text:
A systematic review of interactive multimedia interventions to promote children's communication with health professionals: implications for communicating with overweight children
- Carol Raaff1Email author,
- Cris Glazebrook†1 and
- Heather Wharrad†2
© Raaff et al.; licensee BioMed Central Ltd. 2014
Received: 29 July 2013
Accepted: 9 January 2014
Published: 22 January 2014
Interactive multimedia is an emerging technology that is being used to facilitate interactions between patients and health professionals. The purpose of this review was to identify and evaluate the impact of multimedia interventions (MIs), delivered in the context of paediatric healthcare, in order to inform the development of a MI to promote the communication of dietetic messages with overweight preadolescent children. Of particular interest were the effects of these MIs on child engagement and participation in treatment, and the subsequent effect on health-related treatment outcomes.
An extensive search of 12 bibliographic databases was conducted in April 2012. Studies were included if: one or more child-participant was 7 to 11-years-of-age; a MI was used to improve health-related behaviour; child-participants were diagnosed with a health condition and were receiving treatment for that condition at the time of the study. Data describing study characteristics and intervention effects on communication, satisfaction, knowledge acquisition, changes in self-efficacy, healthcare utilisation, and health outcomes were extracted and summarised using qualitative and quantitative methods.
A total of 14 controlled trials, published between 1997 and 2006 met the selection criteria. Several MIs had the capacity to facilitate engagement between the child and a clinician, but only one sought to utilise the MI to improve communication between the child and health professional. In spite of concerns over the quality of some studies and small study populations, MIs were found useful in educating children about their health, and they demonstrated potential to improve children's health-related self-efficacy, which could make them more able partners in face-to-face communications with health professionals.
The findings of this review suggest that MIs have the capacity to support preadolescent child-clinician communication, but further research in this field is needed. Particular attention should be given to designing appropriate MIs that are clinically relevant.
KeywordsChildren Preadolescent Multimedia intervention Clinicians Health professionals Communication Face-to-face Treatment Diet Overweight
Involvement of children in their healthcare decisions is a legal requirement [1]. An important component of effective communication about treatment choices is the provision of information that enables shared decision-making [2]. Information must be conveyed in a way that is clear and engaging, supporting both the health professional and enabling the child, and their family, to become competent partners in the consultation [3, 4].
Presentation of information must suit the child's existing knowledge and what they are able to understand [5]. Historically, health professionals have used leaflets [6–8], as well as diagrams and three-dimensional visual aids [9]. Technology-based resources are also being explored. However, simply making information available does not necessarily make it accessible. Unfortunately, children do not always understand aspects of their treatment and have raised concerns over the way information is conveyed by health professionals in clinical settings [10].
Information contained in traditional resources can be reorganised within interactive multimedia in a variety of non-linear and interesting formats conducive to introducing a topic of conversation, or providing more detailed explanations. This might prove particularly useful to the health professional delivering information on a sensitive and complex topic, such as dietary and behaviour change discussions during child weight management consultations. For many young children, the concept of energy balance and aspects of dietary management are beyond their cognitive capacity [11]. For their part, health professionals can misunderstand the child's priorities and therefore fail to frame information in a meaningful way [12]. Parental influence may also contribute to the tendency for preadolescent children to be marginalised during diet-related appointments [12, 13]. While parental involvement is integral to successful paediatric weight management outcomes [14, 15], a number of preadolescent children would like a greater degree of involvement in decisions affecting their food choices [16, 17]. Greater child participation may be entirely feasible from about seven-years-of-age, when children are cognitively more able to engage in conversations, particularly where there is structure and a concrete basis for discussion [18]. A communication tool, such as interactive multimedia could act as scaffolding to facilitate these more complex and sensitive child-clinician conversations.
This review was undertaken to inform the development of a multimedia intervention (MI) to communicate within the context of weight management consultations with preadolescent children. The target age range for the proposed MI and the systematic review was 7 to 11-years. This review aimed to evaluate the impact of MIs, delivering health information to children in a clinical context, on the quality of child-clinician communication. Although diet-related communication was of particular interest, communication about all health conditions were considered. A secondary objective was to evaluate the effectiveness of MIs in improving satisfaction and indicators of self-management including knowledge, self-efficacy, healthcare utilisation, behaviour change and health outcomes.
Inclusion criteria
This systematic review included papers that evaluated the effectiveness of MIs used in a clinical context to provide information about a health condition and/or treatment. For the purpose of this review, MIs refer to computer-based educational multimedia programmes using images, animation and sound to engage the user [19]. Papers were considered if at least one child-participant was between 7 and 11-years-old at commencement of the study. Child-participants were required to have a medical diagnosis (such as overweight, asthma, diabetes, cystic fibrosis or cancer). Studies where child-patients were recruited from active clinical treatment lists were included (in order to increase the likelihood of face-to-face child-clinician communication at the time of the study), while those identified through discharge records or schools, and not explicitly in receipt of on-going treatment or monitoring of the medical condition in question at the time of the study, were excluded. Only studies with both an intervention and a comparison group were retained; these included clinical trials, randomised controlled trials, and prospective studies.
There was no restriction on the setting within which the intervention was delivered. Interventions that took place within the community, at a healthcare setting (general practitioner (GP) surgery, community clinic or hospital), at a school or in the child's home were all eligible.
Studies had to report one or more of the following primary or secondary outcome measures to be included in the review. Of primary concern was the effect of the multimedia technology, if any, on the quantity and quality of face-to-face communication between health professional and child, and level of child-engagement in treatment. Attrition rates (appointment non-attendance and dropout rates) were therefore analysed. Stakeholders' satisfaction and views of the intervention were also considered. Other secondary outcomes were measures of health change. They included a wide range of possible treatment outcomes: knowledge acquisition, changes in self-efficacy, attitude to health or motivation to make the desired health change, changes in health outcomes or symptoms, and a reduction in emergency appointments or hospitalisation.
Search strategy
The literature search to identify studies for inclusion was conducted during the third week of April 2012. The search strategy was designed to capture published research, grey literature and on-going or recently-completed clinical trials.
Ovid MEDLINE(R) 1946 to April Week 3 2012 search strategy
1. (appointment$ OR consultation$).tw,kf
49. exp Attitude to Health.sh (includes Health Knowledge, Attitudes, Practice/, Patient Acceptance of Health Care/)
2. Health Communication.sh
50. Self Efficacy.sh
3. (health ADJ3 communicat$).tw,kf
51. (self ADJ efficacy).tw,kf
52. (health ADJ competence).tw,kf
5. (e-communicat$ OR ecommunicat$).tw,kf
53. Health Behavior.sh
6. (e-health OR ehealth).tw,kf
54. ((health ADJ behavi*r$) OR (chang$ ADJ3 behavi*r$) OR (behavi*r$ ADJ3 change$)).tw,kf
7. electronic$.tw,kf
55. exp Self Care.sh (includes Blood Glucose Self-Monitoring/, Self Administration/ and Self Medication/)
8. virtual.tw,kf
56. (self ADJ manag$).tw,kf
9. Virtual Reality.sh
57. exp Patient Satisfaction.sh (includes Patient Preference/)
10. (virtual ADJ reality).tw,kf
11. (Hypermedia OR Multimedia).sh,tw,kf
59. Randomized Controlled Trial.sh
12. animation.tw,kf
60. Randomized Controlled Trials as Topic.sh
13. ((information ADJ technolog$) OR IT).tw,kf
61. (randomized controlled trial).pt
14. (Decision Making, Computer-Assisted OR Therapy, Computer-Assisted).sh
62. (controlled clinical trial).pt
15. (computer ADJ (assisted OR based OR mediated)).tw,kf
63. Random Allocation.sh
16. (Computers OR Computers, Handheld).sh
64. Double-blind Method.sh
17. (computer$ OR (hand ADJ held ADJ3 computer$) OR (handheld ADJ3 computer$)).tw,kf
65. Single-blind Method.sh
18. (mobile ADJ communic$).tw,kf
19. ((personal ADJ digital ADJ assistant) OR pda$ OR (pocket ADJ pc) OR (pocket ADJ computer$)).tw,kf
67. Animals.sh NOT Humans.sh
20. ipad$.tw,kf
21. Internet.sh,tw,kf
69. (clinical trial).pt
22. World Wide Web.sh
70. exp Clinical Trial.sh (includes Clinical Trial, Phase I/, Clinical Trial, Phase II/, Clinical Trial, Phase III/, Clinical Trial, Phase IV/, Controlled Clinical Trial/, Multicenter Study/ and Randomized Controlled Trial/)
23. ((world ADJ wide ADJ web) OR www OR website$ OR (web-site$) OR (web ADJ based) OR (web-based) OR webbased).tw,kf
71. Case-Control Studies.sh
24. Online Systems.sh
72. (clin$ ADJ25 trial$).tw,kf
25. (online OR on-line OR portal).tw,kf
73. ((single OR double OR triple OR treble) ADJ25 mask$).tw,kf
26. Compact Disks.sh OR CD-I.sh OR CD-ROM.sh
74. Placebos.sh
27. ((cd ADJ rom$) OR cd-rom$ OR cdrom$).tw,kf
75. (placebo$ OR random$).tw,kf
28. Software.sh,tw,kf
76. Research Design.sh
29. (interactive ADJ3 (technolog$ OR application$ OR program$) OR ITA).tw,kf
30. Video Games.sh
31. ((video OR computer) ADJ game$).tw,kf
32. (wii OR nintendo).tw,kf
80. (Comparative Study OR Evaluation Studies OR Follow-Up Studies OR Prospective Studies).sh
81. (control$ OR prospectiv$ OR volunteer$).tw,kf
34. Pediatrics.sh
82. intervention$.tw,kf
