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South African Journal of Occupational Therapy
On-line version ISSN 2310-3833
Print version ISSN 0038-2337
S. Afr. j. occup. ther. vol.44 n.1 Pretoria Jan. 2014
Occupational performance factors perceived to influence the readmission of mental health care users diagnosed with schizophrenia
Rulaine SmithI; Patricia De WittII; Denise FranzsenIII; Michelle PillayIV; Nadine WolfeIV; Carrie DaviesIV
IB.Occ Ther (Pret), Dip Vocational Rehabilitation (Pret); Lecturer, Dept. of Occupational Therapy, School of Therapeutic Sciences, University of the Witwatersrand
IIDip OT (Pret), MSc OT (Wits); Adjunct Professor and Head, Dept. of Occupational Therapy, School of Therapeutic Sciences, University of the Witwatersrand
IIIBSc OT (Wits), MSc OT (Wits); Senior lecturer, Dept. of Occupational Therapy, School of Therapeutic Sciences, University of the Witwatersrand
IVStudents in the Department of Occupational Therapy University of the Witwatersrand at the time the study was carried out
Schizophrenia is a complex disorder due to the range of deficits with which mental health care users (MHCUs) present. In addition, the high rate of relapse and readmission in clients diagnosed with schizophrenia complicates the effective management of the condition. Medical factors have been evidenced to affect relapse and readmission rates however limited data exists regarding the influence of occupational performance factors. The aim of this study was therefore, to determine which occupational performance factors are perceived to affect the readmission of MHCUs diagnosed with schizophrenia. A descriptive, cross-sectional quantitative design with qualitative elements was conducted. Card sorting was implemented in two phases to a conveniently sampled population of occupational therapists and MHCUs diagnosed with schizophrenia. Data were analysed by means of descriptive statistics. It was found that social participation was perceived to be the most influential factor in the readmission of MHCUs diagnosed with schizophrenia. In conclusion, both medical and occupational performance factors affect readmission rates of MHCUs diagnosed with schizophrenia. Therefore to implement a client centred approach in occupational therapy, therapists may need to reconsider the priorities they address in treatment.
Keywords: occupational performance, readmission, schizophrenia
The term 'schizophrenia' was coined by Eugene Bleuler in 1911 and is directly translated from Greek origins to mean skhizein: "to split" and phrên: "mind"1. Schizophrenia is viewed as a complex, debilitating disorder where symptoms in affected persons' range from altered cognitive capacity to disrupted social relationships2.
The prevalence of schizophrenia worldwide appears to be fairly common, as it is rated at 5-5.0 per 100001 according to the DSM-IV-TR. The range of symptoms present in mental health care users (MHCUs) diagnosed with schizophrenia is often difficult to manage for various reasons, but it has been said that one of the main difficulties complicating treatment is the high rate of relapse and readmission despite treatment. Limited empirical data exist in terms of the specific relapse and readmission rates within South Africa2,3. However, in a study done by Kazadi et al4, it was reported that 61% of MHCUs diagnosed with schizophrenia in Johannesburg relapse at least once, with the majority having two or more relapses.
The need for clinicians and researchers to develop the evidence for interventions that prevent early psychiatric readmission was emphasised by Vigod et al5. With the occurrence of relapse being so apparent, it is important for occupational therapists to determine and understand which occupational performance factors are associated with relapse in MHCUs diagnosed with schizophrenia.
A literature search into the factors that affect relapse and readmission of MHCUs diagnosed with schizophrenia revealed that many studies focussed on contributing medical factors. Aspects such as comorbid medical conditions, substance abuse, and non-compliance to psychotropic medications were identified4,5. Various studies allude to evidence which suggests that factors other than biomedical phenomena play a role in readmission; however they do not specify what these factors are4-6.
Jibson et al7 revealed that all areas of occupational performance and engagement in occupation for MHCUs diagnosed with schizophrenia have been impacted by the recurrence of active psychosis and readmission to hospital. One could then question whether these areas of occupational performance, which in occupational therapy include functioning in personal management, work, leisure, social participation and routine8, play any role in relapse and readmission. Odes et al9 in their study showed that the level of function of MHCUs with schizophrenia on discharge could predict long-term outcome in terms of the rate of readmission. Those MHCUs who were not readmitted during the period of this study (1999 - 2005) had a significantly higher (p < .05) comprehensive functional score when discharged from hospital in terms of cognitive, social and task related behaviour.
Research linking employment to relapse has identified a perpetuating negative cycle between these two factors as MHCUs experienced increased hospital admissions during economic slumps when they were less likely to retain their employment10-12. Engagement in work or work related activities has been shown to result in improved mental health. Furthermore, employed MCHUs show improved quality of life and report that active engagement provides them with a purpose in life10.
Provencher, et al13 found that 'profiles of recovery' related to work required an understanding of the benefits of work as perceived by MHCUs themselves. Supportive employment was found to reduce readmission14, and this was supported by the perceptions of MHCUs who felt they were more successful in obtaining and retaining a job with supported employment15. There is evidence that support should not be given by health professionals such as occupational therapists, as their belief system about the stresses of work precipitating relapse tend to make them overprotective of MHCUs16. Rinaldi et al16 found that professionals underestimated their clients' coping abilities and advised them to not engage in work at all.
Mental health care users diagnosed with schizophrenia have poor personal management skills and in the long term are less likely to perform self-care or health promotion activities, than persons without a mental illness17,18. These MHCUs were found to have a high external locus of control with regards to their health beliefs. Many were dependent on family members to complete or assist with their personal management activities however, it has been shown that if they had no family support in this regard they were more vulnerable to relapse and readmission18. There is limited research to indicate that poor personal management directly contributes to readmission.
The social support that MHCUs receive and the social activities that they participate in after discharge have been found to have a major impact on the course of the illness, as returning to live with family or carers can either positively or negatively influence the MHCUs vulnerability for relapse and readmission19. A strong social support system has been evidenced to prevent readmis-sion20. Cohen and Sokolovsky20 highlighted this in their study of a Puerto Rican man diagnosed with catatonic schizophrenia who was frequently readmitted to hospital secondary to relationship stressors. Interventions aimed at improving socialisation prevented his readmission for nine years. However, when this social intervention was discontinued, readmission to hospital followed shortly after. Enhancing skills in social abilities appear to help patients re-engage in their relationships and are instrumental in maintaining their supportive social networks21.
Another contributing occupational performance factor associated with readmission in MHCUs is a lack of routine. Chugg and Craik22 found that MHCUs diagnosed with schizophrenia had difficulty maintaining daily routines and that they spent most of the day sleeping23. The importance of constructive use of free time for MHCUs therefore needs to be emphasised12 as involvement in leisure provides opportunity for the "development of a person's identity, motivation, autonomy, self-regulating behaviour, personal enrichment and socialisation"24:304. Many MHCUs engage in disruptive behaviours such as substance abuse in their free time which has been found to contribute to relapse4.
Literature has shown that all areas of occupation are seen to be affected by schizophrenia and dysfunction in these areas may actively contribute towards readmission. However, minimal research has been done into which occupational factors are perceived to have the most influence on relapse and readmission. Identification of these factors could have implications for the prioritisation of meaningful occupational therapy intervention to prevent readmission25. However, as occupational therapy practice is based on a client centred frame of reference, obtaining evidence for practice must include the opinions of MHCUs in relation to the effects of occupational performance on the outcomes of therapy24. The objectives of the study were therefore:
- To identify the perceptions of MHCUs diagnosed with schizophrenia with regards to which occupational performance factors have the greatest influence on their readmission.
- To identify the perceptions of the occupational therapists working in the mental health field of practice with regards to which occupational performance factors have the greatest influence on the readmission of MHCUs diagnosed with schizophrenia.
Study Design
A descriptive, cross-sectional quantitative study was implemented after obtaining ethical clearance from the Human Research Ethics Committee (HREC) of the Faculty of Health Sciences at the University of the Witwatersrand. The study aimed to determine which occupational performance factors were perceived by MHCUs diagnosed with schizophrenia and occupational therapists to affect readmission the most; therefore there were two phases.
Population and Sampling
For phase 1 of the study, sample A consisted of 30 adult clients diagnosed with schizophrenia who had been readmitted to hospital. They were conveniently selected over a period of three months in 2010 from six facilities offering services to MHCUs in Gauteng. Permission was obtained from the Gauteng Department of Health, as well as CEOs of the facilities who consented for the research to be conducted at the occupational therapy departments. The occupational therapists at the facilities identified potential participants during the prescribed time period; however, only 26 participants met the inclusion criteria of being: apsychotic, over the age of 18 years, and literate.
For phase 2 of the study, sample B consisted of 10 conveniently sampled South African occupational therapists working in the field of mental health for at least one year.
Research Tools
The research team consisted of three researchers who gathered data by:
- Completing a demographic questionnaire with the MHCUs diagnosed with schizophrenia,
- Implementing card sorting with both samples A and B. The same first and second card sort was used for both samples.
- Questioning the participants regarding the ranking of the cards for the first and second card sort.
The demographic questionnaire consisted of 17 items which included questions relating to personal and medical background. The questionnaire took 20 minutes to administer.
Card sort26 is a technique used to explore the way in which preselected information can be grouped by people. This technique was chosen as it was found to be an easy method of gathering information related to the specific occupational performance factors assessed in this study27. This technique allowed the participants to rank occupational performance factors as they perceived them to influence readmission. The content of the card sort was developed by the researchers by:
1. Reviewing the literature to determine the occupational performance factors influencing readmission. Six categories were identified, namely 'work', 'personal management', 'leisure', 'social ability', 'routine' and 'other'. These categories were then reworded into simple phrases for clients' ease of understanding, as follows:
- Work - 'I did not have a job'
- Personal management - 'I could not care for myself'
- Leisure - 'I did not have anything to do in my free time'
- Social ability - 'I did not have anyone to support me'
- Routine - 'I did not have a structure to my day'
- Other.
These phrases, which formed the cards for the first card sort, related directly to occupational performance8 thereby ensuring face validity of the tool.
2. The first card sort cards were then sent to a panel of six experts in the field of mental health. The experts were asked to critique the content of the cards and they found that the reworded phrases were too broad and would not yield adequate data. The researchers then drafted cards for a second card sort (see Table I) in order to yield explanations specific to the occupational performance factor ranked first in the first card sort. Thus, in the second card sort, participants were exposed only to the cards linked to the specific occupational performance factor, e.g. if a participant chose "I did not have a job" in the first card sort the only cards presented in the second card sort were: 'I could not keep a job', 'I could not find an available job', 'I did not have the skills to work' and 'I did not want to work' (see Table I).
Participants were also expected to rank the cards of the second card sort according to their perceived level of importance for readmission.
Experts reviewed the content of both card sorts thereby ensuring content validity of the tool.
3. To ensure inter-rater reliability the card sort and demographic questionnaire were piloted by each of the three researchers on three clients at a facility offering services to MHCUs. Participants in the pilot study showed no difficulties when ranking the first and second card sort activities, hence the content of both card sorts was unchanged.
Data gathering procedure
For phase 1, occupational therapists working at the participating facilities identified readmitted MHCUs diagnosed with schizophrenia according to the inclusion criteria. The identified participants were approached and informed consent was obtained. The demographic questionnaire was then completed with each participant individually; after which the first and second card sort were implemented. Each participant was asked to prioritise the occupational performance factors that they perceived to have the greatest impact on their current readmission using the first card sort. The second card sort was implemented thereafter based on the ranked choice from the first card sort (see Table I). The researchers questioned participants regarding the ranking of the cards in order to understand the reasons for prioritisation.
For phase 2, the ten participating occupational therapists completed the card sort individually as administered in phase 1. The occupational therapists were asked to rank the cards of the initial card sort to indicate which occupational performance factors they perceived to have the greatest impact on readmission of MHCUs diagnosed with schizophrenia. The second card sort was implemented thereafter based on the ranked choice from the initial card sort in order to yield explanations for the initial ranking (see Table I). The researchers questioned therapists regarding the ranking of the cards in order to understand the reasons for the prioritisation.
All participants' rankings of the cards were photographed for data collection. The principles of informed consent, and confidentiality were adhered to27.
Data analysis
