work force optimization because of utilizing information technology and communications. Also they complete new confirmation to estimate the amount of utilize and creation of information technology and communications in contrast to economic growth in Finland. This research showed that the share of information technology and communications compared with production in Finnish markets, has amplified from 0.3 percent in the early 1990s to 0.7 percent in late 1990s [4]. Zaree (2004) deliberate this issue in his paper entitled: "Studying the obstacle of developed use of e-commerce in Iran, with a special look at the big import companies of the country". He used random example technique and his sample consisted 68 companies. The results of the investigate showed that increasing knowledge about the capabilities of e-commerce can augment the amount of e-commerce. Also knowledge of computer use and internet will have the most impact on the amount of e-commerce [5]. Torabi & et al. (2008) deliberate the significance and effects of globalization and the effects of novel economics highlight on the role of e-commerce on economic growth of the developing countries. The results of this research demonstrate that in developing countries with an takings level higher than the Vol. 2 No. 4 April IJARMSS 86
4 average, the variable coefficient of e-commerce is positive and meaningful, but the globalization variable coefficient is meaningless statistically. And in countries with an income level lower than the average, both e-commerce and globalization criterion variables have a positive relationship with economic growth [6]. Figure 1: A company incorporating a virtual process as part of its own business processes. 2.1 E-Commerce in increasing Countries: E-commerce is an objective effect of ICT enjoying such advantages as globalization of commerce, removal of time and space limits, increase in purchase rate, easy access to information, significant decrease of transaction costs and reduction of duration of transaction. Electronic commerce presents developing countries an opportunity that can potentially enhance economic growth and development [7]. The acceptance of e-commerce in rising countries differs greatly from developed countries. Developing countries often lack the necessary financial, legal, and physical infrastructures for the development of e - commerce. In calculation, developing countries often have different cultures and business philosophies, which limit the applicability and transferability of the e-commerce models calculated by Western countries. However, some developing countries have begun strategies to achieve an appropriate level of e-commerce development [8]. Vol. 2 No. 4 April IJARMSS 87
5 2.2 E-Commerce in Iran & UAE According to Internet World Stats, there was a sharp growth of Internet users 13180% in Iran. This is from 250,000 users in 2000 to about 33 million users in June 30, 2010; this shows the main amount of Internet users (52.5 percent) in the Middle-East. No misgivings to the United Arab Emirates and Dubai in particular, enjoy much compensation for Internet and e-commerce growth and development. Some of these advantages were throughout the opening of the Internet city. Dubai Internet City is predictable to attract $400 millions in investment. With the cost of two and half billion dollars ($2.5 billion), Dubai Technology and Ideas Oasis is under the procedure to be the largest enterprise for investors and dedicated people in the electronic industry [8]. More than two third of the citizens of the United Arab Emirates or 75.9% use the Internet regularly, according to Internet World Stats (2011). The top five countries of the list of nations of the Middle East in Internet penetration are as follows. First, Bahrain with 88%. UAE is the second, where 75.9% of residents use the Internet. Rank third is Qatar with 51.8%. Then Iran with the penetration of 43.2% connects to the World Wide Web. 2.3 RESEARCH MODEL AND THEORY Explore Model This paper examines the relationship among nation and attitudes towards e-commerce. The autonomous variables were the nations involved, national cultures, gender and previous Web purchase experience, while the needy variables were the approach about e-commerce. Public Policy is a major aspect of e-commerce identified by Turban (2010). According to Turban, Public Policy includes taxation, legal and privacy issues, regulations and technical standards [9] Control and Privacy Privacy has been defined in three main ways. First, privacy is a "claim, entitlement or right" of a person to determine what personal information may be converse to others. Secondly, solitude is defined in relation to the "control" of access to personal information. Lastly, privacy is often unwritten with an individual's "rightful sphere of autonomy", the intimacies of life and one's thoughts or body. [10] Isolation Cost: Vol. 2 No. 4 April IJARMSS 88
6 Nations enact laws to protect from the loss of privacy, and that the Internet has sensitive the consciousness of the potential privacy loss due to technology. Privacy can be secluded by information control, property control and the use of secrecy of addresses in Internet communications. [10] Assets Rights and Infrastructure: Academic property IPR legislation applies to e-commerce comprises the international Trade- Related feature of Intellectual Property (TR1PS) agreement. TRIPS provide international IP standards, and purposely provide copyright protection for computer programs as intellectual creations Access Rights: The World Wide Web Consortium (W3C) defines the Web as the "universe of networkaccessible information". One of the W3C's primary goals is to make these benefits, including universal access, available to all people, whatever their hardware, software, network infrastructure, native language, culture, geography, location, or physical or mental ability" (www.w3.org/consortium/points) Consumer partiality Consumer partiality was defined in this paper as the tendency to prefer the store as the purchase position instead of the Internet. Consumers in nations where face-to-face concord are considered important, such as the Middle East, may cause consumers to prefer stores over the Internet. These consumers may use the Web to obtain information, and conduct their transactions in the store. III RESEARCH THEORY: Nation Culture The users in various nations have conflicting approach about aspects and issues related to information technology and electronic commerce, expressed in the hypothesis as: H1: Cultural groups will differ in attitude about e-commerce. Attitudes may be statistically different yet essentially appear to relate the same opinion in differing degrees. 