35. (p*ediatric OR p*ediatrics).tw,kf
36. Child.sh,tw,kf
37. (children OR childhood).tw,kf
39. (Diet OR Diet Therapy OR Nutrition Therapy).sh
40. (diet$ OR nutrition$).tw,kf
88. limit 87 to yr=1990-2012
41. (Health Education OR Patient Education as Topic).sh
89. exp Schools.sh (includes Schools Medical/, Schools Nursery/ and Universities/)
42. (health ADJ education).tw,kf
90. Vocational Education.sh
43. Health Promotion.sh
44. ((health ADJ promotion) OR (promot$ ADJ health)).tw,kf
45. Patient Participation.sh
46. exp Patient Compliance.sh (includes Medication Adherence/)
47. Motivation.sh
48. motivat$.tw,kf
The final searches were run on all 12 databases. Two of these (SciVerse SCOPUS and Reuters Web of Knowledge) yielded more than 500 papers each. In both cases, research categories on the search results page were used to further limit the searches. Tick boxes to exclude research areas deemed unrelated to the scope of the review (such as engineering, chemical engineering and mathematics), were selected. As a relatively new field of research, studies dating from before 1990 were not considered. No language filter was applied.
Exclusion hierarchy 1 for elimination of full text papers at stage 5 of the search process
Exclusion criteria
No. of studies
and references
No children 7–11 years
No educational multimedia
Not recruited from active clinical treatment lists
Participants have no diagnosed health condition
No comparison group
Descriptive paper, not an intervention study
Abstract/summary article
Data extraction
Data from the included studies were extracted by the main review author, and synthesised into a database developed for the review. An overall lack of robust studies and heterogeneity precluded the amalgamation of data into a meta-analysis. Data were therefore summarised qualitatively and checked by the two review authors.
Quality appraisal
The quality of the studies was determined by applying the risk of bias assessment outlined by Higgins and Altman [54]. Due to the behavioural nature of the studies and the type of interventions under investigation, it would have been virtually impossible for the researchers to eradicate all potential investigator bias in gathering their data. Strategies to limit such bias–blinding or masking–are important considerations even for behavioural studies, and are recommended in the CONSORT Statement [55], p.11. However, in recognition of the inherent difficulty facing researchers in this area, data pertaining to other study quality features were also analysed.
Study quality coding criteria
Quality item
Scoring criteria
MI development
Evidence-basis and theoretical underpinning of intervention design
Was the multimedia intervention (MI) developed according to cited evidence-based guidelines related to the health condition? And/or was mention made of theoretical constructs used in the development of the MI?
• If either or both of these aspects were mentioned, the quality is coded as YES, otherwise it is coded as NO
• PARTIAL YES (½) is given to interventions that only invite health professionals to be involved in the design and/or development, i.e. no reference to clinical guidelines or theoretical underpinning
Intervention piloting/ testing prior to study commencement
Was the MI piloted during or after the development phase with children of the appropriate age range? Was the MI developed for children of a specified age range, and was it then piloted with this age group prior to undertaking the study?
• The quality is coded as YES if piloting, or iterative child-involvement, has been integral to the MI design and/or development or post-development piloting has taken place that may have led to amendments
• Where piloting or testing has been mentioned, without details about the rigour of the process (such as the ages of the children, the number of children involved, the outcome of the piloting process, etc.), the quality is coded as PARTIAL YES (½)
• The quality is coded as NO if no mention is made of child-involvement during development, piloting or testing
Study design
Appropriately selected age ranges for potential research participants
Did the study include children of an appropriate age range? If the MI was piloted or developed in conjunction with children, are study subjects of a similar age range? Could the MI design be developmentally appropriate for the youngest and the oldest study subjects? In other words, is the age range appropriate or is it too large?
• The quality is coded as YES where the MI has been piloted or tested with children of a similar age to those recruited as study subjects, and the age range is ≤ 7-years
• YES is also given to MIs catering for a wider range of ages, e.g. by way of different levels or difficulties, designed cope with the discrepancies in developmental ability of the children, and study data have been analysed and presented within narrower age ranges
• PARTIAL YES (½) is given to studies where the age range is 7 to 8-years, and the above conditions have not been met
• The quality is coded as NO if piloting of the MI took place with a different age group of children to those recruited to the study, without valid reason or explanation, or the age range of study participants was > 8-years with no stated strategy to deal with differences in developmental abilities
Data collection
Amount of time children viewed the multimedia intervention
How much time did children have to familiarise themselves with the content of the MI? Was the number of sessions reported? Was the length of these sessions stated?
• In order to be coded as YES, the paper must indicate (even if a calculated estimate) the amount of time children spent using the intervention. This may be stated as a total time, or length of time for each session
• A PARTIAL YES (½) is given if the total number of sessions is stated, with no indication of time spent viewing the MI
• The quality is coded as NO if no data, data is unclear, or only partial data is provided (e.g. the length of the first session but not subsequent sessions)
Studies retrieved
The database search produced 2409 citations. After removing duplicates for published papers, 1536 titles and abstracts were screened for relevance. Main reasons for exclusion were:
Age–participants fell beyond the target 7 to 11-year age group (such as studies with exclusively preschool, adolescent or adult subjects);
No diagnosed health condition;
Participants not recruited from active clinical treatment lists;
No comparison or control group.
Study characteristics
All of the 14 included studies were randomised controlled trials, with the exception of one [73] that was non-randomised. Most of the studies were from the United States, with only three from Europe; two originated from the United Kingdom [6, 8] and one from Germany [73]. Ethnic groupings of study participants were poorly reported in five papers [6, 9, 70, 73, 74]. Of the eight studies that provided a breakdown of the ethnic origin of participants, most children were classed as white [7, 8, 71] or 'Caucasian' [69, 72].
Study characteristics
No. of studies
And references
United States
United Kingdom
Ethnic majority
White and 'Caucasian'
Not reported
Health condition
Type 1 diabetes
Dental malocclusion
Leukemia (remission)
Nocturnal enuresis
Cystic fibrosis
Sickle cell disease
Recurrent headache (non-malignant)
Sample size
Reported sample size calculation
No sample size calculation; total participants n < 120
No sample size calculation; total participants n ≥ 120
< 6 months
≥ 6 months
(post- intervention)
< 6 months
≥ 6 months
Quality assessment ratings
Risk of bias
Sequence generation proved inadequate in several studies; one used children's medical record numbers [7], two others randomised according to period of hospital admission [65] and clinic allocation [6], and one allowed children (and parents) to self-select either the intervention or comparison group [73]. As would be expected, studies that demonstrated a potential risk of bias in ensuring random sequence generation, posed a similar risk of lack of allocation concealment [6, 9, 65, 73].
In addition to the relative risk of bias in how study subjects were assigned to either the comparison or intervention group, some studies [7, 9, 67] lacked rigour, and balance in their data reporting and discussion. One paper made unfounded deductions about findings, concluding that children in the intervention groupwithout acknowledging that the measure for this outcome data was biased. Another [73] failed to adequately explain why 45% (n = 66) participants in the intervention group did not use the multimedia tool. This study also deviated from the original protocol, transferring children allocated to the intervention group to the comparison group.
"experienced significantly improved communication with parents about diabetes"[70], p. 87
The 'other bias' varies from a potential conflict of interest [73]; to lack of clarity on study protocol such as the number of the different leaflets distributed to comparison group participants [6]; possible treatment bias, with intervention group children having more appointments [67]; the time of year children were recruited to the intervention and comparison groups and whether there was any seasonal effect on the chronic health conditions under investigation [65]. One study [7] published some of the results in a second paper [75] using different age groups and slightly altered descriptors of user satisfaction questions.
At their outset, most of the included studies were small [8, 65, 69–72, 74] and could more accurately by described as feasibility studies. Two studies reported a sample size calculation. In the first of these, Krishna, et al.[7] had a 22% completion rate which translated into one quarter of the calculated desired number of children completing the 12-month study. The second, a study by Redsell, et al.[6], had better retention figures (92% of the intervention and 87% of the comparison group) at discharge (not stated, but estimated to be at approximately 6-months). At the 6-month post-discharge follow-up however, data for only 24% and 31% of the intervention and comparison group, respectively, were available.
Studies with more than the conventionally accepted 20% study drop out rate [77] were classed as high risk for attrition bias. Attrition rates in many of the studies were difficult to quantify; two studies [70, 71] neglected to address children lost to follow-up and a further three papers [65, 67, 69] provided insufficient detail on non-completers, the point at which children dropped out, whether they belonged to the intervention or comparison group and/or the reasons for their attrition. These three studies, together with Runge, et al.[73], Homer, et al.[66] and Eckler [9] had relatively high drop out rates. The work by Bartholomew, et al.[68] could also be placed in this category, however their higher drop out numbers should be balanced with the fact that their study spanned three years.