Descriptive statistics, in the form of percentages was used to describe the demographics of sample A. The ranking of the occupational performance factors for both card sorts was analysed using percentages and presented as a matrix. Content analysis of the participant responses was done.
Of the 26 participants who met the inclusion criteria, 73% (n=l9) were male and 26% (n = 7) female. Seven percent (n=2) fell within the ages 20-25, l9% (n=5) within 26-30 years, l9 %
(n=5) within 3l-35 years, 15% (n = 4) within 36-40 years, and 38% (n=l0) over 40 years of age. Ninety two percent (n=24) of the participants reported to be single, indicating not having a life partner or being widowed or divorced. Only 7% (n=2) indicated that they were married.
In terms of the level of education, 11% (n = 3) completed grade 7, 26% (n = 7) completed grade 10, 34% (n=8) completed grade 12 and 34% (n=8) had further educational training.
100% of the participants fell within the low socioeconomic status category, i.e. earning an income of less than R2000/month if earning at all.
Card sort 1: The perceptions of MHCUs diagnosed with schizophrenia
The results of the first card sort for the MHCUs diagnosed with schizophrenia indicated that the factor they perceived as most influential in contributing to readmission was in the occupational performance area of support where 30% (n=8) ranked it first. Leisure was ranked as the second most contributing factor to readmission. The highest percentage for work was ranked second at 23% (n=7), however this was lower than leisure and was then ranked as the third most influential factor. 30% (n=8) of the participants ranked routine as the fourth most influential factor. Self-care was ranked equally at fourth and fifth, but was less than routine at rank at number four, therefore overall it was rated as the fifth most influential factor. Fifty seven percent (n=15) ranked other as the least influential factor affecting readmission (See Table II).
Card Sort 1: The Perceptions of Occupational Therapists
Fifty percent (n=5) of the occupational therapists ranked support as the main contributing factor to readmission in the first card sort. For rank two, the results were equally split between a self-care, routine and work at 10% (n=1). Therefore the percentages that were higher at other rankings for each factor were taken into consideration first, and through a process of elimination, self-care was identified as the second most influential factor. Routine was ranked fourth by 50% (n=5) of the OTs, and 50% ranked work as the fifth most influential factor. Other was chosen as the least influencing factor affecting readmission, by 60% (n=6) of the OTs (See Table II).
Card Sort 2:
The findings of card sort 2 are presented in Table II. The only agreement between the perceptions of MHCUs diagnosed with schizophrenia and the occupational therapists is in the category of support. All other categories show varied rankings.
The main factor impacting on readmission, as perceived by both the readmitted MHCUs diagnosed with schizophrenia and occupational therapists was support. This is reinforced by the work of Niehaus19, as poor social support was found to have a negative impact in influencing the vulnerability for relapse and readmission. The MHCUs diagnosed with schizophrenia identified lacking support due to familial conflict as a result of psychotic behaviour as the stressor resulting in readmission, as highlighted in the statement below:
I was always fighting with my family because they thought I was trying to cause trouble... they did not understand what was happening.
A limitation to the study was that the card sort statements were chosen in order to make them unambiguous for the participants. This resulted in certain terms, such as social participation being translated into lay terms, i.e. 'support'. However, some MHCUs diagnosed with schizophrenia viewed this support as being financial support indicating ambiguity of the phrase of the card. This could be seen where 'other' was chosen as the main reason for readmission, but when asked to explain what 'other' was, the participant stated:
I was always fighting with my mother and having problems with my family, so I struggled to be around people and had no one to talk to.
The participant did not prioritise this as support even though that card best described the situation.
This skewed interpretation of support was highlighted by Marwaha and Johnson28 where MHCUs viewed support as social aspects and not financial aspects as indicators for wanting to be employed.
Besides support being the top factor perceived as influencing readmission, no other similarity in the ranking exists between the perceptions of occupational therapists and MHCUs diagnosed with schizophrenia.
Routine was identified by the occupational therapists as a necessity in order to engage in leisure and work, therefore they prioritised this above leisure and work as essential in preventing readmission. This finding is emphasised by the underlying occupational therapists' belief that routine is vital in carrying out all activities of daily living23. In contrast, the MHCUs diagnosed with schizophrenia felt that if they had something to do in their free time, or if they were employed, this would lead to a routine in their day. Therefore, leisure and work were ranked higher than routine.
This raises the question as to whether the occupational therapists are addressing routine and structure in therapy. If routine is perceived to be a highly contributing factor to mental health23 as reflected in the literature, it needs to be addressed first and foremost within intervention. Mental health care users need to understand the role that routine plays with regard to work and leisure, so that treatment efforts are focussed on achieving a balanced lifestyle, which results in improved mental health and fewer readmissions.
The prioritisation of work was influenced by additional factors and this was a limitation to the study. When asking the MHCUs diagnosed with schizophrenia about where they had placed work, the majority either said they had placed it high as they did not have work, or low because they did have work. Therefore this category was heavily influenced by their personal situations as well as their concept of the importance of work to their recovery13. Most participants did not have the insight to describe what relationship work had to relapse and readmission. These findings should however be explored in relation to the work profiles described by Provencher, et al13. They found that many MHCUs experienced the role of work in their recovery as "uncertain" or "as a challenge" due to a lack of self efficacy, social abilities and support. For the MHCUs who perceived work as "a self-empowering experience", being employed facilitated their recovery and ability to maintain themselves outside of the hospital. Thus there is a need to understand the MHCUs context and previous experience of work in relation to how they view work in influencing their readmission.
With regard to factors impacting on the constructive use of free time, especially for those participants who did not have employment, the occupational therapists felt that the lack of leisure activities was the next most important factor in readmission as MHCUs did not know what to do in their free time. The MHCUs diagnosed with schizophrenia responded differently, identifying this as the least contributing factor and reporting an inability to access resources as the main problem as highlighted in the statement below.
When I was at home, I thought about doing things for fun or with my friends, but I did not know where to go to have fun.
For those clients involved in occupational therapy programmes, many had engaged in leisure activities but within the structure of the department programme, therefore after discharge, although they may have wanted to engage in leisure activities, they felt they did not have access to resources. Thus the value placed on leisure by the MHCUs appears to be affected by the context to which they return. Inclusion of aims on how to access recreational and leisure resources in that context therefore need to be emphasised as outcomes in occupational therapy to prevent MHCUs from spending their free time unconstructively and to assist them to develop an understanding of the importance of constructive leisure in their recovery.
The MHCU participants prioritised personal management as the occupational performance factor that contributed least to readmission, whereas the occupational therapists ranked it second. This may be due to the training the occupational therapists receive, that individuals must be able to care for themselves first, before being able to engage in work, leisure or social activities. According to the Vona Du Toit Model of Creative Ability17, independence in personal management is the first area of occupation to develop.
Research has shown that unless personal management goals are prioritised with the MHCU and their family or carer the level of function in personal management was not maintained and readmission was more likely to occur29. The MHCUs themselves did not prioritise personal management and felt that the ability to care for themselves did not have a significant impact on their level of functioning. For them, the areas of work, leisure and social participation and support were more important, indicating a possible problem with insight into the importance of personal management as one of the factors identified as most affecting readmission.
The findings for personal management could have been affected by the level of creative ability, as described by du Toit17, as the MHCU participants completing the card sort were at least on the level of passive participation and thus were already functioning fairly independently in personal management. The concern of the occupational therapists was about the ability of the MHCUs to maintain this level of functioning once they were discharged. Shimozono et al29 evidenced that MHCUs must be supported after discharge in order to maintain functioning achieved within therapy programmes.
The only other agreement between the perceptions of the two groups was that 'other' was prioritized as the least contributing factor to readmission. The card 'other' was included in the card sort to allow the MHCUs and occupational therapists an opportunity to describe any other factors that they felt had a large impact on readmission. When explaining the card sort, this card was offered as an option in the first card sort. If the participant ranked 'other' first they needed to explain, in the second card sort what 'other' was and how it impacted on readmission. Once the participants became aware of this, many of them changed their ranking and placed 'other' further down, so they would not have to describe it. This affected the ranking of the occupational performance factors and should have been omitted from the original categories.
Occupational factors and medical factors should not be viewed in isolation. There is a two-way relationship between these factors, each impacting on the other. They cannot be viewed as separate entities as they contribute together to the readmission of MHCUs diagnosed with schizophrenia.
For this study, prioritisation of the occupational performance factors was done as separate entities. It is difficult to determine which one factor in isolation has the most influence on readmission, as the factors influence one another however, in this study both samples identified support as the most influential factor affecting readmission. The perceptions of both samples differed for all other occupational performance factors indicating a need for therapists and MHCUs alike to collaborate when establishing therapeutic goals30 to prevent relapse and readmission of MHCUs diagnosed with schizophrenia.
1. Sadock BJ, & Saddock VA. Schizophrenia. In: Sadock BJ, & Saddock VA. Synposis of Psychiatry. 10th ed. Philadelphia: Lippincott Williams & Wilkins; 2007: 471-504. [ Links ]
2. Tsuang M, Faraone S, Glatt S. Schizophrenia. The Facts. 3rd ed. London: Oxford University Press; 2011: 1-2. [ Links ]
3. Kazadi NJB. Schizophrenia Relapse in a Community Mental Health Setting. Unpublished Masters Dissertation, Department of Psychiatry, University of the Witwatersrand Repository; 2008. [ Links ]
4. Kazadi NJB, & Moosa MYH, & Jeenah FY Factors Associated with Relapse in Schizophrenia. South African Journal of Psychiatry, 2008; 14 (2): 52-62. [ Links ]
5. Vigod S, Kurdyak P, Dennis C, Leszcz T, Taylor V, Blumberger D, et al. Transitional interventions to reduce early psychiatric readmissions in adults: systematic review. British Journal of Psychiatry, 2013: 202 (1): 187-194. [ Links ]
6. Emsley R, Chiliza B, Asmal L, Harvey B. The nature of relapse in Schizophrenia. BioMedCentral Psychiatry, 2013; 13 (50): 1-8. [ Links ]
7. Jibson MD, Glick ID, & Tandon R. Schizophrenia and Other Psychotic Disorders. Focus, 2004; 2 (1): 17-30. [ Links ]
8. American Occupational Therapy Association. Occupational therapy practice framework: Domain and process(2nd ed.). American Journal of Occupational Therapy, 2008; 62 (6): 625-683. [ Links ]
9. Odes H, Nachum Katz N, Noter E, Shamir Y. Level of Function at Discharge as a Predictor of Readmission Among Inpatients With Schizophrenia. American Journal of Occupational Therapy, 2011; 65 (3): 314-319. [ Links ]
10. Crist PH, Davis CG, & Coffin PS. The Effects of Employment and Mental Health Status on the Balance of Work, Play, Leisure, Self Care and Rest. Occupational Therapy in Mental Health, 2000; 15 (1): 27-42. [ Links ]
11. Mueser KT Salyers MP & Mueser PR. A Prospective Analysis of Work in Schizophrenia. Schizophrenia Bulletin, 2001; 27 (2): 281-296. [ Links ]
12. Lloyd C, King R, McCarthy M, & Scanlan M. The Association between Leisure Motivation and Recovery: A Pilot Study. Australian Occupational Therapy Journal, 2007; 54: 33-41. [ Links ]
13. Provencher H, Shery Mead R & Mueser K. The Role of Work in the Recovery of Persons with Psychiatric Disabilities. Psychiatric Rehabilitation Journal, 2002; 26 (2): 132-144. [ Links ]
14. Oka M, Otsuka K, Yokoyama N, Mintz J, Hoshino K, Niwa S, et al. An evaluation of a hybrid occupational therapy and supported employment program in Japan for persons with schizophrenia. American Journal of Occupational Therapy, 2004; 58 (4): 466-475. [ Links ]
15. Johnson R, Floyd M, Pilling D, Boyce M, Grove B, Secker J, et al. Service users' perceptions of the effective ingredients in supported employment. Journal of Mental Health, 2009; 18 (2): 121-128. [ Links ]
16. Rinaldi M, Perkins R Glynn E, Montibeller T, Clenaghan M, Rutherford J. Individual placement and support: from research to practice. Advances in Psychiatric Treatment, 2008; 14 (1):50-60. [ Links ]
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18. Dangdomyouth P, Stern P, Oumtanee A, & Yunibhand J. Tactful Monitoring: How Thai Caregivers Manage their Relative with Schizophrenia at Home. Issues in Mental Health Nursing, 2008; 29 (1): 37-50. [ Links ]
19. Niehaus DJH, Koen L, Galal U, Dhansay K, Oosthuizen PP Emsley RA, et al. Crisis discharges and readmission risk in acute psychiatric male inpatients. BioMedCentral Psychiatry, 2008; 8 (44): 1-6. [ Links ]
20. Cohen CI, & Sokolovsky J. Schizophrenia and Social Networks: Ex-clients in the Inner City. Schizophrenia Bulletin, 1978; 4: 546-560. [ Links ]
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23. Ludwig FM. How Routine Facilitates Wellbeing in Older Women. Occupational Therapy International, 1997; 4 (3): 215-230. [ Links ]
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29. Shimozono N, Usami S, Nakayama Y, Nozue K, Yano C. The Characteristics of Self-care Ability and Self-care support for Successful Community Living among Schizophrenic Patients Readmitted within 3 months of Discharge, or with Continued Hospitalization of more than 3 months in M-CBCM. Departmental Bulletin Paper, 2012; 8 (1): 31-45. [ Links ]
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Rulaine Smith


