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BAHRAIN PROPERTY SITE, Bahrain Flat and House Rentals and Sales.
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Bahrain Business Directory - Companies in Bahrain


text:
Variety in meals keeps illness away
Food containing anti-oxidants, wholegrains and vital fatty acids are likely to cut the risk of killer illnesses including heart disease, Alzheimer`s and diabetes, a new study has suggested.
Scientists have found that rather than just a narrow range of foods being responsible for boosting health; the answer was a widely varied diet that might include oily fish, porridge oats and blueberries.
"The key is definitely to introduce these kinds of foods into the diet. It is a very healthy diet and completely proves the point that it is about healthy eating as a whole, not just doing one thing," the Daily Express quoted nutritionist Angela Dowden, as saying.
"It is a lifestyle change instead of tweaks here and there. It could be that it is just one of the foods that is producing these effects but it is much more likely that it is an additive affect of them all contributing," she added.
Results of the study carried out at Antidiabetic Food Centre at Lund University in Sweden have shown that it is multiple rather than just single foods with anti-inflammatory effects that work wonders.
Inger Bjorck of the Antidiabetic Food Centre, who carried out the research, said, "Our purpose was to find out which preventive effect can be obtained on established risk markers by combining food concepts with an expected positive impact on inflammation.
"We hope that these results on healthy subjects will inspire more intense preventive efforts in society."
The study saw 44 healthy but overweight people between the ages of 50 and 75 take part.
They ate foods, which are presumed to reduce low-grade inflammation in the body, a condition that in turn triggers metabolic syndrome that leads to obesity, Type 2 diabetes and heart disease.
The results showed that the diet slashed bad cholesterol by 33 per cent, lipids - blood fats - by 14 per cent, blood pressure by 8 per cent and a risk marker for blood clots by 26 per cent.
A marker of inflammation in the body was also greatly reduced, while memory and cognitive function were improved.
More from India
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- Amitabh Bachchan for higher public spending to prevent Hepatitis B
- First batch of Haj pilgrims from J&K to leave on August 10
- White dwarf found lashing red dwarf in space
- Land of believers! Out of 1.2 billion people, only 33,000 are atheists in India

subset: commoncrawl


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A little over a year ago I reported that pascal should have syntax highlighting, but there seems to have been no reaction. Can someone please enable default syntax highlighting for that tag?
Meta Stack Exchange is where users like you discuss bugs, features, and support issues that affect the software powering all 158 Stack Exchange communities.
What is meta?
What is meta?
Here's how it works:
- Any Stack Exchange user can ask a question
- The community provides support, votes on ideas, and reports bugs
- Your voice helps shape the way Stack Exchange operates
(and I've locked that other question, since it's too easy to miss new answers at this point)


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Internet Explorer
by Linda Spalding
|September 25, 2012
$22.27 online
save 25%
In stock online
Not available in stores
In 1798, Daniel Dickinson, a young Quaker father and widower, leaves his home in Pennsylvania to establish a new life. He sets out with two horses, a wagonful of belongings, his five children, a 15-year-old orphan wife, and a few land warrants for his future…
by Sonali Deraniyagala
|March 5, 2013
Out of stock online
Available in stores
A brave, intimate, beautifully crafted memoir by a survivor of the tsunami that struck the Sri Lankan coast in 2004 and took her entire family. On December 26, Boxing Day, Sonali Deraniyagala, her English husband, her parents, her two young sons, and a…
by Rainbow Rowell
|February 26, 2013
$13.47 online
save 38%
#1 New York Times Best Seller! " Eleanor & Park reminded me not just what it's like to be young and in love with a girl, but also what it's like to be young and in love with a book."-John Green, The New York Times Book Review Bono met his wife in high school ,…
by Mindy Kaling
|September 18, 2012
$15.00 online
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Mindy Kaling has lived many lives: the obedient child of immigrant professionals, a timid chubster afraid of her own bike, a Ben Affleck–impersonating Off-Broadway performer and playwright, and, finally, a comedy writer and actress prone to starting fights…
by A S A Harrison
|June 25, 2013
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Jodi and Todd are at a bad place in their marriage. Both are at the mercy of their unrelenting wants and needs, and both are unaware that the path they are on is careening toward murder. Much is at stake, including the affluent life they lead in their beautiful…
by Brian K Vaughan
|October 23, 2012
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Winner of the 2013 Hugo award for Best Graphic Story! When two soldiers from opposite sides of a never-ending galactic war fall in love, they risk everything to bring a fragile new life into a dangerous old universe. From New York Times bestselling writer Brian…
by Gary Keller
|April 1, 2013
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The ONE Thing has made more than 200 appearances on national bestseller lists, including #1 Wall Street Journal, New York Times, and USA Today. It won 12 book awards, has been translated into 24 languages, chosen as one of the Top 5 Business Books of 2013 by…
by Barbara Reid
|February 1, 2013
Board Book
$9.05 online
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In this love letter to babies and their families, Barbara Reid captures the special joy that a newborn brings to the world. Welcome, baby, welcome! All the world is new, And all the world is waiting To be introduced to you. In this essential gift for new parents,…
by Jon Klassen
|October 9, 2012
Picture Books
$13.64 online
WINNER OF THE 2013 CALDECOTT MEDAL! From the creator of the #1 New York Times best-selling and award-winning I Want My Hat Back comes a second wry tale. When a tiny fish shoots into view wearing a round blue topper (which happens to fit him perfectly), trouble…
by Walter Isaacson
|October 24, 2011
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From the author of the bestselling biographies of Benjamin Franklin and Albert Einstein, this is the exclusive, New York Times bestselling biography of Apple co-founder Steve Jobs. Based on more than forty interviews with Jobs conducted over two years—as…
by Hugh Howey
|March 12, 2013
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For suspense-filled, post-apocalyptic thrillers, Wool is more than a self-published ebook phenomenon―it's the new standard in classic science fiction. In a ruined and toxic future, a community exists in a giant silo underground, hundreds of stories…
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|April 2, 2013
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Flower arranging has never been simpler or more enticing. The women behind Studio Choo, the hottest floral design studio in the country, have created a flower-arranging bible for today's aesthetic. Filled with an array of stunning, easy-to-find flowers, it…
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New deals added at 12pm every day. Limited stock!
Ends 11 August
Ends 26 August
Ends 31 August
Ends 11 August
Have been using this regularly over the past weekends. Family really looking forward to it every time. Very easy to use and clean and you can experiment with different ingredients. High recommended!
My daughter brought me the Yonanas for Xmas, I love it! Healthy eating and refreshing during the hot weather........you gotta get one, now! :)
I love this, so healthy, easy to use and easy to clean, have purchased another as a Christmas gift
Awesome gift idea
Yonanas is easy to use and easy to clean. Fruity, refreshing desserts, oh so easy to eat!
Yonanas turns frozen fruit and other flavorings into a delicious, healthy soft-serve treat. The unit combines frozen bananas and any additional fruit or chocolate and instantly churns the ingredients to produce a treat with the texture of frozen yogurt or soft-serve ice cream, but without the additional fat, sugar, or preservatives.
The chute easily accepts berries, sliced mango, or cantaloupe along with frozen banana, and the integrated spinning blade mashes and incorporates the fruit into a silky-smooth confection with the texture of soft-serve ice cream or yogurt. The chute, plunger, and blade are dishwasher safe.
A Quick Explanation:
Find loads of great recipes here: http://yonanas.com/recipes/
Sorry! There are currently no Marketplace listings available for this product.
(If you require assistance from Mighty Ape, please contact us.)
Mighty Ape is 100% New Zealand owned


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Creepy new screenshots for Murdered: Soul Suspect
Square Enix has released a few new screenshots for the intriguing-looking mystery game, Murdered: Soul Suspect.
The four images below were tweeted from the game's profile, with the caption, "The hunt for the Bell Killer takes a grave turn in Salem's Cemetery". Those wraith things look particularly grave.
Murdered: Soul Suspect will be released for PC, PS4, Xbox One, PS3 and Xbox 360 on June 3 in North America, and June 6 in Europe and PAL regions.
Thanks, CVG.
Sometimes we include links to online retail stores. If you click on one and make a purchase we may receive a small commission. For more information, go here.