3.1 Gender Genders might also differ in e-commerce approach. H2: Gender influences attitude about e-commerce. Vol. 2 No. 4 April IJARMSS 89
7 Harris and Davison (2009) study computer anxiety and involvement with personal computers in six Pacific Rim nations, and note that gender may have an influence on technology attitudes and use. They report that males have a more positive attitude towards technology. [11] 3.2 Infrastructure and e-support impediments to e-commerce: Our reading contributor recognized exact infrastructure related obstruction that will contain and be obstacle to full development of e-commerce in China in the near future. amid the most repeatedly state issues were lack of credit cards (wide availability of them for the general public in China) and convenient payment means, poor distribution logistics, lack of specialized, trust-worthy online merchants of sensible size (too many small players facing many bottlenecks and without needed resources to set up e-commerce systems), imperfect legal system, and lack of large scale telecommunication transmission capability (broadband). As users of e-commerce, the primary obstruction for our study group, in the order of importance, were Internet security, lack of feel-and-touch associated with online purchases, problems in returning products, and selection (product availability and breadth). 3.3 EXPANSION OF THE E-COMMERCE INFRASTRUCTURE: In universal, information system development is defined as mounting a system that convene needs or civilizing the existing system [21]. The expansion process occupy organization of the process, mapping of the organization, mapping of the present state of information dispensation and the actual design process, [12]. Here we apply these stages into development of e-commerce infrastructure. Once the need of or moving towards e-commerce is recognized the development process must be organized and a development group must be formed. Members of the group are often selected based on the skills, role and interest that they have towards the e -commerce platform. Here business knowledge and interactive skills are at stake. A typical development group could include IT people, business managers and other key people, users and outside consultants. The important issue is that the development group has enough expertise in order to evaluate different alternatives and make design choices. Also business understanding is vital as noted by interviewed business managers. Vol. 2 No. 4 April IJARMSS 90
8 In development work can outside sources of information be valuable. This mayinclude advice from consultants, a academic people or experts. Also conferences, professional journals and other e -commerce sites can give ideas. The second stage in the development work is mapping the organization. This refers to developing a mutual understanding of the key sectors of operations, how the information flows from one department and person to others etc. It is vital to have business understanding because e-commerce should be integrated to business processes. Fig2. Evolving the E-Enterprise Mapping the present state of information systems refers to existing information system: the development group needs to understand what the underlying infrastructure is. For example, e -commerce applications are often linked to existing databases and financial systems. This is why new technology should fit into the existing IT infrastructure [13], [10]. Building a robust and reliable system that integrates existing systems with new technologies is a challenge for the development group. Therefore the actual design process calls for technical expertise. The development of an e-commerce infrastructure takes a long time. It involves also other than technical issues, for example identifying potential products and customers for e -commerce. Typically, the development of e -commerce is an evolutionary process of moving traditional business into e - business [14]. The other alternative is that company builds operations to Internet alone. In both cases there are several stages involved in the Vol. 2 No. 4 April IJARMSS 91
9 process (Figure 2). A s Earl [15+ notes lessons learned in each stage and where each stage leaves behind critical imperatives for the next one.in first two stages the main emphasis is often on external or internal communication. Possible applications range from company s home pages to extranets that connect business partners to company s information systems. In these stages learning how IT can be applied has an important role. It involves skills and knowledge in technology (web -technology, security etc.), business understanding (importance of up -to- date content on the home page etc.) and interactive skills (organizing the development work, involving technical experts, business people and outside service providers etc.). The next two stages are about selling or buying online. The key challenges here are connected to promoting e-commerce, selecting and pricing products for e- commerce and managing brand. On deeper level e-commerce and e- business involves positioning e- activities with traditional business and