text:
Cultural Materialism – 'an anthropological school of thought (or "research strategy") that says that the best way to understand human culture is to examine material conditions – climate, food supply, geography, etc.' (link)
From Charles C. Mann's 1491, an interesting perspective on the potato; another foodplant that 'doesn't belong' outside (perhaps) of its home in South America, but was adopted – apparently – for the relative social benefits it conferred when compared to the other major introduced species feeding the growth of civilisation:
The staple crop of the [Peruvian] highlands was the potato, which unlike maize regularly grows at altitudes of 14,000 feet; the tubers, cultivated in hundreds of varieties, can be left in the ground for as long as a year (as long as the soil stays above 27°F), to be dug up when needed. Even frozen potatoes could be used. After letting freezing night temperatures break down the tubers' cell walls, Andean farmers stomped out the water content to make dried chuño, a nigh-indestructible foodstuff that could be stored for years. (The potato's cold tolerance spurred its embrace by European peasants. Not only did potatoes grow in places where other crops could not, the plant was an ally in smallholders' ceaseless struggle against the economic and political elite. A farmer's barnful of wheat, rye, or barley was a fat target for greedy landlords and marauding armies; buried in the soil, a crop of potatoes could not be easily seized.) (pp.225-6)
More info from Wikipedia:
Following the Spanish conquest of the Inca Empire, the Spanish introduced the potato to Europe in the second half of the 16th century. The staple was subsequently conveyed by European mariners to territories and ports throughout the world. The potato was slow to be adopted by distrustful European farmers, but soon enough it became an important food staple and field crop that played a major role in the European 19th century population boom.[7]
Across most of northern Europe, where open fields prevailed, potatoes were strictly confined to small garden plots because field agriculture was strictly governed by custom that prescribed seasonal rhythms for plowing, sowing, harvesting and grazing animals on fallow and stubble. This meant that potatoes were barred from large-scale cultivation because the rules allowed only grain to be planted in the open fields.[29] In France and Germany government officials and noble landowners promoted the rapid conversion of fallow land into potato fields after 1750. The potato thus became an important staple crop in northern Europe. Famines in the early 1770s contributed to its acceptance, as did government policies in several European countries and climate change during the Little Ice Age, when traditional crops in this region did not produce as reliably as before.[30][31] At times when and where most other crops failed, potatoes could still typically be relied upon to contribute adequately to food supplies during colder years.[32]
I suppose a key factor undermining the potato's egalitarian potential is its storability*: if it can be stockpiled (to any degree – even if less so than grains) this basically invites an elite group to come along, stick surpluses in a guarded barn and deny access to anybody refusing to pay tribute (as Richard Manning put it: 'Agriculture was not so much about food as it was about the accumulation of wealth'). Naturally, this would only work if they also found ways to deny access to comparable plants freely available in the wild. (Destroying non-agricultural land to plant more potatoes would be a good start…) Here's either Ray Mears or Gordon Hillman writing in Wild Food, the book accompanying the BBC series:
Roots were an extremely important food source for our ancestors. In Britain we have more than 90 indigenous species of edible root of which most were probably used by the combined populations across the country. Evan an individual band of hunter-gatherers probably used 20-30 species in the course of their annual round. Compare this to our present-day diet, in which root foods are dominated by a single introduced species – the potato – and in which our cultivated carrots, turnips, swedes and radishes were probably much later additions, domesticated in the Mediterranean Basin from where they were introduced into Britain, although wild forms were native here. The bland taste of these domestic forms probably appeals to a lot of palates in contrast to the broad range of distinctive and often strong flavours offered by wild roots. (pp.80-1)
Of course, decentralised self-sufficiency and a degree of social equality aren't much good to you if you're dead. Ask the Irish about the dangers of relying too heavily on a few varieties of non-native foodplants. Not that they had much choice in the matter:
The Celtic grazing lands of… Ireland had been used to pasture cows for centuries. The British colonised… the Irish, transforming much of their countryside into an extended grazing land to raise cattle for a hungry consumer market at home… The British taste for beef had a devastating impact on the impoverished and disenfranchised people of… Ireland… Pushed off the best pasture land and forced to farm smaller plots of marginal land, the Irish turned to the potato, a crop that could be grown abundantly in less favorable soil. Eventually, cows took over much of Ireland, leaving the native population virtually dependent on the potato for survival.[25]
If cultures are what they eat, what kind of food staples would lead to the least hierarchical social organisation? The above seems to suggest: as many different ones as possible, and the more uncontrollable (perishable), localised and wild the better.
Food for Freedom!
* – Indeed, Mann doesn't mention that conquistadors later made use of it as a 'convenient food for slaves in the Spanish silver mines and sailors on the Spanish galleons' (link) – in this instance the plant acted less as an 'ally' than a collaborator with the enemy in the indigenous struggle against a foreign 'economic and political elite'.