text: 123 items matching your search terms. Filter the results. Item type Select All/None Article Blog Entry Collection Page File Folder Issue Link Old Collection New items since Yesterday Last week Last month Ever Sort by relevance · date (newest first) · alphabetically We Have a Massive Student Loan Forgiveness Program—Why Is It So Complex? For a quarter of the nation's workers, public service could mean billions of dollars in student loan forgiveness—but they'll need persistence, patience, and fingers crossed. Ava Kofman Sep 07, 2015 Want to Build an Economy that Works for Everybody? Next Week, We're All About It Next Monday, YES! and the New Economy Coalition kick off New Economy Week—five days of national conversation about the ideas, strategies, and projects that make up the movement. Mary Hansen Oct 10, 2014 Vermonters Lobby for Public Bank—And Win Millions for Local Investment Instead Advocates didn't get the public bank they wanted. But the compromise they reached in the end was still a rare and significant win over Wall Street banks. Alexis Goldstein Jan 07, 2015 Unleashing Empathy: How Teachers Transform Classrooms With Emotional Learning The secret to learning self-awareness, cooperation, and other "social and emotional learning" skills lies in experience, not in workbooks and rote classroom exercises. Lennon Flowers Apr 04, 2014 Two Things White People Should Never Say "I'm not racist, but..." and other things to avoid saying when talking about race. Robert Jensen Jun 17, 2015 To Save Family Farms from Corporate Buyout, Retiring Farmers Connect with a New Generation In the next 20 years, many American family farmers are likely to retire—putting enormous amounts of land on the market. Here's how they're connecting with young farmers to make sure the family farm survives. Liz Pleasant Sep 05, 2014 Tiny House Living: How Two Families Made It Work—Teenagers, Sleepovers, Alone Time, and All How do you fit a full-sized family into a tiny house? The Morrisons and Kasls found that the benefits of life in 200 square feet outweigh the difficulties. Liz Pleasant Dec 24, 2014 This Guy Moved Into His Parents' House So a Homeless Family Could Live in His Three extraordinary, everyday people who will make your day better. Chris Francis Aug 09, 2013 This Fifth-Grader Raised $200,000 to Clean Up the Gulf Oil Spill by Selling Watercolors These three young activists found creative ways to tackle issues from climate change to voting rights. Christine St. Pierre Apr 30, 2014 This Earth Day, Listen Up: Mother Earth Is Calling Us Back Those of us who succumbed to the false promises of Western consumerism at great cost to the planet and to ourselves are Earth's prodigal children now returning home. David Korten Apr 20, 2016 Previous 10 items 1 2 3 4 5 6 7 Next 10 items


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I Spanked In Hotel
Personal Stories, Advice, and Support 199 People
Many A Belt Whipping...When I was younger we would drive long distances on vacation. I grew up in suburban Chicago and we had a cottage in Maine where we would spend two weeks each summer. I suppose that it might have been possible to make the drive in one day but it would be a marathon drive. We...
spankedjenny 51-55, F 2 Responses 9 Jan 27, 2013
HotelWe were in Austin for a weekend trip it was later in the evening like 7 and growing up I always had a bed time of 9 and I had to be up by 7 but anyway my step mother told me to get ready for my bath she gave me a bath everyday because she caught me playing with myself and didn't...
Abusedasachild43 22-25, F 1 Response 4 Jun 8, 2013
That's where I get pretty much all my spankingsanymore, meet in a hotel and get my spanking, everything you need in there
HorseAngel33 36-40, F 2 Dec 21, 2014
Hotel PunishmentOnce I was in a hotel with my aunt Kerstin. She is very strict, but somehow I gave her a few cheeky responses. She said she could not spank me, because it would be too loud. Instead, she made me lay down on my back and trampled my stomach in high heels. Tears ran down my face...
danieljohansson 41-45, M 5 Responses 0 Mar 5, 2013
Best guest house appropriatefor leisure guests, this guest house offers easy accessibility to major business and Commercial areas of the city ,Facilities offered laundry and travel table. Basic medical help is additionally accessible at this guest house.For additional query visit on website .
thecorporateinn 22-25, M 1 Response 0 Mar 31, 2015


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hitting a glass cup
Mechanical keyboard typing
A medium wind atmosphere. This is the best part of a longer recording. Could be looped to extend. There is ...
In an attempt to add warmth to my productions, I sampled some of the more distinctive sounds mostly from the ...
A sound good for disturbing jump scares in horror movies/videogames etc. Federico Manuti
Fire burning in stove Recorded with digital recorder
Field recording in late autumn, New England, during 20+ MPH wind gusts. Pine forest.
video game sounds games
this is the background loop that goes with the nano blade. It could be used for any of my sci-fi ...
Sci-fi energy glove that is dissipates energy when contact is made. Used punch along with energy burst sound to create.
A stereo recording of a futuristic vehicle passing.Download sounds much better than preview. Probably needs subwoofer to hear correctly.
Sound of a laser rifle firing.
Really over-produced and mashed up various sounds but it ended up sounding like somebody being electrocuted - sort of. This ...
The sound of birds taking off made with an umbrella


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Like his name, Muhammad Ali was the "most high," the epitome of athletic
grace, political integrity, and total love for the human family.
Breaking MLB's color barrier in 1947, Inge Hardison, a sculptor, memorialized Jackie Robinson
with one of her creations. She died on March 23.
For the next 28 days of Black History Month, AT&T will honor African American men and
women, from popular artists and ambassadors, to college presidents and
business leaders, who are uplifting their communities, making strides in
their professions and wowing the world at large. A series of inspiring articles and videos will be uploaded to the company's website beginning with Wayne A. I. Frederick; Ambassador Andrew Young; and Rosalind Brewer just to name a few.
The last two weeks of HARLEM WEEK 2015 were amazing and historic. On
Tuesday, August 11th at Columbia University, the 2nd Annual Basil
Paterson Business Awards Luncheon was held. The luncheon was emceed by
NY1 senior Anchor Cheryl Wills to a full house of four hundred
Harvard professor, scholar and author Henry Louis Gates, Jr. has received stellar reviews for his in-depth new documentary, "The African Americans: Many Rivers to Cross," which premiered on PBS last Tuesday.
Madam C.J. Walker, a laundress, became the first African American millionaire by selling her line of beauty products door-to-door.


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I have custom class that extends WebViewPage that I use as the base for all my Razor views using the method outlined here: http://haacked.com/archive/2011/02/21/changing-base-type-of-a-razor-view.aspx. Everything works fine unless I move it to a namespace that's different from the namespace of the views themselves whereupon the IntelliSense stops working (yes, I included the namespace of the custom WebViewPage in the namespaces section in the system.web.webPages.razor section of the web.config in the views folder). Is there a way around this?
What I want to do eventually is move all the views into another project that the graphic designers have access to, but I don't want the custom WebViewPage class in that project. Is this possible without breaking IntelliSense?