The included papers are mostly unclear about the potential for performance bias. Several researchers took steps to limit subjective outcomes: interviewers in the study by Dragone, et al.[69] were taught to avoid biasing subjective outcomes during training sessions; and neurologists in the paper by Connelly, et al.[72] were blinded to the child's group allocation; and interim phone contacts, relating to medical issues, were handled by nursing staff not directly affiliated with the research. A number of papers [6, 66–68, 70, 71, 73, 74] overlooked the potential impact lack of blinding may have had on study outcomes.
Quality assessment
Aside from the risk of bias, the quality of this type of research also relies on the design of the MI itself. Assessing the papers in this way enabled an important cross-referencing of the extent to which the evidence they hold was potentially valid. The results of the quality assessment, Table 4, confirmed the strength of the research by [72] and [8]. However, it also rated 9 out of the 14 included studies as 'medium' quality, with Davis, et al.[74] the poorest of these. This study omitted details on the development and age-appropriateness of the STARBRIGHT World website (used in the research), raising questions over the suitability of the MI and therefore the validity of the study findings.
"We had anticipated that parents of younger children with asthma would actually use the program themselves, but we found that the program did not consistently engage parents–except the more didactic video elements" [66], p. 214
Studies were generally better at their measurement of the time children spent using the MI, their reporting thereof, or both. Nevertheless, 4 [6, 67–69] of the 14 studies failed to provide adequate detail. Of the studies that did provide data, two [7, 70] offered self-reported estimates of duration and frequency of use, with no apparent means of validating the data. Runge, et al.[73] used the time children were logged onto the server as the time they spent using the MI. Six studies demonstrated greater reliability in their data tracking methods through built-in intervention monitoring [65], researcher monitoring [9, 66], and required activities and assignments [71, 72, 74].
In evaluating its effect on knowledge, self-efficacy and/or health behaviour change, the time children are exposed to a MI has a bearing on the extent to which it had the opportunity to affect attitudes and motivation to change [56, 57]. The ten studies that reported on this quality indicator differed significantly in the time children spent using the intervention, from less than 30-minutes to 34-hours).
Intervention and comparison group characteristics
No. of studies
And references
MI type
Nintendo® game console
MI group information formats1
Multimedia only
Multimedia + written information
Comparison group
information formats1
Written information, e.g. leaflets*
Conventional aids, i.e. dental models, radiographs*
Not reported
Intervention setting
Outpatient clinic
During hospitalisation
At home
At school (school nurse office)
Time MI used
< 60 minutes
1–2 hours
≥ 2 hours
Not reported
Intervention length
< 6 months
≥ 6 months
< 6 months
≥ 6 months
Participant age
While there was a wide age variation amongst study participants, several papers [7, 65, 69] analysed data within narrower age groups. Data relating to the age category closest to, and incorporating 7 to 11-year-olds, were selected for inclusion. Only two studies focussed on 7 to 11, or 7 to 12-year-olds; either as the total study population [72], or analysed as a subgroup [69]. Differing age ranges in turn affected the mean ages of recruited children.
The ability to compare mean ages was compromised by a lack of data. With the exception of five studies [6, 9, 66–68], papers failed to provide the mean age of recruited children. One paper reported the median age of the comparison and intervention group [8] instead of the mean. This study reported a significant age difference (p = 0.012) between the two groups. Five studies [7, 65, 68–70] offered no indication as to group similarity or differences in participant's mean ages. Where necessary, and feasible, the mean age of participants was calculated from study data [8, 71–74] (Figure 4). Within the ten studies, the mean age of children was 10.11 ± 2.13 with the mean range from 7.40 to 13.05-years.
Multimedia intervention (MI)
The heterogeneity evident in the age ranges of child-participants was further apparent in the MIs themselves (Table 5). Diversity existed on a number levels; including platform delivery (CD-ROM, web-based, etc.) and the setting in which child-participants accessed the MI (medical settings, school, home, etc.).
Perhaps the most obvious difference between the selected studies was what the MIs were designed to achieve. Most of the interventions had either stated or implied aims of educating children about their health-related condition; and improving skills and confidence to manage symptoms, triggers and medication. Some MIs [65, 69, 70, 73] had an additional dimension; to improve social support. Kidz with Leukemia: A Space Adventure provided a short video clip on "siblings views on leukemia"[69], p. 299. Packy and Marlon[70] had a two-player option, in which children needed to help one another to succeed in the game, encouraging children to communicate with others about their diabetes. The interventions used by Hazzard, et al.[65] and Runge, et al.[73] both offered chatroom facilities; Hazzard et al. featured videoconferencing, and Runge et al. enabled email contact with other children. Social networking and peer-to-peer communication opportunities may have affected study outcomes, such as self-efficacy and motivation to change, to a greater or lesser degree, thereby confounding the effect of the MIs that relied solely on animation design elements.
Outcomes may also have been influenced by the extent to which health professionals were engaged in the MI. Clinicians were more involved in the MI delivery in three studies [6, 9, 73], although clinicians were only consistently involved with each child (and their family) in the Eckler [9] study; orthodontists actively using the MI to deliver information within the consultation. In contrast, Redsell, et al.[6] mentions a 'passport' given to children to indicate the MI modules they had worked through and record comments for later discussion with the school nurse, but omits to report on whether this resulted in children and school nurses discussing the MI. Similarly, asthma experts (not the children's health professionals) in Runge, et al.[73] were available online for scheduled chatroom chats and via email but it is unclear the extent to which these facilities were used. In an attempt to prevent performance bias, two studies [7, 72] aimed to avert child-clinician communication about the intervention through blinding. Bartholomew, et al.[67] and Bartholomew, et al.[68] actively encouraged physicians to become more involved in the care of children using the MI. Researchers encountered a general resistance, these health professionals cited lack of time [68] and the MI content not suited to their institution's clinical procedures [69] as barriers to engaging with the MI.
In addition to the MI, some studies provided additional information to intervention group children. Children in nine of the included studies [8, 9, 66–71, 74] were given the MI only. Others were given the MI as well as education sessions [73] or more frequent face-to-face consultations [6, 65, 72]. One study [7] provided written information as well as periodic contact with a health professional. Other papers failed to clarify whether or not health information was given to children in the comparison group [68] or what form this may have taken [9]. Inequality in study intervention approaches hinders comparison of results. One might argue that these anomalies could be accounted for by the choice of comparison treatment.
A number of MIs [6, 9, 66, 67, 74, 75] were designed for use at outpatient clinic settings. There was variation within these studies; one researcher demonstrated the MI [9], others offered researcher assistance, as required [66, 74], and another did not state the level of support available [6]. Five studies required children to work independently, at home [8, 69, 70, 72, 73]. Again, not all had a similar experience; Connelly, et al.[72] posted the MI to the child's home, while Mcpherson, et al.[8] and Ritterband, et al.[71] visited children in their homes to offer initial support. Some children used the MI in the nurse's office at school [68] and others during a period of hospitalisation [65]. The setting and level of researcher involvement will have affected children's experiences of the MI, particularly for younger or less confident children, thereby creating discrepancies between study findings.
Multimedia intervention (MI) use, study duration and follow-up
There were significant differences of MI use, both within and between studies. Some studies [6, 9, 72] controlled the order in which multimedia modules were viewed, or indeed offered a limited time in which children were able to use the MI [74]. Other studies [65–67, 69–71, 73] allowed children freedom over how they chose to use the MI, if at all. Consequently, reported MI usage also varied greatly. Some children [9, 74] had a total of 30-minutes or less, and others [70] were reported to have used the interventions for up to 34-hours.
The study period for half of the interventions were for less than six-months; one [9] was used within a half-hour consultation, another [65] spanned three-days, while the majority of shorter studies were for three [69, 74] or four-months [6]. Of those lasting 6-months or more, 3 [8, 70, 73] ended at 6-months, 2 [7, 68] were for 12-months and one study [67] had a mean duration of 7.6-months, with participant involvement ranging from 4 to 15.6-months. Most (10 of the 14) studies had no follow-up period (Table 4). Connelly, et al.[72] tracked outcomes for three-months post-intervention and two studies [6, 73] had a six-month follow-up period. One school-based study [68] continued to collect data for two years post-intervention.
Variations in intervention usage, study duration and follow-up period all would have influenced the opportunities children had to familiarise themselves with the multimedia content, and subsequently make behavioural changes.
Outcome measures
Multimedia intervention outcome measures and intervention effects
Study outcome
No. of studies
Outcome measures/scale1
Reliability tested2
ES (d)
No. child-initiated diabetes discussions: Parent recall (one month)
Child Satisfaction Survey:
Felt involved in the consultation
Orthodontist understands me
User satisfaction: Instrument not described
Liked the explanation: Satisfaction Survey4
Satisfaction and Use Questionnaire:
Used assigned intervention ≥ once
Used intervention 'for a long time'
Found intervention 'easy to use'
DNA rate
DNA at least 1 appt
DNA two consecutive appts
Appts kept out of total planned appointments
Appts kept out of total planned appointments
Knowledge acquisition