subset: commoncrawl


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FRACKING tests are to be carried out in Glazebury, it has been confirmed this morning.
TESLA Exploration International Ltd wrote to Warrington Borough Council last week to tell the Town Hall of the intention to carry out 'three dimensional seismic survey' work within the Glazebury area.
The controversial fracking tests are taking place across the country with large scale protests ongoing at the Barton Moss site, close the M62 in Manchester.
The council's development manager Daniel Hartley commented: "Under the law, companies are not required to seek planning permission for this activity, but they must notify the relevant mineral planning authority, in this case Warrington Borough Council.
"The council does not have any say in the matter."
Warrington North MP Helen Jones is against the plans.
The Labour MP said: "I am opposed to this proposal, because of its impact on one of our lovely villages and the possible impact on the green belt.
"The technology is not proven and people will naturally be worried about the impact of this exploration.
"The Government should be investing more in energy-saving measures and renewable technologies to provide the jobs of the future, and Warrington people are well placed to get jobs in these industries.
"Yet apparently, the Prime Minister has told his ministers to cut out "the green crap". This is the result of that flawed decision."
In a letter, seen by the Warrington Guardian, sent to the council, bosses at TESLA - who are carrying out the work on behalf of IGas - say work will start in the autumn and last for around six weeks.
But IGas say they do not intend to get seismic data from the area, putting them at odds with the letter sent to the council from TESLA.
An IGas spokesman added: "IGas commissioned TESLA to carry out a feasibility study over the Warrington area.
"As part of that process TESLA would have informed local stakeholders of its work. However, at this stage it is not our intention to acquire seismic data in the area."
Although no date has yet been confirmed.
The letter says the survey is part of a wider plan to map the geological structure of the region.
Holes will be drilled six metres deep at 50 metre gaps.
The council said further enquiries regarding the proposed survey or related activities should be addressed to: TESLA Exploration International Ltd Unit 2, Nix's Hill Nix's Hill Industrial Estate Alfreton Derbyshire DE55 7GN.
Or e-mail email@example.com 01773 838950


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Katz Gluten Free
Certifications and ingredients are subject to change at the manufacturer's discretion. For the most complete and up-to-date information, please refer to the product packaging.
Information, statements, and reviews regarding products have not been evaluated by the Food and Drug Administration. Results vary person to person, and there is no guarantee of specific results. The Gluten Project assumes no liability for inaccuracies or misstatements about products.


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Cloth diapers run you $18 to $20 dollars new, and it's pretty rare to find them on sale for more than 15% off at retail stores. That doesn't mean you can't cut the cost of cloth diapers by more than that, though. Far from it. Here are some ways to save big:
Watch for limited-time only deals.
Watch for vouchers to stores that sell cloth diapers (Ecomom or Abe's market for example) at sites like Groupon and Living Social. You can save up to 50%.
Daily deal sites like BabySteals and Eco Baby Buys offer them sometimes, too.
Flash sale sites like Zulily.com and The Mini Social.com occasionally run cloth diaper sales for brands like Fuzzibunz and Kushies. Be sure to factor the cost of shipping into the equation to ensure that you're getting the deal you think you are.
Consider gently used diapers.
Parent-to-parent swapping and selling sites like Spot's Corner at Hyena Cart, Re-Diaper, Diaper Swappers, the Diaper Pin forums, Baby Center's Cloth Diaper Swap group and even Craigslist and ebay (if you get lucky). Diaper Swappers and Spot's Corner are reader faves. Expect to pay about $10 to $13 per diaper. That's 35% to 45% off the cost of new diapers.
Look for sellers with plenty of good feedback and listings with photos. There should also be a description of any stains, pilling, damage or wear to the diaper. I'm sure it goes without saying, but wash and strip the diapers before using.
Scout clearance sections for gently used, closeout and seconds (irregular diapers).
Cloth diaper retailers often sell their "seconds" or slightly irregular diapers as well as gently used diapers that have been part of their trial program (and thus used very few times). Some diapers may only be a dollar or two off, but look for reductions of 25% or more. Note: sales are usually final, so order carefully.
The list below links to clearance sections at the various retailers. If you don't see any offerings there right now, try following the site on Twitter or Facebook or sign up for emails to find out when the clearance sections are restocked.
- Thirsties Outlet
- Green Mountain Diapers. Various brands.
- Dapa Diapers. Various brands
- Kelly's Closet clearance. Various brands
- Cotton Babies clearance. Various brands.
- Jillian's Drawers. Various brands.
- Diaper Junction.Various brands.
- Swaddlebees and Blueberry
- Nicki's Diapers
And finally, if they're in good shape when you've finished with them, you can resell your cloth diapers to recoup part of the cost.
What are your best tips for saving on cloth diapers?
See more posts about cloth diapering
image of diapers courtesy of supafly on flickr
This post may contain affiliate links. See BC's disclosure policy for more info.