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Member Favorites: 89
Connie Springer (コニー・スプリンガー)Age: 15
Birthday: May 2
Height: 158 cm (5'2")
Weight: 54 kg (128 lbs)
Affiliations: 104th Trainees Squad, Scouting Legion
Graduation Rank: 8th
Ranked 8th of the trainee class. Upbeat and naive. Is also extremely dumb for not being able to differentiate left and right. Aims to apply to the scouting legion because he was motivated by Eren. From Ragako District.
(Source: Wikipedia)
Voice Actors
Top 15 Enormously Funny Attack on Titan GIFs
Attack on Titan (Shingeki no Kyojin) is meant to be a serious anime, but that doesn't mean it can't be seriously funny! Here are some funny moments in the anime as well as hilarious fan-made content!
13,654 views
Top 20 Funny Quotes from Attack on Titan
Attack on Titan (Shingeki no Kyojin) features the terrifying prospect of the extinction of humanity at the hands of nearly unstoppable monsters. But that doesn't stop the characters from having a bit of darkly humorous fun. Here are 20 of the funniest quotes from the series!
by mkane
6,786 views


text:
Code covered by the BSD License
Download apps, toolboxes, and other File Exchange content using Add-On Explorer in MATLAB.
Be the first to rate this file! 12 Downloads (last 30 days) File Size: 1008 Bytes File ID: #20835 Version: 1.0
Find 'orphaned' m-files
23 Jul 2008 (Updated 04 Apr 2016)
(in a directory tree)


text:
Book your room at Super 8 Ankeny / Des Moines Area
Get an overview of this hotelHotel in Ankeny with free breakfast and indoor pool
Situated in Ankeny, this hotel is within 3 mi (5 km) of Otter Creek Golf Course, Des Moines Area Community College, and Ankeny Art Center. John Deere Des Moines Works Tours and Woodland Hills Golf Course are also within 6 mi (10 km).
Hotel Features
Along with an indoor pool, this hotel has a fitness center and a 24-hour front desk. Free continental breakfast, free WiFi in public areas, and free self parking are also provided. Additionally, tour/ticket assistance, multilingual staff, and RV/bus/truck parking are onsite.
Room Amenities
All 45 rooms provide conveniences like refrigerators and microwaves, plus free WiFi and TVs with satellite channels. Separate bathtubs and showers, coffee makers, and free local calls are among the other amenities available to guests. Limited housekeeping is available.Would you like to give us feedback? Share it! Opens in a new window
Super 8 Ankeny / Des Moines Area206 SE Delaware Ave Ankeny IA 50023
Renovations & Closures
- Swimming pool
Hotel Amenities
Hotel Amenities
Super 8 Ankeny / Des Moines Area features an indoor pool and a fitness center. Public areas are equipped with complimentary high-speed wireless Internet access. A complimentary breakfast is offered. This Ankeny hotel also offers tour/ticket assistance, multilingual staff, and RV/bus/truck parking. Onsite self parking is complimentary.
- 24-hour front desk
- Fitness facilities
- Free breakfast
- Free self parking
- Free WiFi
- Indoor pool
- Multilingual staff
- Number of floors - 2
- RV, bus, truck parking
- Total number of rooms - 45
- Tours/ticket assistance
Family Friendly Amenities
- Free Wi-Fi
- Indoor pool
- Microwave
- Refrigerator
Available in all rooms: Free WiFi
Available in some public areas: Free WiFi
Free self parking, RV, bus, truck parking
Room Amenities
- Air conditioning
- In-room climate control (air conditioning)
- Coffee/tea maker
- Free toiletries
- Desk
- Free local calls
- Free WiFi
- Hair dryer
- Iron/ironing board
- Microwave
- Private bathroom
- Refrigerator
- Satellite TV service
- Separate bathtub and shower
- Television
Where to Eat
Guests are offered a complimentary continental breakfast.
Nearby Things to Do
Recreational amenities at the hotel include an indoor pool and a fitness center.
To make requests for specific accessibility needs, complete the "Special or Accessibility Requests" section of "Trip Preferences" when you book your hotel.
- Accessible bathroom
- In-room accessibility
Hotel Policies
Check-in time starts at 3 PM
Check-out time is 11 AM
Payment types
- Pets not allowed (service dogs only)
You need to know
Extra-person charges may apply and vary depending on hotel policy.
Government-issued photo identification and a credit card or cash deposit are required at check-in for incidental charges.
Special requests are subject to availability upon check-in and may incur additional charges. Special requests cannot be guaranteed.
Only service dogs are allowed
Optional extras
- Early check-in fee: USD 30
- Rollaway bed fee: USD 20 per night
Hotel Name
- Super 8 Ankeny Moines Area Hotel
- Super 8 Moines Area Hotel
- Super 8 Ankeny Moines Area
- Super 8 Moines Area


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Bass-Baritone Arias with Orchestra, Vol. II
Bass/baritone voice
Vocal Score and CD+G. Published by Music Minus One (MO.MMOCDG4066).
Item Number: MO.MMOCDG4066
ISBN 1596155507. Soloist: Ivajlo Djourov, bass-baritone; Ensemble: Plovdiv Philharmonic Orchestra; Conductor: Nayden Todorov.
A second volume of bass-baritone operatic standards from great basso Ivajlo Djourov and the Plovdiv Philharmonic. Study Mr. Djourov's interpretations, then fashion your own with your own personal orchestra.
Includes a printed vocal score on high-quality ivory paper, with informative liner notes; and a CD+G graphics-enabled compact disc with complete versions (with soloist) followed by stereo orchestral accompaniments to each piece, minus the soloist.
About CD+G
CD+G (CD+Graphics) is a special disc format in which simple graphics and text are stored in the sub channels of an audio disc. When you play a CD+G disc in a CD+G compatible player (like a karaoke machine), lyrics and images appear on the monitor or TV screen in time to the music. If you play a CD+G disc in a regular CD player, you'll still be able to hear the music and sing along to your favorite tracks, but the graphics features won't function. The CD+G format is a fun and useful learning tool!
- Aleko - Act I: Aleko's cavatina (Aleko) Performed by Sergei Rachmaninov
- Faust - Act IV: 'Vous qui faites l'endormie' (serenade) (Mephistopheles) Performed by Charles Francois Gounod
- Fidelio: 'Hat man nicht auch Gold daneben' (Rocco) Performed by Ludwig Van Beethoven
- Le Nozze di Figaro (The Marriage of Figaro), KV492 - Act I: 'Non piu andrai' (Figaro) Performed by Wolfgang Amadeus Mozart
- Don Giovanni, KV527 - Act I: 'Madamina! Il catalogo e questo' (Leporello) Performed by Wolfgang Amadeus Mozart
Customers Who Bought Bass-Baritone Arias with Orchestra, Vol. II Also Bought:
24 Italian Songs & Arias of the 17t...
10 Hymns and Gospel Songs for Solo ...
Piano Sonatas - Volume 1
Cantolopera: Arias for Bass - Volum...
$29.95 $23.96
Cantolopera: Arias for Baritone - V...
$29.95 $23.96
Cantolopera: Arias for Bass - Volum...
$29.95 $23.96
Cantolopera: Arias for Bass - Volum...
$29.95 $23.96
Cantolopera: Arias for Baritone - V...
$29.95 $23.96
Cantolopera: Arias for Baritone - V...
$29.95 $23.96


text:
If you have troubles since the update to WordPress 4.5 please read this post before opening a new thread.
Tagged: Portfolio, propulsion
Is there a way for me to add multiple images to the portfolio categories without me having to upload them individually one by one and then name each entry?
The featured media uploader doesn't support such a feature but you can try plugins like: http://wordpress.org/extend/plugins/nextgen-gallery/ which allow you to create multiple galleries and to display them by using a shortcode.
The topic 'Portfolio Categories Individualized' is closed to new replies.