redesigning business processes [16]. These challenges require mostly business expertise and understanding of what are the strategic goals of e-commerce related activities in the company. E-commerce makes it possible to collect and use data of all online transactions. It allows decision-making that is based on real -time information. Therefore, management processes should be redesigned so up -to- date information can be used in company management. This can introduce new ideas of management control, thus being the basis for ins situation ailing the online business model [14].Another interesting framework of e-commerce positioning and development is a awareness/positioning framework (or commitment -implementation matrix)proposed by Stroud [17+. It is based on two questions: firstly, what is the managements vision of the relative importance of technology. Secondly, how can Internet be integrated into existing organizational structures? Based on these questions company s level of commitment ranges from wait and see approach to bus lines innovation where processes are redesigned so that the potential of Internet can be used maximally. Similarly, the mode of development varies from building separate applications to business centric development where the potential of Internet is understood [17]. The interplay of technical and business understanding is a key issue in this framework. If company lacks technical expertise, opportunities may be lost as technology is not utilized. It is also possible that the importance of technology is diminished, left to technical people alone and not considered worthy of management s time and effort *17].The solution to Vol. 2 No. 4 April IJARMSS 92
10 these problems is in interaction between technical people and less-technically oriented business people. In general, interaction is recognized as one of the primary requirements for successful information systems development and implementation [18]. Open discussion and changing opinions are critical for the development work. However, there are also other factors such as personal characteristics of the group members and rewarding methods that affect the interaction and performance of the development group. Consequently, enhancing group interaction and discussion are important, but may not automatically ensure better results. IV CONCLUSION: Expansion of e-commerce infrastructure and information technology development in general is more than production right scientific choices. Administration the expansion process is a challenge, it requires business Understanding in how technology can be utilized in the best possible way. In this extended abstract, we have presented a basic infrastructure for business to business electronic commerce. REFERENCES: [1] Salehi-e-Sadeghiani, Jamshid, Dehghan, Nabiollah, Presenting a fourfold substructure model to implement and develop e-commerce in Tehran Food Industries, Management Message,vol. 3, no. 9, pp , [2] M. N. Baily and R. Z. Lawrence, Do we have a new e-economy? American Economic Review, vol. 91, no. 2, pp , 2001 [3] J. F. Allen, K. B. Donna, D. Myroslava, G. Ferguson, L. Galescu, and A. Stent, Towards conversational human-computer interaction, Dept. of Computer Science University of Rochester, *4+ M. Pohjola and J. Jalava, The role of electricity and ICT in economic growth:case of Finland, Explorations in Economic History,vol. 45, no. 3, pp , 2007 *5+ Zaree, Maryam (2004), Studying the obstacles of e-commerce use spread in Iran with a special look at our country's big Export Companies, Tehran. [6] Torabi, Taghi, Mohammadzadeh-e-Asl, Nazi, Globalization interactions, economic growth and e-commerce: a case study in developing countries, Economics and novel business seasonal Journal,no. 12, pp , 2008 Vol. 2 No. 4 April IJARMSS 93
11 [7] A Molla, R. Taylor and S. Licker. E-commerce Diffusion in Small Island Countries: the Influence of Institution in Barbados. Developing Countries. Vol. 28, 2006, pp The Electronic Journal of Information Systems in [8] 10. F. Uzoka, A. Shemi and G. Seleka. Behavioural influences on e-commerce adoption in a developing country context. The Electronic Journal of Information Systems in Developing Countries, Vol. 28, 2007, pp [9] E. Turban, J. Lee, M. King and H. Chug. Electronic commerce: A managerial perspective. NJ: Prentice Hall, 2010 [10] 12. G. Walters. Privacy and security: An ethical analysis. Computers and Society. June, 2001, pp [11] R. Harris and R. Davison. Anxiety and involvement: Cultural dimensions of attitudes toward computers in developing societies. Journal of Global Information Management. Jan- Mar 2009, pp [12] Checkland, P. -Scholes, J. (1999). Soft Systems Methodology in Action. John Wiley & Sons Ltd [13] Star, S.L. -Ruhleder, K. (1996). Steps Towards an Ecology of Infrastructure: Design and Access for Large Information Spaces. Information Systems Research, Vol 7, No 1, pp [14] Willcocks, L.P. Plant, R. (2001). Pathways to E -business Leadership: Getting from Bricks to Clicks. Sloan Management Review, 42(3), pp [15] Earl, M.J. (2000). Evolving the E -business. Business Strategy Review, 11(2), pp [16] Shapiro, Carl Varian, Hal R. (1999).Information Rules: A Strategic Guide to the Network Economy. Harvard Business School Press. Boston,Massachusetts [17] Stroud, D. (1998). Internet Strategies. London:Macmillan Press ltd. [18] King, W.R. (1978). Strategic planning formanagement information systems. MIS Quarterly, Vol 2, No 1, pp Vol. 2 No. 4 April IJARMSS 94
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Even if it is somewhat distasteful, the thought has kept the nation in idle amusement for 10 years and will no doubt continue to dog the former Tory minister right up to the day his obituaries are printed. Today, however, it was finally confirmed what many have long suspected: the whole thing was made up. The lovemaking in Chelsea strip (top only), the toesucking, the spanking - all fibs.