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Monday, July 6, 2009
Faction Transfer and Character Identity
Ever since the announcement that faction transfers would be available, I have felt myself backed into a corner. I have two druids: my feral is my first character, and alliance; my second is my resto main now and is horde. I have longed to be able to play my feral druid with my horde friends, and often wished that she could just flag herself "Cenarion Circle" and thus raid with the horde guild.
Faction Transfers will, in a twisted way, give me the opportunity to have feral-Kae join my horde guild.
The price? She'll be a moocow.
No more slim elven features. No more blue hair. No more panther form. No more Shadowmeld. No more flippy-jumps. No more "Justicar" title, nor "Commander." No more saber mounts, no more war pony that I ground both pvp and Stormwind rep for 6 months to earn in vanilla WoW. No more glowy silver eyes. No more facial tattoos. No more elf.
She'd be a cow.
Would she still be Kae? I have played her for 4 years now; I have written little stories about her... she is thoroughly ingrained in my mind as an elf. I can't help but feel a bit of awkwardness towards the idea of changing her race. I'd be able to chat in guild-chat, run instances with my guildies, and more easily run their alts through instances if I switched her to horde, but... can I get over the loss of her identity to do so?
I'm not sure, yet.
2 comments:
I have given this topic some thought myself. I have a warlock and a hunter on the alliance. The warlock is camped in Howling Fjord, but I've not started Northrend with her to date.
I also created another little BE warlock on the horde so that I could have one on the horde.
So...when the transfers come around what should I do? When I made my human warlock, I gave her my hair color and style, and she really was a little piece of "me". But I don't have many friens on the alliance anymore, and what I seek when I am overthere is solitude. So, what do I gain if I make my level 70 human warlock a level 70 BE warlock? The opportunity to play her socially. What do I loose? My solitude.
I'm not really sure if I want to give that up.
I definately feel your dilemia here, Kae. Even if its for different reasons =)
Perhaps it's time for a "pros" and "cons" list?! I wish you luck in weighing this out and making a decision that you are pleased with!
- July 6, 2009 at 12:51 PM
- Kae said...
The pros and cons will be different for everyone, certainly. Some people can easily drag their character over from one side or the other, as the character itself has little identity... or an identity than no longer wish to play (such as in the case of a failed RP character). It's an opportunity for a fresh start, in such cases, and sometimes will provide the side benefit of a more preferable racial ability (draenei auras, perhaps, or weapon skills).
The pros must outweigh the cons (and the likely high price of the genetic recombobulation from the Blizzard Billing end) in order for the decision to be made for a faction transfer. Many of the small details haven't been finalized yet (mounts, reps, etc), but I think most people don't need them in order to make their decision.
Personally, I'm in no rush to make my own decision, but it is certainly gnawing away in the back of my mind :)
- July 6, 2009 at 5:40 PM


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Solestruck, the online shoe emporium and general keeper of the virtual street-wear obsessive flame, had a dream, one that many of us have had before and one that can be realized in all its rubberized glory. That dream, if you will, is the Spice Girl shoe: a graphic sneakerized vision that gives you at least four inches in height.
The store headed over to Spain to find the original purveyors of the '90s sneaker, a company that is now involved in European fast fashion. Yet, it still has its archives intact. Solestruck has brought back a handful of wild styles for both men and women (sadly, some of our favorite kicks are for the boys), and they're chock-full of serious '90s nostalgia. These might not be your everyday shoe (or maybe they are?), but no one can deny that these throwbacks certainly look fun.


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I've been having some rather morbid thoughts lately, so, naturally, I decided to share:
Suppose I have a deadly disease, which has a chance of killing me every day that it is left uncured. Also, suppose that there's this operation I can go through, but it is not without its risks: If it is successful, I won't have to worry about the disease killing me ever again. If it's a failure, I die there and then.
More formally, let $q : N \rightarrow [0,1]$ be the probability that the disease kills me at any given day $t \in N$. Also, let $p : N \rightarrow [0,1]$ be the probability the that the operation fails if I have it on day $t \in N$. Assume that both $p$ and $q$ are monotonically increasing. The question is: At what day $t_0$ do I have to go through the operation in order to maximise my expected lifespan?
Now, to solve this: It is obvious that at any day that $p(t) \leq q(t)$ you're better off having the operation because if you don't, you'd have the same chance of dying and no chance of being cured.
However, that can't possibly be the whole story. What if $p(t) > q(t)$ for every $t \in N$? You would still have to do the operation at some point, otherwise you'll eventually die because of the accumulated probability of all those days you're left uncured.
In that light, let $f(t) = \prod_{k=0}^{t}(1-q(k))$ be the probability that you survive $t$ days without going through the operation. Then, all you need to do is to solve the inequality $f(t_0) < f(t_0-1) \cdot (1-p(t_0))$. Is that correct? Or am I still missing something?


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Article contributed by www.walvoord.com
An Exposition of the Epistle of Paul to the Philippians
Copyright 1961 by
Dunham Publishing Company
Findlay, Ohio
The Epistle to the Philippians is one of the most practical of the Pauline letters and comes to us from the heart of the apostle through the inspiration of the Holy Spirit. As a letter addressed to "all the saints in Christ Jesus" it was not intended to be a learned treatise for technical scholars, but practical instruction for the laity. The fact that he includes special mention of the bishops and deacons means only that as leaders they had special responsibility in apprehending and putting into action the truths revealed.
This exposition of the epistle is an outgrowth of the Bible conference ministry of the author. It is written for general reading by laymen as well as ministers of the gospel who have some technical tools. The Authorized Version has been adopted as the text to be used in the exposition but is carefully compared to the original Greek and corrected or amplified where necessary. If the ordinary reader catches new insight and understanding of the truth of God through the reading of these pages, the author will be grateful.


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What Cancer Cannot Do Fabric Panels - White or Natural
Defy cancer with the 12 inspirational quotes on the What Cancer Cannot Do Fabric Panel!
Cancer may cause pain and hardship, but this fabric panel reminds us that cancer cannot shatter hope, cripple love, corrode faith, destroy peace, silence courage, kill friendship, steal humor, stifle laughter, erase memories, conquer the spirit, erode confidence or invade the soul.
The What Cancer Cannot Do Fabric Panel's 12 blocks finish to 6" x 3". The quotes are hand printed on 100% Kona cotton in black print on natural or white cotton fabric. With just 1 fabric panel, you can make the Hope Quilt, shown below and sold separately.
(5 reviews)
How do you like this product?
Share your thoughts with the Annie's community.
January 3, 2018
It took a while, but my son in law is now in remission from cancer.We have only hit the one month mark but we will have many more. Just before we got word of his good news, his wife, my daughter, was told she has cancer. Now he is helping her through the good and bad times. I plan to make this into a wall hanging using their favorite colors intertwined with each saying.
June 19, 2017
I bought the panel of "What Cancer Cannot Do". I then made a lap quilt for a friend in my church that is battling cancer. I choose green colors because that was her favorite color. I wanted to give her something that would give her encouragement as she fights this battle. She loved it and wanted to show it off to everyone who came to her house to visit with her. I would urge anyone who wants to make any kind of quilt for someone battling cancer to get this panel. The words are very encouraging.
January 11, 2017
I have purchased several of these "What Cancer can not do" panels. I make and donate a quilt each year to be auctioned off/ fund raiser for the "Pink Ribbon Ride" snowmobile Rally in our area. I have also made a quilt for a lady who was battling breast cancer and also for an 8 year old girl who was battling cancer. Both are now Cancer Survivors along with myself.... This is one of those "feel good about what you're making" products....
November 29, 2015
I put this in a quilt for my daughter who is battling leukemia. It turned out beautiful.
December 5, 2014
So many ways this panel could be used. I used it with breast cancer fabric for a wall hanging or lap quilt, but it can be used for all kinds of cancer. Many who saw it agreed with how positive the outlook can be.