text:
- Sign in
- Join
- Find a rental
- Manage your booking
- Kings Beach rentals
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- Kings Beach Rentals with Hot Tub
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- Cheap Kings Beach Rentals
- Kings Beach Rentals with Pool
- 5-Star Kings Beach Rentals
- See more rentals
- How to book
- Traveler Help Center
- Write a review
Kingswood Village 108
From $150 / night
balance of due
Description from the manager
Description from the manager
Bedrooms: 3/
Bathrooms: 2/
Sleeps: 9/
Type: Apt. / Condo
Book this 3 bedroom, 2 bathroom apt. / condo in Kings Beach today! A total of 9 people can sleep here comfortably.
Guests can enjoy a pool, internet access, and dishwasher among other amenities offered by this rental.
Travelers are sharing their opinions on this property. It has an overall rating of 5/5 thanks to an average of 3 reviews.
Costs vary, with the average weekly rate as low as $1,050.00 to as high as $1,750.00, depending on travel dates.
The owner responds to 60% of inquiries, which is lower than average, and last updated the property's calendar 9 months ago, so this rental may not be available for your requested dates, but please inquire to confirm.
About the manager
About the manager
Stay In Lake Tahoe
Stay In Lake Tahoe
- Response rate: 60%
- Response time: A few hours
- Calendar updated: 9 months ago
Overall rating:
4.1 / 5.0
More properties Call: +1-844-424-4058


text:
The Clarence Schock Foundation, formerly The SICO Foundation, located at 15 Mount Joy Street, Mount Joy, PA 17552, will cease all operations effective December 31, 2015. The Foundation has gifted its assets to three major Charitable Trusts, two in support of Scholarships and Fellowships at four public universities (Kutztown, Millersville, Shippensburg, and West Chester) and one in support of Clarence Schock Memorial Park at Governor Dick. Gifts to other charitable organizations such as the Milanof-Schock Library and the Mount Joy Area Historical Society have also been made.
Founded by the personal philanthropy of business leader Clarence Schock, the Foundation has been supporting deserving college students from the South Central Pennsylvania region since 1951. Mr. Schock also gifted the Governor Dick Park to the Public in an act of extraordinary generosity. The Trusts that have been established will ensure that these two primary charitable purposes will be fulfilled in perpetuity.
After December 31, 2015, there will be no official means of contacting the Foundation. This website will remain available for historical purposes only, for a period of up to two years. As an historical document, this site will not be up to date and may not apply to current practices and circumstances.
The Foundation continues to be represented by Richard Caputo, Attorney at Law, Fox Rothschild, LLP.
Thank you.
The Board of Directors
© 2006 Clarence Schock Foundation


text:
retail jobs near Cibolo, TX
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Fraud Customer Service Representative San Antonio
Citi - San Antonio, TX
In addition, our team members enjoy an extensive and highly competitive benefit package that includes a comprehensive insurance plan, matching 401K program ,...
Retail Sales Associate
McCoy's Building Supply - San Antonio, TX
Reviews merchandise movement within an assigned area, compares record with merchandise on-hand, and reports discrepancies to Store Inventory Coordinator in...
Ulta Beauty - New Braunfels, TX
Assist in store duties (e.g., filling and Salon retail displays and shelves). An Esthetician delivers quality technical service with emphasis on the customer's...
Retail Sales Associate
CW Floors & Lighting - San Antonio, TX
* Helping customers with flooring and lighting selections * Measuring projects to determine how much product is needed * Scheduling and managing
Restaurant General Manager & Assistant Managers
MUY Companies - San Antonio, TX
And, you're at least 18 years old with a valid driver's license, reliable transportation (not public transportation – you may need to drive to make deposits for...
Salon Manager-New store-Bandera Pointe
Ulta Beauty - San Antonio, TX
Demonstrates business acumen, with an understanding of key business drivers and can identify opportunities for growth with in own location especially payroll...
Hiring Kitchen Prep Cooks New Braunfels Restaurant!
Freebirds World Burrito - New Braunfels, TX
Freebirds is searching for people who believe it's what is on the inside that matters. Whether you have experience in the food service industry, or none at all...
Assistant Manager | Retail Sales Associate
Aria Bridal & Formal Wear - San Antonio, TX
Retail Clothing Sales:. Aria Bridal & Formal Wear (in North Star Mall) is looking for energetic and outgoing Retail Sales Associate....
Sales Associate, $9.75 per hour
World Duty Free Group - San Antonio, TX
Help maintain a neat, clean, organized store, which includes sweeping, dusting, straightening of merchandise on store fixtures and displays....
Sales Associate – Management Trainee
Furniture Row - Selma, TX
Successful Management Trainees have come from administration, marketing, customer service, hospitality, automotive, real estate, insurance, warehouse /...


text:
Hello this template is so nice, thanks for it.
I got a problem. I change domain and all run good, just i got 1 problem in Primary Menu: "Inicio". When i touch that button, i go the old domain.
I not create "Inicio", no is one page, it is there from the beginning, in the theme.
Can u said me, where i need edit for correct it, when i touch "Inicio" i wanna go to the Home Page but correct domain.
This is the webside: http://bit.ly/1gSlW5s
Thanks u very much, and sorry for my bad english.


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Seattle, WAUSA
February 27, 2012
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Some Evacuation Orders Lifted In Southern California Wildfire
Monday, July 25, 2016
The body of a man was found in an area burned by a 33,000 acre wildfire north of Los Angeles. The Sand Fire has destroyed more than a dozen homes and is one of 19 major fires burning in California.
Police Utilize Soft Force Tactics At Cleveland Convention Protests
Wednesday, July 20, 2016
The overwhelming use of soft force and quick reaction times are two tactics among many being used in Cleveland this week to keep protests peaceful.
Mormons Uneasy With Trump Make A Question Of Reliably Red Utah
Thursday, July 14, 2016
Utah has gone for every Republican presidential nominee since 1968, but this year could be different because Donald Trump is a hard sell with many of the state's Mormon voters.
Call Logs Reveal New Details From Orlando Shooting
Tuesday, June 28, 2016
The city of Orlando released hundreds of pages from police and fire communications the day of the nightclub shootings that killed 49 people and injured more than 50 others.
#NPRreads: Drink In These 3 Stories This Weekend
Saturday, June 25, 2016
June 18, 2016 • Correspondents, editors and producers from our newsroom share the pieces that have kept them reading, using the #NPRreads hashtag. Each weekend, we highlight some of the best stories.
Southwest Heat Wave Causes Snowpack To Melt Earlier, Quicker
Wednesday, June 22, 2016
Scientists say more heat will likely be the new normal for the Southwest. Water managers are warning that soaring temperatures are also causing the region's already stressed snowpack to melt faster.
Grand Jury Considers Whether To Charge Orlando Gunman's Wife
Wednesday, June 15, 2016
Police in Orlando have released new details on Sunday's deadly shootings at a nightclub. Forty nine people died and more than 50 others were injured.
Investigators Probe Why More Wasn't Done About Shooter's Red Flags
Wednesday, June 15, 2016
As Orlando continues to mourn the victims of last weekend's massacre, some in the city are bristling at how quickly the national conversation has shifted from healing to politics.
Orlando's LGBT Bars Respond Differently To Pulse Massacre
Tuesday, June 14, 2016
The Orlando shootings sent a wave of shock across the city that is known as a premier destination for gay nightlife. Pulse is one of about a dozen gay bars and night clubs. Some clubs closed temporarily at the request of police while safety protocols are revised, others are hiring armed security guards and remaining open.
Utah Sheriffs Threaten To Arrest Rangers If They Try To Close Public Lands
Tuesday, May 31, 2016
Clashes over grazing rights continue. Local sheriffs will give you an earful about how they believe environmental extremists have taken over federal agencies. But this is more than just a turf battle.
Even With Bundy Behind Bars, 'Range War' Lives On For Some Ranchers
Wednesday, May 25, 2016
Cliven Bundy and many of his militia followers are now in jail, but some Western ranchers vow to continue defying the federal government when it comes to cattle grazing on public lands.
Transportation Milestone: Last Leg Of LA's Metro Expo Line Completed
Monday, May 23, 2016
After more than 30 years of planning, legal battles and cost overruns, passenger rail is once again connecting downtown Los Angeles to the ocean.
Firefighters Watching Canadian Blaze, Worry About Summer Conditions In U.S.
Tuesday, May 17, 2016
The U.S. Forest Service says the South and Southwest may face above-normal fire danger. In California, for instance, drought has killed millions of trees that are now dry fuel.
Texas Oil Company Faces Criminal Charges Over Southern California Spill
Tuesday, May 17, 2016
The oil company responsible for a large spill along the Southern California coast a year ago has been indicted by a state grand jury on criminal charges stemming from the disaster.
Grim Sleeper Verdict Renews Push To Investigate Murders In South Los Angeles
Friday, May 06, 2016
A guilty verdict in the months-long "Grim Sleeper" serial killer trial has brought some closure to many families of the victims. But community leaders in south Los Angeles are pressing forward with pressuring police to investigate at least 35 other possible murders.
Families Of LA Serial Killer's Victims Still Await Closure
Monday, May 02, 2016
Police allege Lonnie Franklin Jr. terrorized LA for decades, targeting mostly young black women. As his trial wraps up, critics wonder if racial bias caused the investigation to take so long.
In The Rural Northwest, A Growing Market For Survivalist Homes
Thursday, April 28, 2016
A Montana couple is looking to meet a growing demand in the real estate business, at least in the rural Northwest: off-grid properties that include bunkers and secret rooms.
Court Upholds Snowboarding Ban At Utah Ski Resort
Tuesday, April 19, 2016
Alta Ski Area markets itself as just for skiers. It is one of the few U.S. resorts to do that.
California Gov. Jerry Brown Signs State's $15 Minimum Wage Law
Monday, April 04, 2016
California becomes the first state in the nation to raise its minimum wage to $15 an hour Monday, when Gov. Jerry Brown signs a bill in Los Angeles that phases in the increase over the next six years.
California's Sierra Snowpack Shows Improvement; Drought Still Not Over
Thursday, March 31, 2016
Updated snowpack measurements show El Nino has helped ease the drought in California. While reservoirs are filling up, conservation measures remain in place.