Interview questions, blood glucose logbook, food exchange chart
Child Short Answer Knowledge Questionnaire4:
Three major orthodontic problems
Two orthodontic appliances/devices used
Three risks
Two instructions followed
Total recall and retention of information presented
Leukemia Event Knowledge Interview [78]
Cystic Fibrosis Knowledge Questionnaire (adapted Quittner & Drotar (1997))7
Child Knowledge of Asthma Management Questionnaire
Child Knowledge of Asthma Questionnaire
Pediatric Asthma Care Knowledge Survey
Child Knowledge of Asthma Management Questionnaire [67]
Asthma Knowledge Assessment
Asthma Knowledge Scale (modified [79])
How Much Do I Know About Sickle Cell Disease? Questionnaire (shortened [80])
Encopresis Knowledge Questionnaire
Virginia Encopresis/Constipation Apperception Test [81]
Changes in self-efficacy
Interview questions
Child Satisfaction Survey4:
'Satisfied that I know the causes'
'Satisfied that I know the treatment'
'Satisfied that I know the expected outcome'
'Satisfied that I know the risks'
'Satisfied with the explanation of the problems'
'Confidence in the Orthodontist'
'Not afraid of the treatment'
Leukemia Children's Health Locus of Control [82]
Role Play Inventory of Situations and Copy Skills [83]
Self-esteem Scale (shortened [84])
Child Self-efficacy Expectations Questionnaire
Child Self-efficacy Expectations Questionnaire [67]
Parent recall: Child attitude toward asthma care
Parent recall: Behaviours related to asthma care
Children's Asthma Locus of Control ([85], derived from [82])
Kidcope [86]
Kidcope [86]
Health outcomes/symptoms
Long-term blood glucose control: HbA1c measurements
Time to dry (Length of time to achieve 14 consecutive dry nights): Not described
Not stated
Dry on discharge: Not described
Not stated
Dry 6 months post-discharge: Questionnaire not described
Not stated
Headache activity: Headache Index Composite calculated from Headache Diary [87]
Headache frequency, duration and severity: Pediatric Migraine Disability Assessment [88]
Asthma symptoms: Usherwood Symptom Questionnaire [89]
Asthma severity: Parent recall
Lung function (FEV 1 ): Instrument not described
Not stated
Days of asthma symptoms since last visit:
Parent recall
Asthma symptoms: Usherwood Symptom Questionnaire [89]
Lung function (FEV 1 ): Micromedical Super-Spiro spirometer
Not stated
Lung function (PEF): Mini-Wright Peak Flow Meter
Not stated
Lung function (FEV 1 ): Instrument not described
Not stated
Lung function (PEF): Instrument not described
Not stated
Child Information Form:
Trips to toilet without parental prompt
Bowel movements in the toilet
Overall encopresis symptom improvement
Emergency medical visits
Emergency room/GP visits over past 3 months 10 : Parent recall
Number of visits over past year: Parent recall
Emergency room visits: Parent recall
Acute GP visits: Parent recall
Asthma Summary Since Last Visit Questionnaire:
Urgent medical visits
Emergency room visits
Unscheduled visits to the GP over past month: Parent recall
Emergency room visits over past 6 months: Parent questionnaire and GP electronic record
Not stated
Hospitalisation over past 3 months 10 : Parent recall
Hospitalisation over past year: Parent recall
Asthma Summary Since Last Visit Questionnaire:
Days of stay in hospital
Hospitalisation over past year: Parent recall
Hospitalisation over past month: Parent recall
Days of stay in hospital over past 6 months: Parent questionnaire and GP electronic record
Not stated
A number of health outcomes depended on parent recall. These included episodes of emergency medical care and hospitalisation for the chronic condition under investigation. Timescales for recollecting these episodes of emergency care varied from one-month [8] to three-months [70], six-months [73], nine-months [7] and even 12-months [67]. Memory is inherently unreliable. Only Runge, et al.[73] attempted to validate the reliability of the data obtained through parent recall, by using GP electronic records.
Despite the diversity of the research presented in these papers, and their associated methodological differences and limitations, there is value in reflecting on individual study outcomes.
Study outcomes
The stated aim of this review was to evaluate the effectiveness of MIs in promoting the quality of face-to-face communication between health professionals and children, within a health context. One paper [9] aimed to facilitate child-clinician communication. In this study, orthodontists used a MI to clarify treatment options with children and parents. Children who viewed the MI felt more involved in the consultation (p < 0.05) but did not report to feel more understood by the orthodontist (p = ns). Another study considered the effect of a MI on a different type of face-to-face interaction; Brown, et al. [70] considered its effect on children talking to parents about diabetes. The study found the effect to be statistically significant (p = 0.0025).
Of further interest, was the extent to which MIs affected the child's (and family's) involvement in their healthcare or treatment. Outcomes connected to this aim are attendance rates and relative satisfaction with the MI. However, for both outcomes, minimal comparison data were available.
Three studies reported on appointment attendance. Bartholomew, et al.[67] cited significantly greater attendance rates among intervention group children. In contrast, Homer, et al.[66] found no significant difference between the intervention and comparison groups in this regard. However, data from Redsell, et al.[6] are less clear. The paper reports no difference in attendance rates. Isolating the data of children who failed to attend two consecutive appointments; 26 (24.1%) of the intervention group versus 12 (13.8%) of the comparison group; implied better appointment attendance amongst children who did not use the MI [6]. This leads to an inconclusive assessment of the affect of MIs on attendance rates.
Another proxy for evaluating the quality of communication should be satisfaction with care. However, data were extracted from only three papers [9, 69, 70]. Outcomes from several of the included studies [7, 8, 65, 67, 71] were discounted because of a lack of comparison group data. Davis, et al.[74] designed a cross-over trial, having no comparison group for this outcome measure. Homer, et al.[66] reported no significant group differences for parental satisfaction on physician communication, physician involvement or overall care. The study reported that healthcare professionals were not engaged in the MI and neither were parents; with some parents choosing to sit in a separate room, away from where their child was using the MI, potentially explaining this finding. The 'not significant' outcome of Brown, et al.[70] could be interpreted as the MI was no more engaging than the alternative treatment. In this case however, the comparison group received a non-health-related MI. These data could therefore equally be interpreted; that the health-related MI was as enjoyable as the entertainment game. In fact, children in this study used the MI for an average of 18-hours in the first 3-months and 16-hours in the second 3-months. Likewise, Eckler [9] found no significant difference in preference for either the MI or traditional visual aids–dental models, radiographs and photographs–all of which could conceivably be interesting and informative to children within a consultation-setting. Data from Dragone, et al.[69] implied that the MI was equally as useable as the book, but potentially more engaging (as more children used the MI more often and for longer).
Of the three studies, Dragone, et al.[69] was rated 'high' quality and at lower risk of bias. However, it would be unreasonable to judge the extent to which MIs encourage 7 to 11-year-old child engagement with health-related treatment, based on 17 children.
Knowledge acquisition
The findings for the effect of MIs on knowledge gained are mixed. Six MIs [7, 65, 67, 70, 71] were found to be no more helpful than comparative interventions. The other six MIs were found to be effective [9, 69] or very effective [8, 66, 68, 74] education devices. Three [8, 69, 74] of these studies had a comparatively more robust research strategy, lending more weight to the suggestion that multimedia may be a worthwhile health education tool. Moreover, equipped with greater knowledge about a health condition, and it's treatment, may enable children to understand health-related conversation in a more meaningful way, thereby facilitating their future involvement in consultations-settings with health professionals [2].
Changes in self-efficacy
Apart from Hazzard, et al.[65] and Homer, et al.[66], all studies reporting on self-efficacy, presented data pointing towards a significant link between MIs and enhanced self-belief [6, 8, 67, 70], a number of which were highly significant [68, 69, 74]. Although intervention children in the Eckler [9] study were no more confident about their treatment than their counterparts in the comparison group, they were sure of the problems associated with the proposed orthodontic treatment. These data echo those reported for knowledge acquisition.
Self-belief is affected by the time spent learning and practising new behaviours, as confirmed by Bartholomew, et al.[67] who found a correlation between time using the MI, and self-efficacy. Children using the STARBRIGHT: Fitting Cystic Fibrosis into your Everyday Life MI, only used it for 30 minutes [74], probably not enough time to influence self-belief in a meaningful way. Children in the Mcpherson, et al.[8] study typically used the Asthma Files once, for 60 to 90 minutes.
Care must be taken when quantifying the variable and subjective nature of self-efficacy. However, children who feel more able to manage their health condition have a degree of self-control that may afford them greater self-confidence when communicating with clinicians. Parental involvement in the education activity will likely also play a role in a child's ability to improve self-management [66].
Health outcomes
The litmus test of someone's ability to cope with, or manage, a health condition is how this translates into physical health and wellbeing. Likewise, the ultimate goal of many of these MIs is to change health behaviour and improve disease-related symptoms.
Of the four studies [7, 67, 71, 72] that described MIs as having made a significant improvement to symptoms; three [7, 67, 72] demonstrated inconsistencies. Krishna, et al.[7] found a correlation between use of the IMPACT MI and fewer days of asthma symptoms. However, this outcome was not confirmed by an improvement in lung function (FEV1). Bartholomew, et al.[67] reported fewer asthma symptoms, but only in children with mild asthma. Connelly, et al.[72] too had mixed results. The Headache Index Composite score (derived from data collected through headache diaries) was lower in children who used the MI. However, the Pediatric Migraine Disability Assessment questionnaire showed no significant difference between the intervention and comparison group children. The authors pointed out that, following the one-month intervention, children were tracked only for a further three-months but their data points towards a gradual decline in Migraine Disability scores amongst children who used the MI.