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Hey, it's International No Diet Day! Of course, we strive to make EVERY day No Diet Day, but if you've been teetering on the edge, today is the day to try it out for 24 hours and see how you function when you make peace with food. Or maybe it's time to spread the word to some friends, or post a flyer next to the stats for your office "Biggest Loser" competition. Or maybe it's just a day to eat a big piece of cake.
Or, you know, maybe it's a day to eat a big piece of tofu. Posting about this initially made me feel a little weird about my breakfast, which I am eating right now and which is cottage cheese and some very gorgeous fruit. But then I thought, hey, isn't this just another reason to resent the diet industry? Dieting has reinscribed excellent food like fruit and cottage cheese and spinach into Virtuous Diet Food, to the degree where it's hard for a proud fatty to eat it without feeling a little furtive, like she has to make excuses. To the degree where people who have grown up in diet culture actually assume they don't like really amazing food, just because its good-for-you reputation must mean it's officially No Fun. (Of course, it's entirely kosher to genuinely dislike food that's also considered diet food, but I know plenty of people who turn their nose up at anything that's supposed to be "healthy" because it smacks to them of deprivation.) Or they eat it because they think they've gotta get some virtue down their gullets, instead of because it tastes amazing and gives them energy. Fuck that — INDD is a day when food has no moral weight. I love cottage cheese (and if you think you don't, give it another shot without thinking of it as a Diet Food), and I love chocolate chip cookies, and I might very well eat both today. Though not at the same time. And neither will make me bad or good, or a Typical Fat Person, or a Traitor to the Cause, or anything except a hungry person relishing some tasty comestibles. For at least this one day, let yourself off the hook. Count nothing. Judge nobody's food choices, including your own. Let's have food mean nothing but "substances that provide energy and are also as delicious as possible."
To get you in the mood, here's the Council on Size and Weight Discrimination's list of the top ten reasons not to diet. (The links are added by me.)
10. DIETS DON'T WORK. Even if you lose weight, you will probably gain it all back, and you might gain back more than you lost.
9. DIETS ARE EXPENSIVE. If you didn't buy special diet products, you could save enough to get new clothes, which would improve your outlook right now.
8. DIETS ARE BORING. People on diets talk and think about food and practically nothing else. There's a lot more to life.
7. DIETS DON'T NECESSARILY IMPROVE YOUR HEALTH. Like the weight loss, health improvement is temporary. Dieting can actually cause health problems.
6. DIETS DON'T MAKE YOU BEAUTIFUL. Very few people will ever look like models. Glamour is a look, not a size. You don't have to be thin to be attractive.
5. DIETS ARE NOT SEXY. If you want to be more attractive, take care of your body and your appearance. Feeling healthy makes you look your best.
4. DIETS CAN TURN INTO EATING DISORDERS. The obsession to be thin can lead to anorexia, bulimia, bingeing, and compulsive exercising.
3. DIETS CAN MAKE YOU AFRAID OF FOOD. Food nourishes and comforts us, and gives us pleasure. Dieting can make food seem like your enemy, and can deprive you of all the positive things about food.
2. DIETS CAN ROB YOU OF ENERGY. If you want to lead a full and active life, you need good nutrition, and enough food to meet your body's needs.
And the number one reason to give up dieting:
1. Learning to love and accept yourself just as you are will give you self-confidence, better health, and a sense of wellbeing that will last a lifetime.


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|Welcome to the Wolfdog Project!
|This page is sort of a Site Map to the various articles and ideas which, up until now, have been scattered randomly across the Project. Pages are text-based as often as possible, to minimize transfer & download time. Comments and opinions welcome! Here's my Email.
|*A note on the facebook page by the same name:
Though some of my material is hosted there, I myself do not have a facebook account, and I don't visit the page or see messages sent to it. If you'd like to ask questions, share pictures or experiences, or otherwise reach me, please contact me directly. Thanks! :-)
|WolfdogProject Articles Index
|"OWNER" Section: Info on Canis lupus (wolves, dogs, and wolfdogs)
|EVERYONE: Myths, rumours, and...what ARE wolfdogs, anyhow?
|Some related links:


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Some of the visitors will be experiencing problems with the forums if they are using any style other than subSilver.
I am currently rebuilding the forums, removing features thet are no longer supported, little used, or have security issues.
Spelling will return.
Real Classifieds will not.
Medals may come back.
Digests probably.
I'm also looking at other mods, but those that requre a change to the menu or certain other areas will only be applied to the subSilver style.
Site Rebuild
What's new
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Re: Site Rebuild
Just want to say I love the look and feel of the site. Great work.
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Members: €1450
Non-Members: €1650
NOTE: You can only book online using credit or debit card details. If your preferred method of payment is by invoice / purchase order / bank transfer / other, please contact the CPD Training Team on 01-6651305, or email email@example.com to secure a place.
Note: Delegates are required to attend all four sessions.
This course is the start of the process to achieve Project Management Professional (PMP) certification. It is run in conjunction with the Centre for Project Management, University of Limerick.
Those completing this programme can claim 35 hours formal project management education, which is one of the pre-requisites for sitting the Project Management Professional Certification exam with the PMI.
Participants will:
The course consists of two modules, each module lasting two days. Attendance at module 1 is a prerequisite to attending module 2. There is a gap of 2 weeks between modules to allow some application of the techniques after the initial sessions.
Course content is structured against the five key project management phases & processes:
This course will be of interest to those individuals who seek to gain knowledge and ability in this important management discipline. It will be of importance to all individuals working within a projects-driven company or for those in contemporary organisations that handle projects from time to time. It will be of interest to all those wishing to advance their management careers.
This course offers the participant the opportunity to start the process to achieve Project Management Professional (PMP) certification.
Declan Cunningham is one of Ireland's top tutors on the subject of Project Management for engineers. He brings more than 25 years national and international experience as a senior-level Project Manager. He completed a Masters Degree in Project Management in the University of Limerick (UL) and now develops and delivers numerous project management training projects with the Centre for Project Management in UL.
"Excellent course with excellent delivery from Declan. Hugely beneficial for my career progression"
"Excellent course with practical examples of application of various tools for Project Management"
"Declan is a gifted instructor providing the right amount of industry experience and examples. I would highly recommend this programme"
Confirmation is subject to event fee being finalised. Cancellation fees calculated at 50% of the estimated total bill will be charge for confirmed bookings cancelled less than 5 working days prior to the date of the planned event. A replacement person can attend instead. Cancellations made the day prior to an event will be charged 75% of the total estimated bill. No-shows will be charged the full fee. All cancellations must be confirmed in writing by email. Engineers Ireland will not be liable for any costs in the event of a course being re-scheduled. This applies, but is not limited, to any travelling, subsistence or consequential expenses incurred by delegates.
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Language problems with the 2010 Census may lead to changes in reapportionmentMonday, May 17th, 2010
The following article from the Bellingham Herald is very well written and paints a vivid picture of the problems I have discussed about poor translation services and more:
By DANIEL C. VOCK – Stateline.org
WASHINGTON Upstate New York took in nearly 3,200 refugees during one recent year. That was nearly seven times as many as New York City did. The refugees, more than half of whom came from Myanmar, often need medical care and other social services, but the region does not have the same informational resources – such as translators and English-language classes – as New York City. To help them get those services, upstate hospital officials and other advocates want them recorded in the 2010 census and have helped spread the word to refugees.
It's not an easy job, but it's a potentially important one. The refugees from Myanmar who live in the county that includes Rochester, N.Y., speak six different dialects, making the task of finding a translator who understands medical terms even more difficult. When refugees do visit a doctor or the hospital in the Rochester General Medical Group, says Jim Sutton, who heads the group's office of community medicine, their appointments last longer because of the language barrier and complications related to the fact that refugees often went years without any health care.
An accurate population count could highlight that need to government officials, Sutton says. "Politicians want to represent their constituencies. We have 8,000 refugees in our area. … If a representative saw that much of their population was voting members of their particular area, their ears may perk up a little bit when something comes before them regarding language."
This is the kind of small but ultimately significant problem state and local officials are wrestling with all over the country.
Minnesota state demographer Tom Gillaspy knows how important the census count is for his state. He's done the math himself. The once-a-decade tally is used for many things, but one of the most important is deciding how many seats each state gets in the U.S. House. According to Gillaspy's latest projections, Minnesota could lose a seat by fewer than 1,000 people.
"It doesn't get much closer than that," muses Gillaspy, now involved in his fourth census for Minnesota. Miss just two college dorms – say, by counting them in June instead of April – and there goes the state's eighth congressional seat.
"It is a huge operation to do a census. It is just an enormous, enormous thing. I don't think people appreciate the precision which is required," Gillaspy says. "It's really at the core of everything that's done in government and, to a large extent, in the private sector for an entire decade. So it better get done right."
To the surprise of many, quite a few things are going pretty well this time. Across the country, 72 percent of residents have mailed in their census forms already. That's roughly the same percentage that turned in their forms in 2000, which ended a three-decade slide in participation. That's a good sign, according to experts, because the mail-in participation rate is a good indicator of how accurate the final count will be.
Experts credit several changes over the past decade for making it easier to educate residents about the census.
Perhaps most striking is the publicity blitz that promoted the mail-in portion of the census and continues now that 635,000 workers are going door-to-door to check with people who didn't return their forms. The first big splash in the campaign was a much-maligned Super Bowl ad, but it was only the beginning. By the time the campaign is over, the U.S. Census Bureau plans to spend a record $133 million on advertising in 28 languages.
Behind the scenes, the federal government placed a greater emphasis on partnering with local organizations to get the message out. State and local governments have used a similar approach. Stacey Cumberbach, the head of New York City's 2010 census office, says working with trusted leaders in different communities and across city government has helped the city boost its mail-in rates from 57 percent a decade ago to 60 percent this year.
Working with the city's agency for public and subsidized housing helped get the message to one out of 12 New Yorkers, she says. Immigrants make up more than one-third of the city's population, but that population in itself is very diverse. That's why, Cumberbach says, it was so important for the city to rely on community leaders to promote the census.
In Minnesota, Gillaspy took advantage of a few other opportunities offered for the first time by the Census Bureau. In February, the state compared the numbers of addresses it had on its list for every block against the census' count. Where there were big differences, the state asked the Census Bureau to double check its list of addresses.
Later this summer, Minnesota officials plan to compare state data for the capacity of group quarters – including prisons, nursing homes, halfway homes and dormitories – against the population count the census came up with in those facilities. If there's a large difference, the Census Bureau will go back to recount the population there.
"It's up to each individual state to volunteer to do this," Gillaspy says. "I'm not aware that all states are doing this, but we certainly are."
Gillaspy says Minnesota's efforts during this cycle are more involved than they were a decade ago and far exceed the state outreach during the 1980 and 1990 headcounts. The Legislature approved funding for a three-year effort, and it can pay for itself by successfully counting even a relatively small number of people, he says.
Still, Kim Brace, the head of the consulting firm Election Data Services, is worried that some states have cut back on their outreach efforts to save money during this recession. He predicts, for example, that California will suffer because it couldn't afford to better promote the census.
On the other hand, Brace says, technology has improved the amount of interim census data available to the public during the count.
"Ten years ago, we were lucky to have just to have an overall county-level count of the response rate at this time," he says. "Now we've got it at the (census) tract level. That's phenomenal." Practically speaking, Brace says, that lets elected officials or community leaders check with the Census Bureau's online maps to determine which areas are falling behind and respond immediately.
People who didn't turn in their forms are less likely to answer the door when a Census worker comes knocking, explains New York City's Cumberbach. And even if they do talk, she says, they may not provide accurate information.
In New York City, six people may share a one-bedroom apartment. Or a family of immigrants may include some people who are in the country legally and some who are not. "It's almost like everyone has something in their home that they don't want to share or that they're nervous about," Cumberbach says.
Neighborhoods with the lowest mail-in participation rates tend to have more blacks and more Hispanics than areas that turned in a bigger share of their forms, according to an analysis by the City University of New York. The 5 percent of neighborhoods with the lowest response rates were, on average, 54-percent minority. The rest of the country as a whole is 30-percent minority.
When it comes to states, many of those most in jeopardy of losing U.S. House seats – a number of them clustered around the Great Lakes – had some of the best response rates in the country. Wisconsin, Minnesota, Iowa, Indiana, Nebraska, Ohio, Pennsylvania and Virginia topped the charts.
This is especially important because the housing crisis has slowed the population growth of many Sun Belt states, and because many of those states also have below-average census response rates. Arizona, Texas, Nevada and Georgia all were expected to gain seats, but each had 70 percent or lower mail-in participation rates.
An inaccurate headcount can cost communities more than just political clout. A study by a census oversight board following the 2000 count said the country's 58 largest counties would lose out on a combined $3.6 billion over the decade in funds distributed by population formula, more than $2,900 per person.
"Every person missed," says Arturo Vargas, executive director of the National Association of Latino Elected and Appointed Officials, "is that much less federal resources for everything from schools and medical services to resources to pave the streets."