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Pinnacle Entertainment, Inc. - Financial and Strategic Analysis ReviewSummaryPinnacle Entertainment, Inc. (Pinnacle) is a developer, owner and operator of casino gaming resorts. The company holds and manages six major casinos based in Nevada, Louisiana, Indiana and Missouri, as well as small casinos in Argentina and The Bahamas. In addition, it has a number of development projects under construction. The company is headquartered at Las Vegas, Nevada in United States and employs 8,590 people. On December 20, 2007, the company opened its new casino and entertainment complex, Lumiere Place located in St. Louis. This report presents an in-depthbusiness, strategic and financial analysis of Pinnacle Entertainment, Inc.. The report provides a comprehensive insight into the company, including business structure and operations, executive biographies and key competitors. The hallmark of the report is the detailed strategic analysis and Global Markets Direct's views on the company.Scope' The company's strengths and weaknesses and areas of development or decline are analyzed. Financial, strategic and operational factors are considered. ' The opportunities open to the company are considered and its growth potential assessed. Competitive or technological threats are highlighted. ' The report contains critical company information ' business structure and operations, the company history, major products and services, key competitors, key employees and executive biographies, different locations and important subsidiaries.' It provides detailed financial ratios for the past five years as well as interim ratios for the last four quarters.' Financial ratios include profitability, margins and returns, liquidity and leverage, financial position and efficiency ratios.Reasons to buy' A quick 'one-stop-shop' to understand the company. ' Enhance business/sales activities by understanding customers' businesses better.' Get detailed information and financial & strategic analysis on companies operating in your industry.' Identify prospective partners and suppliers ' with key data on their businesses and locations.' Capitalize on competitors' weaknesses and target the market opportunities available to them.' Compare your company's financial trends with those of your peers / competitors.' Scout for potential acquisition targets, with detailed insight into the companies' strategic, financial and operational performance.