One of the major limitations for many of the identified studies [7, 67, 71] was the brief length of post-intervention follow-up. Despite these, some MIs have played some role in improving health outcomes for some children.
Need for emergency medical treatment or hospitalisation
The evidence analysed thus far suggest that MIs are less beneficial for severe medical conditions. Based on this assumption, emergency medical care and hospitalisation rates would not benefit from MIs. Data presented in Table 6 confirms that only one [7] out of the handful studies reporting on this area, found MIs to be effective to this end.
As with any investigation of this kind, these results should be interpreted mindful of the limitations, not only of the research literature but also of the methods used to identify the research. To begin with, identification of potentially relevant papers was hindered by authors' use of keywords, and keywords definitions offered by database thesauri. Only 5 of the 14 included studies were found through a systematic search of 12 databases. This is in part due to technology advancements and the changing terms then used to describe them [90]. Secondly, relatively few papers met the inclusion criteria and the evidence presented by most of these studies evaluated poorly on a variety of levels. The third limitation was that heterogeneity between studies prohibited meta-analysis of data. Lastly, the research presented in this review could be more appropriately described as pilot studies. Focus needs to be placed on undertaking better quality studies that adequately investigate the role of technology in health communication.
Most of the identified papers were published between 2000 and 2006, representing studies that took place at the end of the 1990s and the first few years of the 21st century. Interestingly, no more recent research was found, despite the apparent usefulness of MIs.
This review was undertaken to inform the development of a diet-related MI for use with overweight children. It should be noted that none of the included MIs were designed for overweight children. The one study [40], that did aim to engage preadolescent overweight children by integrating an activity-promoting MI into an obesity programme did not meet the meet the inclusion criteria for this review (see Table 2). Post-intervention scores showed a significant reduction in BMI, screen time and carbonated drink intake, with increased physical activity levels at the end of the 10-week programme but in common with included studies, impact on communication was not evaluated. This highlights how the capacity for MIs to support health-related communication in the area of child weight management, has been neglected.
Research has tended to define MIs as efficient resources to improve knowledge and promote self-efficacy independently of health professionals, seeking to exploit their cost-benefit in providing alternative healthcare rather than understanding their role in enhancing existing clinical practice. Some studies [6, 9, 73] encouraged health professionals to interact with the children using the MIs, but the level of engagement was not reported, raising doubts over its emphasis and importance within the research. Bartholomew, et al.[67] implied that clinician involvement might have improved asthma symptoms for those children with more complex health needs. The potential role of MIs alongside health professional involvement has not been explored.
Studies [68] had difficulty finding support for MIs among clinicians, with Dragone, et al.[69] achieving a 30% response rate from health professionals asked to feedback on the MI. All but two studies [70, 72] involved clinicians in the MI development phases (one study [73] was unclear). Nevertheless, it is difficult to assess the extent and nature of their involvement. Approaching health experts for suitable content is vastly different to exploring how clinicians provide information to children and families, and providing the opportunity to settle on an agreed format for the MI. These papers are also unclear as to whether health professionals were involved throughout the multimedia development process, or merely at the beginning or end-point.
Included multimedia interventions and on-going availability
Multimedia intervention
MI description
Available/ in use
Interactive Consult 2.0
Stationary and moveable graphics used to illustrate orthodontic diagnosis and treatment (36 treatment plans)
Packy and Marlon
One-or two-player game to save the diabetes summer camp from the rats and mice that have scattered the food and diabetes supplies (24 levels)
Extract available at http://www.youtube.com/watch?v=oWcPf_n8BgM (accessed 7 February 2013)
All About Nocturnal Enuresis
Animated, interactive tutorials based on paper-based pamphlet (7 tutorials)
Kidz with Leukemia: A Space Adventure
A themed MI, providing leukemia information using interactive media, e.g. games and puzzles; and video, e.g. a hospital tour
Watch, Discover, Think and Act
An adventure game to make decisions about managing the game character's asthma and provide tailored treatment asthma plan.
Asthma Control
Game simulation of daily events, while managing the superhero game character's asthma, including brief video clips about specific objects, e.g. triggers or medication
Interactive Multimedia Program for Asthma Control: IMPACT Asthma Kids
Animated interactive tutorials about asthma symptoms and medication use, and real-life scenarios to practice decision-making (44 modules)
Yes, in adapted format
MI content has been converted into a series of interactive educational resources
The Asthma Files
Animated interactive secret-agent themed modules with games and quizzes and provides tailored self-management asthma plan (8 modules)
Not stated
Consists of:
• Adventure game incorporating asthma-related situations that have to be managed;
• Asthma quizzes and material from group education sessions;
• Scheduled chat sessions with asthma experts;
• Online social networking with peers
STARBRIGHT World
Intranet for hospitalised children with interactive games, arts and crafts projects, and opportunities to contact children in other hospitals online
Website is recommended for 13-20 year olds
STARBRIGHT World: Fitting Cystic Fibrosis into your Everyday Life
Animated interactive tutorials about eating, breathing and cystic fibrosis questions and answers (3 modules)
Interactive tutorials and quizzes with illustrations about aspects of encopresis management (27 modules)
Interactive narrated tutorials and quizzes about headache management, e.g. deep breathing and imagery, and a tailored active pain-coping plan (4 modules)
Available only from authors
Proudfoot, et al.[57] have proposed a series of guidelines to support internet interventions. This review suggests that greater emphasis should be placed on the context within which these technologies will be used, and the communication requirements of health professionals. A development methodology that advocates participatory involvement, peer review and evaluation at different stages of MI production needs to be addressed. Investing in the production of useful MIs may help to clarify the potential for this type of technology to realise health behaviour change and improve health outcomes [91].
Although some of the studies were not of the highest quality, and MIs lacked focus in their design and development (a problem not unique to this review [21, 92]) the study outcomes themselves are promising: MIs have the capacity to improve child-clinician communication, 7 to 11-year-old children seem to enjoy using multimedia, MIs may be useful in educating children about their health, MIs show promise in improving self-efficacy among children of this age, and these types of interventions have the potential to improve health outcomes.
Despite calls to investigate using health-related multimedia with face-to-face communication [20, 93], the findings of this review have established this as an area of research yet to be charted, specifically within the 7 to 11-year age group.
This review suggests that MIs can lead to health-related improvements, and they hold the potential to support communication between young children and health professionals. Health professionals may need to be convinced of their benefit, and persuaded to integrate such MIs into routine healthcare. It is therefore critical that these technologies not only meet the requirements and expectations of clinicians who might use them, but that the evidence to support (or refute) their use is robust. Further research is needed to understand the role for clinically relevant MIs to support child-clinician communication.
Multimedia intervention
General practitioner
National Research Register
International Standard Randomised Controlled Trial Number
Body mass index.
Everyone who has contributed to the work has been listed. This review was undertaken as part of self-funded Ph.D. study.
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- Bartholomew LK, Gold RS, Parcel GS, Czyzewski DI, Sockrider MM, Fernandez M, Shegog R, Swank P: Watch, discover, think, and act: evaluation of computer-assisted instruction to improve asthma self-management in inner-city children. Patient Educ Couns. 2000, 39 (2-3): 269-280. 10.1016/S0738-3991(99)00046-4.View ArticlePubMedGoogle Scholar
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- Dragone MA, Bush PJ, Jones JK, Bearison DJ, Kamani S: Development and evaluation of an interactive CD-ROM for children with leukemia and their families. Patient Educ Couns. 2002, 46 (4): 297-307. 10.1016/S0738-3991(01)00166-5.View ArticlePubMedPubMed CentralGoogle Scholar
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- Ritterband LM, Cox DJ, Walker LS, Kovatchev B, McKnight L, Patel K, Borowitz S, Sutphen J: An internet intervention as adjunctive therapy for pediatric encopresis. J Consult Clin Psychol. 2003, 71 (5): 910-917.View ArticlePubMedGoogle Scholar
- Connelly M, Rapoff MA, Thompson N, Connelly W: Headstrong: a pilot study of a CD-ROM intervention for recurrent pediatric headache. J Pediatr Psychol. 2006, 7: 737-747.Google Scholar
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- Krishna S, Francisco B, Boren SA, Balas EA: Evaluation of a web-based interactive multimedia pediatric asthma education program. J Am Med Inform Assoc. 2000, 1055-1055.Google Scholar
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- Parcel GS, Meyer MP: Development of an instrument to measure children's health locus of control. Health Educ Behav. 1978, 6 (1): 149-159. 10.1177/109019817800600106.View ArticleGoogle Scholar
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- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6947/14/8/prepub
Pre-publication history
This article is published under license to BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.