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Intelligent by design
Big on style and features
The Next Gen VERNA gives you everything you have ever wanted in a sporty sedan and much more.
Sporty styling
Possible to show an active style by various exterior color, stylish rear combination lamps and dynamic grille to express your own personality
6 Airbags System
Equipped with a 6-airbag system in all the fundamental spots, Hyundai VERNA ensures reliable protection of all occupants to their destinations
Superior Performance
Quite, clean and responsive, the 1.6L Gamma Dual VTVT Petrol engine and 1.6L U2 CRDi diesel engine are built for optimum fuel efficiency and generates segment best power of 123ps & 128ps respectively
Super Safety
Safety never takes a backseat in the Next Gen VERNA. With its Super body structure, 6 Airbags and a world of active & Passive safety features sets a new benchmark in passenger safety with the New VERNA
6-speed Automatic transmission
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The specification above are subject to change. Images shown above may vary from actual product. Some of the equipments illustrated or described above may not be supplied as standard equipment and may be available at extra cost. Hyundai Motor India reserves the right to change specification & equipments of any product without prior notice. Please consult your nearby dealer for full information and availability on colours and trim


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I had about a dozen multi-tool pens in grade school. I had pens that fired lasers and told time and wrote in invisible ink, but for the life of me, I can't remember using any to actually write something.
That won't be the case with the Metal Pen with Level and Screwdriver. This thing is so hardcore streamlined and utilitarian that it doesn't even have room for all of its features in its name, much less a witty moniker. And thanks to that, it actually looks like something we'd want to write with instead of storing away in case of some kind of hybrid zombie-apocalypse-slash-engineering-convention. [Neatorama]


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Suggestions to Help Your Student Graduate on Time
Begin by setting expectations.
Telling your student you expect them to graduate in two years for an associate degree or four years for a bachelor's degree is simple, but it works.Ā To complete a degree on time, the student needs to enroll in at least 15 credits a semester, consult with an advisor, choose a major early, take courses that fit their major and get involved in campus life.
What can parents do when grades suffer?
Make sure that you understand the problems your student is having and what they have been doing to correct these problems. The many services the university provides for students are useful only if students seek help in a timely manner. Encourage your student to contact their professors and academic advisors for help with study habits, test-taking skills and time-management skills. If your student is struggling with the material covered in their courses, encourage them to seek help as soon as possible by utilizing their professors' office hours or visiting one of the many tutoring options available.
Can students change classes?
At some point, your son or daughter may find it necessary to add or drop a course. This may be due to a change in his or her work or activity schedule or the recognition that a different class would be more beneficial.
Questions related to dropping classes should be directed to their college advisor. If a student withdraws from a class after the drop/add period, he or she is still responsible for paying the appropriate enrollment fees and tuition for the dropped class.
Can my student catch back up?
The University of Alaska offers numerous resources to assist your student. In the end, though, education is the student's responsibility. Encourage your student to take the time to sketch out a rough two-year or four-year plan, keeping in mind that students must complete an average of 15 credit hours per semester to finish the minimum number degree credit hours (some majors require more) in time. Taking summer and mini-mester classes can help compensate for semesters in which they need to take fewer hours.
Don't Tell Me What to Do, Just Send Money: The Essential Parenting Guide to the College Years
H.E. Johnsons, C. Schelhas-Miller (2011)
The iConnected Parent:Ā Staying Close to Your Kids in College (and Beyond) While Letting Them Grow Up
B.K. Hofer, A.S. Moore (2011)
Happiest Kid on Campus: A Parent's Guide to the Very Best College Experience (for You and Your Child)
H. Cohen (2010)
ĀĀĀĀĀĀĀĀĀĀĀĀĀĀĀĀĀĀĀĀĀĀĀĀ For questions or comments regarding this website, contact firstname.lastname@example.com


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Verifying custom HTML with the HTML Validator Tool in Quick Shopping Cart
Quick Shopping Cart® supports the use of custom XHTML on select pages to allow greater customization and optimization of your storefront and catalog. To verify that your HTML has been coded correctly and is XHTML compliant, use the HTML Validator to check it.
You are not required to validate your code. However, by confirming that your code is XHTML compliant, the HTML Validator prevents potential display problems on your storefront. For more information about XHTML, visit the XHTML Tutorial on the W3 Schools website.
The following pages allow custom HTML:
Storefront pages
- About Us Page
- Contact Us Page
- Invoice Customization
- Storefront Header Page
- Storefront Footer Page
- Welcome Message
Catalog pages
- Edit Category
- Product Editor
You can also add widget to the area along the side of you online store, which displays content you create with HTML. For more information, see Managing Widgets in Quick Shopping Cart.
Note: We recommend that you make the suggested changes, save the file, and then re-upload it.
Note: You can proceed through the warnings to post your file containing the non-compliant XHTML code. However, we recommend that you resolve any errors before posting content that could break your shopping cart display.
To Verify Custom XHTML Using the HTML Validator Tool
- Log in to your GoDaddy account.
- Click Quick Shopping Cart.
- Next to the account you want to use, click Manage.
- From the Set Up menu, select a page on which you used or want to use custom HTML.
- If you have not added your custom HTML to the page, enter or paste it in the text area.
- Click Verify.
- If errors were detected, view the error details that display below the menu, make the corrections, and click Verify. Continue making corrections as necessary.
- If there are no errors, click OK to close the Congratulations! This Text is Valid XHTML 1.0 Transitional! message.
- After all errors are corrected and your HTML is valid, click Save.
Note: The HTML Validator automatically checks your code for XHTML compliance when you update or save the HTML fields on these pages.