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One of the most critical issues in mental health services research is the gap between what is known about effective treatment and what is provided to consumers in routine care. Concerted efforts are required to advance implementation science and produce skilled implementation researchers. This paper seeks to advance implementation science in mental health services by over viewing the emergence of implementation as an issue for research, by addressing key issues of language and conceptualization, by presenting a heuristic skeleton model for the study of implementation processes, and by identifying the implications for research and training in this emerging field.
One of the most critical issues in mental health services research is the gap between what is known about effective treatment and what is provided to and experienced by consumers in routine care in community practice settings. While university-based controlled studies yield a growing supply of evidence-based treatments and while payers increasingly demand evidence-based care, there is little evidence that such treatments are either adopted or successfully implemented in community settings in a timely way (Bernfeld et al. 2001; Institute of Medicine 2001; National Advisory Mental Health Council 2001; President's New Freedom Commission on Mental Health 2003; U.S. Department of Health and Human Services 1999, 2001, 2006). Indeed new interventions are estimated to "languish" for 15–20 years before they are incorporated into usual care (Boren and Balas 1999). The implementation gap prevents our nation from reaping the benefit of billions of US tax dollars spent on research and, more important, prolongs the suffering of millions of Americans who live with mental disorders (President's New Freedom Commission on Mental Health 2003). Ensuring that effective interventions are implemented in diverse settings and populations has been identified as a priority by NIMH Director Thomas Insel (2007).
The gap between care that is known to be effective and care that is delivered reflects, in large measure, a paucity of evidence about implementation. Most information about implementation processes relies on anecdotal evidence, case studies, or highly controlled experiments that have limited external validity (Glasgow et al. 2006) and yield few practical implications. A true science of implementation is just emerging. Because of the pressing need to accelerate our understanding of successful implementation, concerted efforts are required to advance implementation science and produce skilled implementation researchers.
This paper seeks to advance implementation science in mental health services by over viewing the emergence of implementation as an issue for research, by addressing key issues of language and conceptualization, by presenting a skeleton heuristic model for the study of implementation processes, and by identifying the implications for research and training in this emerging field.
The seminal systematic review on the diffusion of service innovations conducted by Trisha Greenhalgh et al. (2004) included a small section on implementation which was defined as "active and planned efforts to mainstream an innovation within an organization" (Greenhalgh et al. 2004, p. 582). Their review led these authors to conclude that "the evidence regarding the implementation of innovations was particularly complex and relative sparse" and that at the organizational level, the move from considering an adoption to successfully routinizing it is generally a nonlinear process characterized by multiple shocks, setbacks, and unanticipated events" (Greenhalgh et al. 2004, p. 610). They characterized the lack of knowledge about implementation and sustainability in health care organizations as "the most serious gap in the literature … uncovered" (Greenhalgh et al. 2004, p. 620) in their review.
Fortunately, there is evidence that the field of implementation science is truly emerging. In particular, the mental health services field appears to be primed to advance the science of implementation, as reflected by several initiatives. NIMH convened a 2004 meeting, "Improving the fit between mental health intervention development and service systems." Its report underscored that "few tangible changes have occurred" in intervention implementation (National Institute of Mental Health 2004), requiring new and innovative efforts to advance the implementation knowledge and the supply of implementation researchers. The meeting revealed a rich body of theory ripe for shaping testable implementation strategies and demonstrated that diverse scholars could be assembled around the challenge of advancing implementation science. This meeting was followed by other NIMH events, including a 2005 meeting, "Improving the fit between evidence-based treatment and real world practice," a March 2007 technical assistance workshop for investigators preparing research proposals in the areas of dissemination or implementation, and sessions and an interest group devoted to implementation research at the 2007 NIMH Services Research Conference.
Implementation research is advancing in "real time." The NIH released the Dissemination and Implementation Program Announcement (PAR-06-039), appointed an NIMH Associate Director for dissemination and implementation research, and established a cross-NIH ad hoc review committee on these topics. NIH has funded a small number of research grants that directly address dissemination and implementation (including randomized trials of implementation strategies). More recently, the Office of Behavioral and Social Science (OBSSR) launched an annual NIH Dissemination and Implementation conference and a journal on Implementation Science was launched in 2006. While these developments are important stepping stones to the development of the field of implementation science, they reflect only the beginnings of an organized and resourced approach to bridge the gap between what we know and what we deliver.
In emerging fields of study, language and constructs are typically fluid and subject to considerable discussion and debate. Implementation research is no exception. Creating "a common lexicon…of implementation…terminology" is important both for the science of implementation and for grounding new researchers in crucial conceptual distinctions (National Cancer Institute 2004). Indeed currently the development of theoretical frameworks and implementation models of change is hampered by "diverse terminology and inconsistent definition of terms such as diffusion, dissemination, knowledge transfer, uptake or utilization, adoption, and implementation" (Ellis et al. 2003).
Implementation research is increasingly recognized as an important component of mental health services research and as a critical element in the Institute of Medicine's translation framework, particularly it's Roadmap Initiative on Re-Engineering the Clinical Research Enterprise (Rosenberg 2003; Sung et al. 2003). In their plenary address to the 2005 NIMH Mental Health Services Research Conference, "Challenges of Translating Evidence-Based Treatments into Practice Contexts and Service Sectors", Proctor and Landsverk (2005) located implementation research within the second translation step that is between treatment development and integration of efficacious treatments in local systems. The second translation step underscores the need for implementation research, distinct from efficacy and effectiveness research in outcomes, substance, and method. A number of similar definitions of implementation research are emerging (Eccles and Mittman 2006). For example, Rubenstein and Pugh (2006) propose a definition of implementation research for health services research:
Implementation research consists of scientific investigations that support movement of evidence-based, effective health care approaches (e.g., as embodied in guidelines) from the clinical knowledge base into routine use….Such investigations form the basis for health care implementation science…, a body of knowledge (that can inform)…the systematic uptake of new or underused scientific findings into the usual activities of regional and national health care and community organizations, including individual practice sites" (p. S58).
The CDC has defined implementation research as "the systematic study of how a specific set of activities and designated strategies are used to successfully integrate an evidence-based public health intervention within specific settings" (RFA-CD-07-005).
NIH PAs on Dissemination and Implementation Research in Health distinguish between dissemination–"the targeted distribution of information and intervention materials to a specific public health or clinical practice audience" with "the intent to spread knowledge and the associated evidence-based interventions" and implementation–"the use of strategies to introduce or change evidence-based health interventions within specific settings". The CDC makes similar distinctions. Within this framework, evidence-based practices are first developed and tested through efficacy studies and then refined and adapted through effectiveness studies (which may entail adaptation and modification to increase external validity and feasibility). Resultant findings and EBP's are then disseminated, often passively via simple information dissemination strategies, usually with very little uptake. Considerable evidence suggests that active implementation efforts must follow, for creating evidence-based treatments does not ensure their use in practice (U.S. Department of Health and Human Services 2006). In addition to an inventory of evidence-based practices, the field needs carefully designed strategies developed through implementation research. Implementation research has begun with a growing number of observational studies to assess barriers and facilitators which are now being followed by a very small number of experimental studies to pilot test, evaluative, and refine specific implementation strategies. This research may lead to further refinement and adoption, yielding implementation "programs" that are often multi-component. These implementation programs are then ready for "spread" to other sites. We would argue (as does The Road Ahead Report; U.S. Department of Health and Human Services 2006) that implementation research in the area of mental health care is needed in a variety of settings, including specialty mental health, medical settings such as primary care where mental health is also delivered, and non-specialty settings such as criminal justice, school systems, and social services where there is increasing importation of mental health care delivery. In fact, we would also argue that a critical discussion is needed regarding whether implementation research models might differ significantly between these very different sectors or organizational platforms for mental health care delivery.
The CDC defines diffusion research as the study of factors necessary for successful adoption of evidence-based practices by stakeholders and the targeted population, resulting in widespread use (e.g., state or national) (RFA-CD-07-005). Greenhalgh et al. (2004) further distinguish between diffusion which is the passive spread of innovations, and dissemination, which involves "active and planned efforts to persuade target groups to adopt and innovation" (p. 582). Thus implementation is the final step in a series of events, characterized under the broadest umbrella of translation research that includes a wide range of complex processes (diffusion and dissemination and implementation).
Two technologies are required for evidence-based implementation: practice or treatment technology, and a distinct technology for implementing those treatments into service system settings of care. Implementation is dependent on a supply of treatment strategies. Presently a "short lists" of interventions that have met a threshold of evidence (according to varying criteria) are ready or have moved into implementation; these would include examples such as MST (Multisystemic Therapy), Assertive Community Treatment (ACT), supported employment, and chronic care management/collaborative care. Research suggests that features of the practices themselves bear upon "acceptability," "uptake," and "fit" or compatibility with the context for use (Cain and Mittman 2002; Isett et al. 2007). Typically issues of fidelity, adaptation, and customization arise, leading ultimately to the question, "where are the bounds of flexibility before effectiveness is compromised?"