Mr Mellor has, of course, always said it was all a concoction by PR consultant Max Clifford (but he would say that, wouldn't he?). Only today, however, has the other party to those trysts in an Earl's Court flat confessed that the salacious allegations about the former Heritage Secretary's love-making were nothing but fiction.
In an interview with The Independent Ms de Sancha said: "The Chelsea strip was made up." The former actress, who employed Mr Clifford after the first allegations about the affair appeared in The People, added: "I went along with everything at the time. It was almost like I was having an out-of-body experience." Asked about the spanking and toesucking, she said: "It didn't happen."
Responding to the article, Mr Clifford - who is usually credited with being the inspiration for the Chelsea shirt - said today: "That's amazing. All these years I have totally believed it to be true. I'm just a humble public relations person. I tend to believe my clients when they tell me things, but then I'm not cynical. I was totally convinced. I'm quite shocked - disappointed, actually."
Ms de Sancha's confession came in an interview to mark the 10th anniversary of the revelations which led eventually to Mr Mellor's resignation from John Major's Cabinet. In it the 40-year-old, now making her living by importing Indian textiles, addresses the question everyone asks about her affair (apart, that is, from the one about the Chelsea strip).
"What the hell attracted me to him?" she asked. "That's a question I sometimes ask myself on very rare moments at awkward times in my life. Oh God, absolutely nothing attracted me to him physically. But sometimes you can meet somebody who is not an oil painting but you can forget about that and it's no longer important, it's who they are and what they're like inside." Admitting she was "seduced by the power", she said: "He was witty, charming and just
great fun to be with. The excitement was, to be perfectly frank, from being with somebody who was in a peak position of power. Though it was more than that. He made me laugh, I think I made him laugh."
She refused, she said, to accept the potential consequences - which included the possibility of public exposure and the effect on his marriage of 18 years. "I was too excited," she said. The affair was exposed after the owner of the Earl's Court flat, Nick Philp, bugged his own phone and sold the tapes to The People. "The intrusion is like you're sitting there naked and someone is cutting your body up very slowly," said Ms de Sancha. "Why did they [the press] want to give me such a bloody hard time? I had done nothing wrong other than to have an affair with someone who happened to be married. OK, that's not very pleasant, but it wasn't manipulative or vindictive, or a nasty horrible move on my behalf."
She last saw Mr Mellor - now divorced and living with Penny, Viscountess Cobham - at a restaurant a year ago when she was dining with Paul Halloran, the man who introduced them. "He freaked out. He went to the loo for about 20 minutes, then went and sat down at his table. I have never seen a man eat so quickly. He totally ignored us."
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- Kensington And Chelsea
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- Public Relations And Publicity


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Question about 1999 Ford F350 Regular Cab
I'm currently trying to get an F350 to start that hasn't being running in a while. I've changed the batteries, when I went to start it again the engine was turning over but it wouldn't start. We are planning on changing the fuel filter, but are wondering if it won't start because of the fuel heater/injector fuse.
Posted by colie88 on
If its got glow plugs chk. with test light make sure there working, also there might be a fuel shut off selanoid that works from the key, when you turn the key it opens to let fuel flow to start, and shuts when you turn key to off, test light that too. And of course chk. all fuses and relays. New fuel filter is a must. Just make sure you fill filter with fuel before you install it. Its been awhile sense its run, its most likely lost prime, maybe a little either will help it pick up, but just a little. you don't want to blow the heads off it.
Posted on Feb 07, 2009
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Posted on Jan 02, 2017
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