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Grievous - Chapter 5
Walkthrough - Grievous - Chapter 5
You won't be controlling any Jedi this level, but you shouldn't worry. After all, hokey religions and ancient weapons are no match for a good blaster at your side, right?
After watching some enemies blow up your expensive spacecraft, move to the loose pieces on the ground in front of you and build yourself a crane. This will give you the opportunity to grapple down to the lower level, so go ahead and do so.
When the giant worm comes out, jump to avoid its shock waves when he slams into the ground. When he comes out of his hole with a life meter above his head, shoot him to take away one of his hearts. Repeat this until he comes slithering out of his cave. He'll break a platform and leave loose blocks on the ground for you to build with. Fashion yourself a bridge and cross it.
After crossing the bridge, switch over to your Rocket Clone and repeat the same process as before, firing when the worm's life bar is above his head. As it dies, it'll break a platform to the left. You can rebuild the blocks to help you climb up the platform trail that leads to the right.
After you climb, stand on the red button and shoot the open console. Then, switch to your Minigun Clone and fire away at the gold gate to your right. Grapple across your new hook and head into the cave.
Destroy the enemies on the platform and then blow up the silver blocks with a Rocket Clone. Build with its loose pieces and you'll find a console to interact with, but it has a droid's head on it. Shoot the blue Robocop droid and pick up its head with the Action Button. Then interact with the console to open the door.
Make your way down the new hall and continue until you enter the new area. After the cut scene, you'll have an extended mission. You need to gain control of three dynamite trolleys and place them on appropriate buttons.
First, you'll be in control of a Minigun Clone. Run-n-gun your way down the hall until you can shoot at the large goal carrier on the left without interruption. Hop into it and ride out of there from where you came. After you exit the hallway, park your trolley on the orange button to the left.
Hold the Switch Character Button to do some work with the other Clones. Move to the left and you'll find a console that doesn't have power running to it. Destroy the blue block next to it and then hold the Action Button to build the blocks onto the wall to restore power. Pull the new switch and head through the open door on the left.
At the end of the hallway, take your Rocket Clone and aim at the shining silver contraption on the wall. Grapple onto the newly exposed hook to open the gate to your left. Shoot at the droid on top of the trolley and then commandeer it. Ride it all the way back to the center room and place it on one of the orange buttons.
In the center room, head up the stairs and blow up everything to the right of the dead switch with your Rocket Clone. The only item remaining should be a generator. Push it all the way to the right to activate the switch's power. Pull the switch and the door below will open. Use your Rocket Clone to clear out the silver obstacles in the hallway.
Take the trolley at the end of the hall, bring it back to the center room and place it on one of the two remaining orange buttons. This will turn off the shield separating you from Minigun Clone.
Ride the final trolley to the last remaining button and you'll be rewarded with the level's final cut scene.


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Crane hopeful Nolan accepts offer to join Astros
Houston's majority owner praises Hall of Famer's experience on business side
HOUSTON -- Jim Crane said the ball is in Nolan Ryan's court, regarding whether the baseball icon decides to join his son Reid and become part of the Astros organization, of which Crane is majority owner.
Ryan met with Crane and Reid Ryan, the team's president of business operations, on Tuesday to discuss the Hall of Fame pitcher's potential return to the club.
Speaking on Saturday during a college tournament -- the 2014 Houston Winter Invitational at Minute Maid Park -- Crane seemed eager for Ryan to come aboard and help the organization.
"We had a great meeting with Nolan," Crane said. "We're trying to put some parameters around on what he might be interested in. He's thinking that over, and hopefully he'll get back with us soon. The ball is in his court.
"We want him. We'd love to have him. We think he'd be a great addition to the organization."
Ryan stepped down as CEO of the Texas Rangers in October and worked in an advisory role with the Astros from 2004-08.
Crane said he wasn't sure what Ryan's role with the Astros might be, adding that Ryan's input would be valued and that he could be an asset to everyone in the organization, including general manager Jeff Luhnow.
"He'd probably advise in all aspects of the business," Crane said. "He's been at it a long time and certainly has a lot of experience on the field. [Possibly] confirming some of Jeff's decisions and working with Jeff on the baseball side. He ran the business side of the Rangers.
"Last year he came to a game, and he said your speakers are no good in the stadium. We replaced all the speakers. He was right. He picks up on stuff like that. He has a lot of experience."
Growing up in Alvin, Texas, Ryan pitched nine of his 27 Major League seasons with the Astros (1980-88) before finishing his playing career with Texas. He was hired by former Rangers owner Tom Hicks as club president in February 2008.


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Comic-Con International 2013 Fashion Photos: It's Not All Costumes in San Diego, You Know
Comic-Con is known for attracting the most dedicated, fearless fans who dress up in costume. But among the Superwomans and Spider-Mans and Katniss Everdeens at this year's event, there were also designer pieces by Versace, Proenza Schouler, Wes Gordon, and more trudging through San Diego's Convention Center. Stars left their done-up, straight-laced ensembles at home and opted for playful styles, embracing prints and midriff looks with complete abandon to promote their new sci-fi, fantasy and action flicks. One trend we spotted: Micro shorts as seen on Nina Dobrev (in Sachin + Babi), Lily Collins (in Paper London) and Elizabeth Olsen (in Balenciaga), who styled them with mixed prints, trapeze tops and cropped tanks. Click to see more memorable fashion moments.
• Party Photos From Comic-Con 2013
• Ben Lamb Is Excited For You to See Divergent
• All Comic-Con News


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A Tunkhannock Township house was broken into around 1:30 p.m. Wednesday, according to Pocono Mountain Regional Police.
Police received a call from a neighbor who said three men had entered a house on Skyline Drive and were carrying items out of the residence and placing them on the edge of the property. The neighbor described the men, and police found them a short distance from the house when they arrived at the scene.
When police stopped to identify the men, one of them ran off. All were eventually detained, arrested and provided statements to the police. The men include: Derrick Morris, 23, of New York, N.Y.; Jermaine Ringler, 23, of Blakeslee; and Brian Paul Rodriguez, 22, of Stroudsburg.
The men were charged with burglary, criminal trespass, theft, receiving stolen property, criminal mischief and criminal conspiracy to commit burglary. In addition, Rodriguez was charged with an additional count of burglary and criminal trespass for entering the same house on Feb. 1.
All were arraigned before District Magistrate Judge Michael Muth. Bail was set at $20,000 for Morris and Rodriguez and $10,000 for Ringler. All were lodged at the Monroe County Correctional Facility in lieu of bail.
Three charged in burglary of house in Tunkhannock Township
A Tunkhannock Township house was broken into around 1:30 p.m. Wednesday, according to Pocono Mountain Regional Police.


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'Adopt a Liberal' Campaign Pushes Film on Andrew Breitbart
If you've ever wanted to save America from liberalism but never had a clue how, now's your chance. The "Adopt a Liberal" campaign is encouraging people to send their favorite liberal personality a haunting DVD on the life of late conservative gadfly Andrew Breitbart.
The website Hating Breitbart advertises images of NBC journalists Rachel Maddow, Brian Williams, and Chris Matthews as well as CNN's Anderson Cooper, Supreme Court Justice Sonia Sotomayor and others as potential recipients of "Hating Breitbart" DVDs.
"In spite of his strong beliefs, Andrew enjoyed the times he was able to engage his opponents in the mainstream establishment. At Hating Breitbart, we believe liberalism is an illness that is best treated with a healthy diet of being exposed to different points of view," reads a message on the Hating Breitbart website.
"We're offering fans of our movie the chance to 'sponsor' an intellectually malnourished member of the mainstream establishment by ordering a copy of the film to be sent to them to help overcome years of indoctrination by the liberal elite," it continues.
In a recent interview, the director of "Hating Breitbart" Andrew Marcus echoed the sentiments of the statement on the website. "It's similar to those groups who arrange for Americans to sponsor malnourished children overseas," said Marcus. "Only in this case we're talking about intellectually malnourished members of our media."
He further noted: "These are people who live in an echo chamber. We want to help them hear other points of view … We think of it as sensitivity training for insensitive liberal members of the establishment," he said.
"Hating Breitbart" was released in eight theaters with an R-rating last November and generated just $81,000. The movie was re-cut and is now rated PG-13.
Breitbart died of natural causes at the age of 43 just over a year ago. He was the owner of the website Breitbart.com and five others. His dogged investigations played a major role in the resignation of former New York City Congressman Anthony Weiner over a sexting scandal. Weiner is reportedly working on a political comeback according to several media reports.
The conservative watchdog's relentless efforts also led to the controversial resignation of Shirley Sherrod, former Georgia State Director of Rural Development for the United States Department of Agriculture, and was a key factor in exposing the 2009 ACORN undercover video controversy.
Shortly after his death, Breitbart's family released a statement on his website that read: "With a terrible feeling of pain and loss we announce the passing of Andrew Breitbart…We have lost a husband, a father, a son, a brother, a dear friend, a patriot and a happy warrior."