Implementation strategies are specified activities designed to put into practice an activity or program of known dimensions (Fixsen et al. 2005). In short, they comprise deliberate and purposeful efforts to improve the uptake and sustainability of treatment interventions. Implementation strategies must deal with the contingencies of various service system or sectors (e.g., specialty mental health, medical care, and non-specialty) and practice settings, as well as the human capital challenge of staff training and support, and various properties of interventions that make them more/less amenable to implementation. They must be described in sufficient detail such that independent observers can detect the presence and strength of the specific implementation activities. Successful implementation requires that specified treatments are delivered in ways that ensure their success in the field, that is: feasibly and with fidelity, responsiveness, and sustainability (Glisson and Schoenwald 2005).
Currently, the number of identifiable evidence-based treatments clearly outstrips the number of evidence-based implementation strategies. Herschell et al. (2004) review of progress, and lack thereof, in the dissemination of EBP's. Several groups of treatment and service developers have produced similar approaches taking an effective model to scale, but methods have been idiosyncratic, and as likely to be informed by field experience as by theory and research. Most implementation strategies remain poorly defined, can be distinguished grossly as "top down" and "bottom up," and typically involve a "package" of strategies. These include a variety of provider decision supports, EBP-related tool kits and algorithms, practice guidelines; system and organizational interventions from management science, economic, fiscal and regulatory incentives; multi-level quality improvement strategies (e.g., Institute for Health Improvement's Collaborative Breakthrough series, the VA QUERI program); and business strategies (e.g., Deming/Shewart Plan-Do-Check-Act Cycle). Some implementation strategies are becoming systematic, manualized and subject to empirical test, including Glisson's ARC model and Chaffin and Aarons' "cascading diffusion" model based on work by Chamberlain et al. (in press). The field can ill afford to continue an idiosyncratic approach to a public health issue as crucial as the research-practice gap. The Road Ahead report calls for research that can develop better understanding of mechanisms underlying successful implementation of evidence-based interventions in varying service settings and with culturally and ethnically diverse populations.
Implementation research comprises study of processes and strategies that move, or integrate, evidence-based effective treatments into routine use, in usual care settings. Understanding these processes is crucial for improving care, but currently this research is largely case study or anecdotal report. Systematic, empirical or robust research on implementation is just beginning to emerge, and this field requires substantial methodological development.
The emerging field of implementation research requires a comprehensive conceptual model to intellectually coalesce the field and guide implementation research. This model will require language with clearly defined constructs as discussed above, a measurement model for these key constructs, and an analytic model hypothesizing links between measured constructs. Grimshaw (2007) noted at the 2007 OBSSR D & I Conference that we now have >30 definitions of dissemination and implementation and called for the development of a theory and fewer small theories to guide this emerging field. In our view, no single theory exists because the range of phenomena of interest is broad, requiring different perspectives. This paper seeks to advance the field by proposing a "skeleton" model, upon which various theories can be placed to help explain aspects of the broader phenomena.
Our developing implementation research conceptual model draws from three extant frameworks. First is the "stage pipeline" model developed by the National Cancer Institute (2004) and adapted for health services by VA's QUERI program (Rubenstein and Pugh 2006). In the research pipeline, scientists follow a five phase plan, beginning with hypothesis development and methods development (Phase 1 and 2), continuing into controlled intervention trials (Phase 3 efficacy) and then defined population studies (Phase 4 effectiveness), and ending with demonstration and implementation (Phase 5). Here the process is considering as a linear progress with implementation as the "final" stage of intervention development (Proctor and Landsverk 2005). However Addis (2002) has reviewed the limitations of unidirectional, linear models of dissemination. The NIH Roadmap (nihroadmap.nih.gov) has challenged the research community to re-engineer the clinical research enterprise, namely to move evidence-based treatments "to bedside" into service delivery settings and communities thereby improving our nation's health. The Roadmap has compressed the five stages into two translation steps, with the first step moving from basic science to intervention development and testing, and the second translation phase moving from intervention development to implementation in real world practice settings. However, "pipeline" models assume an unrealistic unilinear progression from efficacy to broad uptake, remaining unspecified regarding the organizational and practice contexts for these stages. Moreover, we would argue that NIH's primary focus as indicated by resource allocation, remains the first translation step, with little specification or emphasis on the second translation.
Our heuristic model further draws from Shortell's (2004) multi-level model of "change for performance improvement". This framework offers enormous benefit because it specifies multiple levels in the practice context that are likely to be a key to change. This model points to hierarchical levels ranging from what Greenhalgh and colleagues would characterize as the outer context (interorganizational) through the inner context (organizational) to the actual practice setting where providers and consumers interact. We posit that the four levels in the Shortell model provide contexts where concepts must be specified and addressed in implementation research as follows.
The model's top level, the policy context, is addressed in a wide rang of disciplines. Implementation research has a long history in policy research, where most studies take a "top-down" (Van Meter and Van Horn 1975) or a "bottom-up" (Linder and Peters 1987) perspective. Legislatures mandate policies, with some form of implementation more or less assured. But policy translation into practice through corresponding regulation needs empirical study. Policy implementation research is often retrospective, using focus group or case study methodology (Conrad and Christianson 2004; Cooper and Zmud 1990; Essock et al. 2003; Herschell et al. 2004) which would argue for greater use of hypothesis driven statistical approaches for policy implementation research.
The middle two levels, "organization" and "group/team," are informed by organizational research, with some rigorous study of topics such as business decision support systems (Alavi and Joachimsthaler 1992) and implementing environmental technology (Johnston and Linton 2000). Their themes echo those of health services: "champions" and environmental factors were associated with successful implementation (of material requirements planning) in manufacturing (Cooper and Zmud 1990). Also relevant to the organizational level are provider financial incentives to improve patient health outcomes and consumer satisfaction. Conrad and Christianson (2004) offer a well-specified graphic model of the interactions between local health care market and social environments (health plans, provider organizations, and decisions of organizations, physicians, and patients) with mathematically derived statements. Organizational level financial and market factors at the organizational level clearly affect evidence-based practice implementation in mental health services (Proctor et al. 2007). Moreover, agency organizational culture may wield the greatest influence on acceptance of empirically supported treatments and the willingness and capacity of a provider organization to implement such treatments in actual care. Indeed the organizational context of implementation, particularly where context is emphasized, reflects the most substantial deviation from linear, "pipeline" phase models from the literature emphasizing development and spread of interventions. Complexity science (Fraser and Greenhalgh 2001; Liyaker et al. 2006) aims to capture the practice landscape, while quality improvement approaches such as the IHI and QUERI models further inform implementation at the organizational level.
Finally of course, at the bottom level, the key role of individual behavior in implementation must be addressed. Individual providers have been focused upon in the sizable body of research on implementing practice guidelines in medical settings and EBP's in mental health settings (Baydar et al. 2003; Blau 1964; Ferlie and Shortell 2001; Gray 1989; Herschell et al. 2004; Woolston 2005). Qualitative studies have documented barriers and stakeholders' attitudes toward EBP (Baydar et al. 2003; Corrigan et al. 2001; Ferlie and Shortell 2001). Essock et al. (2003) have identified stakeholder concerns about EBP that impede implementation. The limitations of guideline literature prompted Rubenstein and Pugh (2006) to recommend that clinical guideline developers routinely incorporate implementation research findings into new guideline recommendations.
Models of implementation can further be informed by well known and well specified conceptual models of health services that distinguish structural characteristics, clinical care processes, and outcomes, including Aday and Andersen's (1974) comprehensive model of access to care, Pescosolido's "Network-Episode Model" of help-seeking behavior that has informed research on MH care utilization (Costello et al. 1998; Pescosolido 1991, 1992) and Donabedian's (Donabedian 1980, 1988) pioneering work on quality of care (McGlynn et al. 1988). While these models do not directly address implementation, they underscore that active ingredients of strategy must be specified and linked to multiple types of outcomes, as discussed below.
Informed by these three frameworks, we propose a heuristic model that posits nested levels, reflects prevailing quality improvement perspectives, and distinguishes but links key implementation processes and outcomes (Fig. 1). An outgrowth of Proctor & Landsverk's plenary address at the 2005 NIMH services research meeting, the model distinguishes two required "core technology" or strategies: evidence-based intervention strategies and separate strategies for implementing those interventions in usual care. It also provides for classification of multi-level implementation strategies, drawing on Fig. 2). The model accommodates theories of dissemination (Torrey et al. 2001), transportability (Addis 2002; Hohmann and Shear 2002), implementation (Beutler et al. 1995), diffusion of innovation [posited most prominently by the seminal work of Rogers (1995) as a social process], and literatures that have been reviewed extensively and synthesized (Glasgow et al. 2001; Greenhalgh et al. 2004; Proctor 2004). Indeed some implementation strategies (distinct from empirically based treatments) emerge for facilitating the transport and implementation of evidence-based medical (Clarke 1999; Garland et al. 2001), substance abuse (Backer et al. 1995; Brown et al. 1995; Brown et al. 2000), and mental health (Blasé et al. 2005) treatments. While some heuristics (Ferlie and Shortell 2001; Hohmann and Shear 2002; Schoenwald and Hoagwood 2001) for transportability, implementation, and dissemination have been posited (Brown and Flynn 2002; Chambers et al. 2005), this literature is too often considered from a sole-disciplinary perspective (e.g., organizational, or economic, or psychological), and has not "placed" key variables within levels. Nor has it distinguished types of outcomes. Our draft model illustrates three distinct but interrelated types of outcomes–implementation, service, and client outcomes—that are geared to constructs from the four level models (Committee on Crossing the Quality Chasm: Adaption to Mental Health, Addictive Disorders 2006; Institute of Medicine 2001). Furthermore, this mode informs methodology, which long has plagued diffusion research (Beutler et al. 1995; McGlynn et al. 1988; Rogers 1995). Systematic studies of implementation require creative multi-level designs to address the challenges of sample size estimation; by definition, larger system levels carry sample sizes with lower potential power estimates than do individual level analyses. The model requires involvement of multiple stakeholders at multiple levels.