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Blanche Willis Howard
Blanche Willis Howard (July 20, 1847 – October 7, 1898) (aka Blanche Willis Howard von Teuffel) was a best-selling American novelist who lived most of her productive years in southern Germany.
She was born and raised in Bangor, Maine and, after graduating from Bangor High School, spent a further year of schooling in New York City. She then lived for a year in Chicago with her sister Marion Howard Smith, who was married to Benjamin Fuller Smith, a son of former Maine Governor Samuel Emerson Smith.[1]
Howard's breakthrough novel was One Summer (Boston, 1875), set in the coastal town of Wiscasset, Maine. An 1877 edition of One Summer was illustrated by Augustin Hoppin.
In 1875, Howard went to Europe, having received an assignment from the Boston Evening Transcript for a series of articles. Her articles were published in the travelogue One Year Abroad (Boston, 1877). Howard settled in Stuttgart, Germany and continued to write novels, short fiction, poems, and essays. For two years, she was editor of Hallberger's Illustrated, an English-language magazine first edited by the German poet Ferdinand Freiligrath. To supplement her income, Howard supervised the European education of American girls in Stuttgart. Among her students were the three daughters of the actor Lawrence Barrett and the two daughters of Harriet Hubbard Ayer, founder of the cosmetics and patent medicine company Recamier Manufacturing. In 1890, Howard married Baron Julius von Teuffel, a court physician to King Charles I of Württemberg, thereby becoming the Baroness von Teuffel. She died in Munich in 1898.[2][3][4]
Howard's publications, some of which were translated into European languages, include:
- One Summer (Boston: James R. Osgood, 1875).
- One Year Abroad (Boston: James R. Osgood, 1877).
- Aunt Serena (Boston: James R. Osgood, 1877).
- Guenn: A Wave on the Breton Coast (Boston: James R. Osgood, 1884).
- Aulnay Tower (Boston: Ticknor & Company, 1885).
- Tony, the Maid: A Novelette (New York: Harper and Brothers, 1887).
- The Open Door (Boston: Houghton Mifflin, 1889).
- A Battle and a Boy: A Story for Young People (New York: Tait, Sons, and Co., 1892).
- A Fellowe and His Wife (Boston: Houghton Mifflin, 1893), authored with William Sharp.
- No Heroes: A Story for Boys (Boston: Houghton Mifflin, 1893).
- Seven on the Highway (Boston: Houghton Mifflin, 1897).
- Dionysius, the Weaver's Heart's Dearest (New York: Charles Scribner's Sons, 1899).
- The Garden of Eden (New York: Charles Scribner's Sons, 1900).[5]
Howard was one of only a handful of American novelists of this era to write from abroad, the iconic example being Henry James.
Howard was an accomplished pianist and Franz Liszt is said to have complemented her playing following a performance.[6]
- ^ Gustafson, Melanie (2010). "Legacy Profile: Blanche Willis Howard". Legacy: A Journal of American Women Writers. Retrieved October 16, 2015.
- ^ "Obituary notice". The New York Times. October 10, 1898. Retrieved June 19, 2010.
- ^ Dunbar, Olivia Howard (July 16, 1898). "Authors at Home, XXXI: Blanche Willis Howard in Dresden". The New York Times. Retrieved June 19, 2010.
- ^ "Blanche Willis Howard Married" ("From the Bangor (Me.) Commercial, Aug.4"). The New York Times. August 10, 1890. Retrieved June 19, 2010.
- ^ "Blanche Willis Howard (1847 - 1898)". Maine Writer's Index. Waterboro (ME) Public Library. June 6, 2007. Retrieved June 19, 2010.
- ^ James, Edward T., ed. (c. 1971). "Howard, Blanche Willis". Notable American Women: A Biographical Dictionary 1607-1950. II: G-O. James, Janet Wilson; Boyer, Paul S. Cambridge, MA: The Belknap Press of Harvard University Press. pp. 223–224. ISBN 0-674-62734-2.