Yet to be discovered is whether one comprehensive implementation model may emerge, or different models reflecting specific clinical conditions, treatment types (psycho-social vs. pharmacological, or staged interventions), or service delivery settings (specialty mental health vs. primary care vs. non-medical sectors such as child welfare, juvenile justice, geriatric, homeless services). The relationship between the first column, evidence-based practices, and the second column, implementation strategies, needs to be empirically tested, particularly in light of recent evidence that different evidence-based practices carry distinct implementation challenges (Isett et al. 2007).
Advancing the field of implementation science has important implications. This paper identifies and briefly discusses three issues: the methodological issues in studying implementation processes, who should conduct this important research, and the need to train for this emergent field.
The National Institute of Mental Health (2004) report on Advancing the Science of Implementation; calls for advances in the articulation of constructs relevant to implementation, converting constructs into researchable questions, and advancing the measurement of constructs key to implementation research. Given its inherent multilevel nature as demonstrated in the prior section, the advancement of implementation research requires attention to a number of formidable design and measurement challenges. While a detailed analysis of the methodological challenges in IR is beyond the scope of this paper, two of the major issues will be briefly identified, namely measurement and design.
Regarding the measurement challenge, the key processes involved—both EST's and implementation processes—must be modeled, measured, and their fidelity assessed. Moreover, researchers must conceptualize and measure the distinct intervention outcomes and implementation outcomes (Fixsen et al. 2005). Improvements in consumer well-being provide the most important criteria for evaluating both treatment and implementation strategies—the particular individuals who received treatments in the case of treatment research and the pool of individuals served by the providing system in the case of implementation research. But implementation research requires outcomes that are conceptually and empirically distinct from those of service and treatment effectiveness. These include the intervention's penetration within a target organization, its acceptability to and adoption by multiple stakeholders, the feasibility of its use, and its sustainability over time within the service system setting. The measurement challenge for intervention processes and outcomes requires that measures developed for the conduct of efficacy trials must be adapted and tested for feasible and efficient use in ongoing service systems. It is unlikely that the extensive and data rich batteries of measures developed for efficacy studies, including those developed for efficacy tests of organizational interventions, will be appropriate or feasible for implementation in services systems. Thus researchers need to find ways to shorten measurement tools, recalibrate "laboratory" versions, and link adapted measures to the outcomes monitored through service system administrative data.
In the area of design, studying EBP implementation in even one service system or organization is conceptually and logistically ambitious, given multiple stakeholders and levels of influence. Yet even complex studies have inherently limited sample size, so implementation research is typically beset by a "small n" problem. Moreover, to capture the multiple levels affecting implementation, researchers must employ multi-level designs and corresponding methods for statistical analysis. Other challenges included modeling and analyzing relationships among variables at multiple levels, and costing both interventions and implementation.
Thus the maturation of implementation science requires a number of methodological advances. Most early research on implementation, especially that on the diffusion of innovation, has employed naturalistic case study approaches. Only recently have prospective, experimental, designs been introduced and the methodological issues identified here begun to be systematically addressed.
Implementation research, whether health (Rubenstein and Pugh 2006) or mental health, is necessarily multi-disciplinary and requires a convergence of perspectives. To tackle the challenges of implementation, Bammer (2003) calls for collaboration and integration both within and outside the research sphere. Researchers must work together across boundaries, for no one research tradition alone can address the fundamental issue of public health impact (Stetler et al. 2006). Proctor and Landsverk (2005) urged treatment developers and mental health services researchers to partner for purposes of advancing research on implementation, as did Gonzales et al. (2002), who call for truly collaborative, innovative and interdisciplinary work to overcome implementation and dissemination obstacles. Implementation research requires a partnership of treatment developers, service system researchers, and quality improvement researchers. Yet their perspectives will not be sufficient. They need to be joined by experts from field such as economics and business and management. Collaboration is needed between treatment developers who bring expertise in their programs, mental health services researchers who bring expertise in service settings, and quality improvement researchers who bring conceptual frameworks and methodological expertise for the multilevel strategies required to change systems, organizations, and providers.
Because implementation research necessarily occurs in the "real world" of community based settings of care, implementation researchers also must partner with community stakeholders. National policy directives from NIMH, CDC, IOM, and AHRQ (Institute of Medicine 2001; National Advisory Mental Health Council, 2001; Trickett and Ryerson Espino 2004; US Department of Health and Human Services 2006) urge researchers to work closely with consumers, practitioners, policy makers, payers, and administrators around the implementation of evidence-based practices. The recent NIMH Workgroup Report, "The Road Ahead: Research Partnerships to Transform Services," asserts that truly collaborative and sustainable partnerships can significantly improve the public health impact of research (US Department of Health and Human Services 2006). Successful collaboration demands "transactional" models in which all stakeholders equally contribute to and gain from the collaboration and where cultural exchange is encouraged. Such collaborations can move beyond traditional, unidirectional models of "diffusion" of research from universities to practice, to a more reciprocal, interactive "fusing" of science and practice (Beutler et al. 1995; Glasgow et al. 2001; Hohmann and Shear 2002). Implementation research is an inherently collaborative form of inquiry in which researchers, practitioners, and consumers must leverage their different perspectives and competencies to produce new knowledge about a complex process.
Knowledge of partnered research is evolving, stimulated in part by network development cores to NIMH advanced centers, by research infrastructure support programs, and by reports such as the NIMH Road Ahead report. Yet the partnership literature remains largely anecdotal, case study, or theoretical, with collaboration and partnership broadly defined ideals; "there is more theology than conclusion, more dogma than data" (Trickett et al. 2004, p. 62) and there are few clearly articulated models to build upon. Recent notable advances in the mental health field include Sullivan et al. (2005) innovative mental health clinical partnership program within the Veterans Healthcare Administration, designed to enhance the research capacity of clinicians and the clinical collaborative skills of researchers. Evaluation approaches, adapted from public health participatory research (Naylor et al. 2002), are emerging to systematically examine each partnership process and the extent to which the equitable participatory goals are achieved. Wells et al. (2004) also advocate for and work to advance Community-Based Participatory Research (CBPR) in mental health services research. McKay (in press) models collaboration between researchers and community stakeholders, highlighting various collaborative opportunities and sequences across the research process. Borkovec (2004) cogently argues for developing Practice Research Networks, providing an infrastructure for practice-based research and more efficient integration of research and practice. Community psychology, prevention science, and public health literatures also provide guidance for researcher-agency partnerships and strategies for collaboratives that involve CBO representatives, community stakeholders, academic researchers, and service providers (Israel et al. 1998; Trickett and Ryerson Espino 2004). Partnerships between intervention and services researchers, policy makers, administrators, providers, and consumers hold great promise for bridging the oft-cited gap between research and practice. Implementation research requires unique understanding and use of such partnerships.
No single university-based discipline or department is "home" to implementation science. Nor does any current NIMH-funded pre- or post-doctoral research training program (e.g., T32) explicitly focus on preparing new researchers for implementation research. The absence of organized programs of research and training on implementation research underscores the importance of training in this field. The Bridging Science and Services Report (National Institute of Mental Health 1999) encourages the use of NIMH-funded research centers as training sites, for research centers are information-rich environments that demand continual, intensive learning and high levels of productivity from their members (Ott 1989), attract talented investigators with convergent and complementary interests, and thus provide ideal environments for training in emerging fields such as implementation science (Proctor 1996). The developmental status of implementation science underscores the urgency of advancing the human capital, as well as intellectual capital, for this important field.
In a now classic series of articles in Psychiatric Services, a blue-ribbon panel of authors reviewed the considerable evidence on the effectiveness and cost saving of several mental health interventions. In stark contrast to the evidence about treatments, these authors could find "no research specifically on methods for implementing" these treatments (Phillips et al. 2001, p. 775), nor any proven implementation strategies (Drake et al. 2001). Unfortunately, 7 years later, implementation science remains embryonic. Members of an international planning group that recently launched the journal Implementation Science concur that systematic, pro-active efforts are required to advance the field of implementation science, to establish innovative training programs, to encourage and support current implementation researchers, and to recruit and prepare a new generation of researchers focused specifically on implementation. Ultimately, implementation science holds promise to reduce the gap between evidence-based practices and their availability in usual care, and thus contribute to sustainable service improvements for persons with mental disorder. We anticipate that the next decade of mental health services research will require, and be advanced by, the scientific advances associated with implementation science.
The preparation of this article was supported in part by the Center for Mental Health Services Research, at the George Warren Brown School of Social Work, Washington University in St Louis; through an award from the National Institute of Mental Health (5P30 MH068579).
Enola K. Proctor, George Warren Brown School of Social Work, Washington University, 1 Brookings Drive Campus Box 1196, St Louis, MO 63130, USA.
John Landsverk, George Warren Brown School of Social Work, Washington University, 1 Brookings Drive Campus Box 1196, St Louis, MO 63130, USA; Child and Adolescent Services Research Center, San Diego Children's Hospital Work, San Deigo, CA, USA.
Gregory Aarons, Department of Psychiatry, University of California, San Diego, CA, USA.
David Chambers, Dissemination and Implementation Research Program Division of Services and Intervention Research, National Institute of Mental Health, Bethesda, MD, USA.
Charles Glisson, Children's Mental Health Services Research Center, University of Tennessee, Knoxville, TN, USA.
Brian Mittman, Department of Veterans Affairs, VA Center for Implementation Research & Improvement Science, Greater Los Angeles Healthcare System, Los Angeles, CA, USA.
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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