subset: commoncrawl


text:
- Explore community
- Identify
- Help
Ui plant TW.. 29 Jun 2012 p1
Observed: 29th June 2012 By: Shadow30
Added: 5th September 2012
Other observations of Herb-Robert (Geranium robertianum)
Species with which Herb-Robert (Geranium robertianum) interacts
which plant was intended?
5 September 2012 - 1:40pm lavateraguy
The herb robert, or the rosette of leaves.
Only one person knows
But it wasn't stated, I think it was a fair assumption to ID the flower as it is the central feature.
Chris Brooks - www.dragonfly-images.co.uk
My Flickr site - www.flickr.com/photos/ceb1298
Which plant?
5 September 2012 - 4:19pm Shadow30
The Herb Robert, but rosette of leaves would be nice too (:-)


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German Foreign Policy - An Overview
The primary goal of German foreign policy is to preserve peace and security in the world. The expanded concept of security covers not only questions of conflict prevention, defense, disarmament and arms controls, but also economic, ecological and social issues as well as human rights. This includes a committed effort on behalf of human rights world-wide and a global economy that creates opportunities for everyone, of fostering cross-border environmental protection and an open dialog between the cultures.
Central Topics
Globalization has increased the interconnectedness of peoples and countries — the impact of political decisions and economic and social developments is increasingly felt in faraway lands. Efforts to cooperate rather than confront are important to Germany.
Regional Focuses
Cross-national themes in German foreign policy, including the Middle East Peace Process, the Western Balkans and Transatlantic Relations, as well as global hotspots like Afghanistan are presented here.
International Law
Together with its European and transatlantic partners, Germany is deeply committed to the causes of democracy, development and human rights. One key component in achieving these goals is the protection of and adherence to international law.
International Organizations
German foreign policy is a policy for peace. This principle is a central part of all the activities of the Federal Foreign Office. Specific examples include Germany's engagement in the United Nations and the OSCE, in the areas of global disarmament and crisis prevention.


text:
Kataryna Wolczuk
Kataryna Wolczuk is reader in Politics and International Studies at the Centre for Russian, European and Eurasian Studies (CREES), University of Birmingham. She holds an MA in Law from the University of Gdansk, Poland, an MSocSc and a PhD from University of Birmingham. She has been a director and deputy director of CREES and has had academic positions at University of Florence (Italy), Uppsala University (Sweden) and University of Lucerne (Switzerland). She has extensive experience of working with international organizations, think-tanks, governments and international media and has travelled extensively to the post-Soviet countries. She frequently contributes to conferences and events related to the Eastern Partnership, Eurasian integration as well as Ukrainian domestic and foreign policies.
- Relations between the EU and the post-Soviet states
- EU's policy in the Eastern neighbourhood
- The Eurasian Economic Union and its implications for EU's eastern policy
- Politics of Ukraine
|Senior Lecturer/Reader, University of Birmingham
|Jean Monnet Fellow, European University Institute Florence
|Research Associate, University of Birmingham
Broadcast experience
Extensive experience with UK and international media
- Polish – broadcast standard
- Ukrainian – broadcast standard
- Russian – not for broadcast
- EU Must Be Bolder in Driving Reform in Ukraine 12 April 2017
- No Economic Bright Spot in Tensions Between the EU, Ukraine and Russia 17 December 2015
- R. Dragneva & K. Wolczuk, Ukraine between the EU and Russia: The Integration Challenge (Basingstoke, 2015)
- R. Dragneva and K.Wolczuk (eds) Eurasian Economic Integration: Law, Policy, and Politics (Chelthenham, 2013)
- L. Delcour & K. Wolczuk 'Spoiler or facilitator of democratization?: Russia's role in Georgia and Ukraine', Democratization, 22(3), 2015
- R. Dragneva and K.Wolczuk 'The EU-Ukraine Association Agreement and the Challenges of Inter-regionalism', Review of Central and East European Law, 39 (3-4), 2014
- R. Dragneva and K.Wolczuk 'Trade and Geopolitics: should the EU engage with the Eurasian Economic Union', Policy Brief, European Policy Centre, Brussels, April 2015


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Star Nigerian actress Tonto Dikeh has written a lovely tribute to arguably Nigeria's biggest actress Genevieve Nnaji. The actress/singer made Genevieve her woman crush on Instagram (#wcw) today, April 8, 2015.
"I call her Aunty Gene not cos of her Age, But her Strength** @genevievennaji #by your strength I respect u" wrote the sometimes controversial actress while posting an accompanying photo of the actress tagged as the 'Julia Roberts of Africa'.
Do You Think Tonto Dikeh is Right ??


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As many people may or may not know, #LUBMMA has for many years been a 100% Non Profit advocate for increasing MMA athlete pay (and more recently WMMA).
We have sponsored athletes and promotions from the UFC, Bellator, InvictaFC across to regional circuits around the world in an attempt to help subsidize athletes pay.
After a while however the very small group of people tirelessly contributing their own funds to the cause, began to realize the issue was simply to large to just throw money at, especially once the Reebok deal with the UFC came into play.
Even with the amazing support we have in the community who "get it" and have helped in our mission, by spreading our message and awareness for making a better MMA future through our work…
So we began and have found better ways in addition to our normal sponsorship routes to help by creating community projects involving fighters, other sponsors, promotions, managers and fans, and pushing athletes on social platforms where we can to raise their profiles within the MMA community with the help of all of the above mentioned parties. (This in turn raises their pay as their profile is raised).
We also now produce many behind the scenes assistance projects, and take on others on requests, which are not in the public eye but still carry our same mission statement. (keeping in mind we still run a very small team)
So in order to maximize many of our new projects we have partnered with multiple other groups. And due to this, although we run the daily BAU, and have now made an automated 'choose your news' site like a flip board or apple reader style format to cover all mma content and free up a lot of staff time.
We still felt it better to rename our website to a neutral name so that the "HUB" did not feel like anyone was in charge of any particular project that may fall under its banner in the process down the line. ie. a FighterDojo project may have more than one party involved beyond LUB-MMA.
After all, the whole point of what we do is about #COMMUNITYUNITY and helping ANYONE in the MMA industry. #MMAUNITY.
It's not for us, we don't sell or produce any thing to purchase! We literally give away money and our time for free.
So while we will definitely keep our LUB-MMA brand as its well recognized and trusted.
And a lot of effort has gone into making it something people are proud of over the years. At the end of the day, the work is the most important part, and speaks more than any logo or image seen on an athlete… hence the DoJo for group projects!
So if you think there is a project that we can assist with that's going to help make mma/wmma better somehow , simply let us know and we will always be interested in taking a look and seeing how we can help pitch in and play our part!
Enjoy the fights everyone, and fight prepared and safe!


text:
Rapid Insure is an independent and privately owned UK based insurance business. We specialise in providing flexible home insurance solutions for UK residents with high quality service and a personal touch.
We see our customers as individuals with individual needs, which is why we provide flexible home insurance solutions.
To enable our customers to get the home insurance cover they need, without paying for cover that they don't need our home insurance includes our standard building and contents cover, with the flexibility to add the following additional cover if it is required.
Rapidinsure.co.uk Ltd is an appointed representative of ITC Compliance Limited which is authorised and regulated by the Financial Conduct Authority and whose Firm number is 313486.
Rapidinsure .co.uk Limited is also registered and their Firm number is 416343
You can check our details by entering our firm number on the Financial Conduct Authority website.
Our Home Insurance is Covered by the Financial Services Compensation Scheme
All of the home insurance policies we sell are covered by the Financial Services Compensation scheme. This means that in the unlikely event that the underwriter was unable to meet its liabilities to you compensation may be available.
For more information about the Financial Services Compensation Scheme visit www.fscs.org.uk
A Personal Approach to home insurance and Unrivalled Customer Service
We are a small, professional team who pride ourselves on an unrivalled level of customer service.


text:
web app trivia game using mean stack 60%done rest to be done in 12 hours
This project received 11 bids from talented freelancers with an average bid price of $577 USD.Get free quotes for a project like this
Project Budget$30 - $250 USD
Total Bids11
Project Description
web app trivia game using mean stack 60%done rest to be done in 12 hours , needs to handles routes between client and server and implement some functionality which are not done
Skills Required
Looking to make some money?
- Set your budget and the timeframe
- Outline your proposal
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- Forbes
- The New York Times
- Time
- Wall Street Journal
- Times Online


text:
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Virginia & Truckee Railroad Company, Inc.
Queen of the Short Lines
Virginia & Truckee Historical Societies
Virginia & Truckee Railroad Historical Society
Virginia City Visitor Information
V&T History
UNR V&T Papers Collection
Kent Kristiansson's V&T History Site
UCB Bancroft Library V&T Papers Collection
CA State RR Museum Library V&T Papers Collection M97
Online Nevada V&T History Site
National Park Service V&T History Site
Wikipedia V&T Page
Don Bush's V&T History
RailsWest V&T History
DAR Nevada V&T History
Virginia City Historic District
Virginia City Historic District
Piper's Opera House
4th Ward School
Storey County Courthouse
Mark Twain's Territorial Enterprise
Mackey Mansion
Chollar Mansion
Silver Terrace Cemeteries
Historic Gold Hill
Regional Visitor Information
Reno/Tahoe Territory
Nevada Commission On Tourism
America's Adventure Place
Carson City Visitors Bureau
Lake Tahoe Visitors Authority
North Lake Tahoe Visitors Bureau
Reno-Sparks Convention and Visitors Authority
Carson City Chamber of Commerce
South Lake Tahoe Lodging association
Nevada Roads
Regional Railroad Heritage Sites
NV State RR Museum – Carson City, NV
CA State RR Museum – Sacramento. CA
Comstock History Center – Virginia City, NV
Feather River RR Museum – Portola, CA
Sparks Heritage Museum – Sparks, NV
Nevada Northern RR Museum – Ely, NV
Gold Hill Historical Society – Gold Hill, NV
Nevada Film Office
David Walley's Hot Springs Resort
Lerro Productions Images / Painting
West Coast Railroaders Group — the people who provide the fire patrols behind V&T trains!
Tourist Railways & Museums
Chehalis Centralia RR
Niles Canyon Railway
Australian Rwy Historical Society
Living Steam
Train Arts
Golden Gate RR Museum
Pacific Southwest RR Museum
Poway Midland RR
Redwood Valley Rwy
Roots of Motive Power
Tourism and Events
American Rails
Train Traveling
Rail Travel Center
Nevada Travel
Vacations by Rail
Nevada Day Trips
Project Discovery
Road Trip America
US Coachways, Inc.
Bently BioFuels
The V&T Railroad offers daily scenic, narrated steam and diesel train rides winding through the hills of the Comstock from Virginia City to Gold Hill and back, where, during the Big Bonanza in the 1870's, miners worked one of the richest deposits of silver and gold ever found. This shaped mining throughout the world over the next 50 years.
The Virginia & Truckee is by far the most famous of all American short lines and was brought back to life by Robert C. Gray in 1976, who was one of the passengers on the last train to Virginia City in 1938. Today the V&T is 140 years old and still steaming for you to relive the days of gold and silver mining on the Comstock.
The V&T family wishes you and your families a happy and prosperous year. We invite you to peruse our website and check out what's in store for 2017. See you soon!
For more events and V&T's special event theme trains in Virginia City, please see our 2017 schedule here!
—Donna McNeeley
Mobile, Ala.
Watch the video:


text:
Track & field
Friday, February 24, 2017
The NAIA announced the official qualifiers for the 2017 Indoor Track and Field Championship earlier today. The 52nd annual men's and 37th annual women's events will take place next week, March 2-4, in Johnson City, Tenn.
Northwestern College will send 17 athletes to compete in 10 events, seven individual and three relays. Rebekah Muilenburg (600m), Katie Landhuis (800) and Katie Bosch (1000m) will compete individually for the women's team and will also be part of the 4x800 relay, joining Bre Harthoorn and Kylie Van't Hul.
For the men's team, Aaron Lemon (600m), Peter Hollinger (800m), Tim Rose (Mile), along with Jordan Strand and Calvin Korver (Heptathlon), will compete as individuals. Two relays, the 4x800 and Distance Medley, will also compete on the national stage. The 4x800 could consist of; Bryce Nitzsche, Caleb Benzing, Sean Crowell, Hans Epp, Peter Hollinger, Tim Rose, Tanner Goetsch and Aaron Lemon. The distance medley will be a combination of Rose, Hollinger, Goetsch, Lemon, Benzing, Epp, Levi TeBrink and Austin Krier.
The championships will get underway at noon on Thursday, March 2 at noon.
Women's Qualifiers by Event | Women's Qualifiers by School
Men's Qualifiers by Event | Men's Qualifiers by School
Senior from Vermillion, S.D.
Senior from Sioux Falls, S.D.
Middle Distance/Distance
Junior from Ankeny, Iowa
Junior from Giltner, Iowa
Junior from Spirit Lake, Iowa
Middle Distance
Junior from Orange City, Iowa
Junior from Mitchell, S.D.
Junior from Iowa Falls, Iowa
Junior from Le Mars, Iowa
Sophomore from Gilman, Iowa
Sophomore from Algona, Iowa
Sophomore from Orange City, Iowa
Freshman from Poulsbo, Wash.
Freshman from Orange City, Iowa
Junior from Lincoln, Neb.


text:
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Bus Mielec Podkarpackie Voivodeship » Frederikshavn
Coach and bus timetable from Mielec to Frederikshavn
Mielec to Frederikshavn timetables
Mielec - Frederikshavn route is supported by Agat.
More bus tickets for travels between Mielec and cities in Denmark are available at Mielec - Denmark offer. You can also buy your return ticket at Frederikshavn to Mielec or Frederikshavn to other cities in Poland.
Information about Mielec to Frederikshavn travel is available at Mielec news or Frederikshavn news and FAQ.
Pick the best offer at rebrutto.com.
NewsCheap online tickets from Amsterdam and to Amsterdam
Low cost fares! Discounts! 22/2/2017Becker Reisen • new cities in Denmark
Frederikshavn, Aalborg and Randers wil appear in Denmark timetable from 1 June 2015. 27/5/2015Marolines • additional services to and from Denmark
Marolines launches additional services on Poland » Denmark » Poland route. 27/3/2015All Mielec news 1 »All Frederikshavn news 2 »


text:
Business TypeTrading Company, Distributor/Wholesaler
Main Markets
Business Owner
EmployeesLess than 5 People
RegionTrinidad and Tobago
CategoryConsumer Electronics - MP4 Players
Company TagsArkad Enterprises - Arkad Enterprises Arkad
Company Introduction
Arkad Enterprises is located in trinidad and tobago, we are the electronics supplier.
Contact Information
Contact PersonMr. carl benjamin
Fax Number1-868
Post Code868
Addressbonair west, port of Spain, arouca, Trinidad and Tobago
Online MapArkad Enterprises Map & Directions


text:
The new entry presents a welcoming face to Rodeph Sholom Lower School, receiving the school community and providing neighbors with a lens into the life of the building. A steel awning shelters the entry and frames the new library and art room on the floor above. A limestone-clad wall at the sidewalk level references the limestone Congregation Rodeph Sholom Temple on the opposite side of the block. The choreographed sequence of spaces from the entry to the admissions office is designed as a brief tour, displaying the pedagogy and values of the institution to visitors.
Photography: ©Charles De Vaivre


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The Truth Behind Oil Subsidies
It's easy to take shots at oil companies, especially when gas prices are rising over $4 per gallon. Playing the role of David against an enormous corporate Goliath is a great way to score political points, so it's no wonder that President Barack Obama and liberals in Congress have issued a clarion call for the end to oil subsidies as a way of wreaking revenge against those they say are responsible for the high cost of energy.
The truth, though, isn't as simple as the good-versus evil fable the left would have you believe.
On Wednesday, five Democratic U.S. senators sent a letter to the CEOs of the country's five largest oil companies declaring, "[I]f we are truly serious about cutting our deficit, it is imperative that we start by getting rid of wasteful and ineffective corporate subsidies that have outlived their usefulness."
The left's anti-subsidy rhetoric is right on. Ending all energy subsidies, including those for oil and gas, would be good for American taxpayers and consumers. But if those senators were truly serious about cutting the deficit, they wouldn't stop at just cutting subsidies for oil companies. They would also call for the elimination of subsidies for the president's pet projects such as renewable fuels, electric vehicles, wind and solar. Throw in clean coal and natural gas, too. That would be the right move for the American taxpayers. But good policy isn't their goal – vilifying an industry is their end game.
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