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Access to health services is an important health determinant. New research in health equity is required, especially amongst economic migrants from developing countries. Studies conducted on the use of health services by migrant populations highlight existing gaps in understanding which factors affect access to these services from a qualitative perspective. We aim to describe the views of the migrants regarding barriers and determinants of access to health services in the international literature (1997–2011).
A systematic review was conducted for Qualitative research papers (English/Spanish) published in 13 electronic databases. A selection of articles that accomplished the inclusion criteria and a quality evaluation of the studies were carried out. The findings of the selected studies were synthesised by means of metasynthesis using different analysis categories according to Andersen's conceptual framework of access and use of health services and by incorporating other emergent categories.
We located 3,025 titles, 36 studies achieved the inclusion criteria. After quality evaluation, 28 articles were definitively synthesised. 12 studies (46.2%) were carried out in the U.S and 11 studies (42.3%) dealt with primary care services. The participating population varied depending mainly on type of host country. Barriers were described, such as the lack of communication between health services providers and migrants, due to idiomatic difficulties and cultural differences. Other barriers were linked to the economic system, the health service characteristics and the legislation in each country. This situation has consequences for the lack of health control by migrants and their social vulnerability.
Economic migrants faced individual and structural barriers to the health services in host countries, especially those with undocumented situation and those experimented idiomatic difficulties. Strategies to improve the structures of health systems and social policies are needed.
Health care; Health services accessibility; Emigrants and immigrants; Systematic review; Qualitative research; MetasynthesisBackground
Health has been recognised as a fundamental human right, regardless of sex, political affiliation, social class or ethnicity, as well as the right to minimum conditions of wellbeing, including the provision of medical care and public services for all people [1]. International organisations as United Nations highlight how important it is to ensure these rights, and call for such inequalities to be addressed by identifying their determinants [2]. Reforms in the political and social systems of many countries have also had an impact both on how health systems are organised and on health service user profiles and access [3].
Access to health services is considered a determinant of health inequalities [4]. In terms of the provision of such services, Tudor-Hart's inverse care law [5] identified that population groups with the highest health needs -the most deprived and vulnerable groups in society- tended to receive the least health care provision, whilst those with the least health need -the most affluent and advantaged societal groups- received the most health care. In relation to access to, and use of, health services, conceptual frameworks have been developed, such as that of Andersen [6-8], which stress that access to health services should be analysed from the perspective of health policy objectives, the characteristics of the health system, and the results obtained: input (factors affecting service use) and output (health status and health behaviours). Tanahashi in 1978 [9] proposed a schematic model of health service coverage and utilization, and outline several aspects related to the utilization of health services in terms of the interaction between specific aspects of service provision (service capacity) and the characteristics of the target population (service target).
It is well known that poor health is disproportionately experienced by those on the margins of society and living in disadvantaged socio-economic condition and migrants are represented amongst these groups [10]. Although international migrations are highly heterogeneous, they occur mainly for economic reasons [11]. Economic migrants are defined as people of working age (16–65 years), born outside the country in which they are employed or are residing -either permanently or for an extended period of time. They come from developing countries (Latin-America, Eastern Europe, Africa and Asia) [12]. Research has emphasized that before arrival, migrant populations are characterised by a good state of health but this is often eroded by the migratory process itself and by the living and working conditions experienced in the host country [13].
Studies have been conducted on the use of health services by migrant populations and ethnic minority groups and highlight existing gaps in understanding which factors affect access to these services, by focusing upon structural and individual factors [14-16]. Such studies have sought to formulate propositions that will help to improve communication between service provider and user, thereby enabling the development of effective social and health policies. Of increasing importance is the use of qualitative research in public health studies, in order to capture the subjective experience and individuals' perceptions of their own health, in order to understand how determinants influence the relationship between migrants and health, and to identify causes for existing inequalities between migrant and non-migrant groups [17]. Accordingly, the present review and analysis of the scientific literature has included methodologies to evaluate qualitative studies and draw together the findings, through metasynthesis [18]. As such, this systematic review seeks to describe economic migrants' views of barriers and determinants to health services' accessibility by identifying, evaluating and synthesising qualitative research that relates to the experience of access to health services by economic migrant populations within the period 1997–2011.
An international systematic review was carried out of to identify all qualitative studies whose primary focus was to illuminate the barriers and determinants of health services accessibility amongst economic migrants. The search covered the time period January 1997 to November 2011. In the choice of this period were taken into account factors: 1) some countries since the nineteenth century had greatest migratory tradition, like the U.S., Canada, New Zealand or Argentina (which are called classic immigration countries). However, in the territory the influx of European immigrants is much later [19]. For example, between 1998 and 2007, the migrant worker population in European OECD (Organisation for Economic Co-operation and Development) countries increased significantly, from 3.5 to almost 6 million workers [20,21]; 2) it is important to consider population movement linked to the massive social upheavals and significant world economic conditions and migration created by world events beginning in 1997, such as European, Eastern Block changes, the opening up of China's boundaries and changes to migration policies in a number of developed countries [22]; 3) after an initial search in databases, a list of potential papers for the systematic review were found in the decade of 90's. For that means, the research team decided to establish the point cut for beginning the systematic search in 1997 based on current scientific criteria.
Inclusion and exclusion criteria
The review sought to identify all qualitative research studies related to health services accessibility by economic migrants (based upon phenomenology, ethnography, grounded theory, ethnomethodology, phenomenography and critical, interpretative or feminist analyses). These had to be focused on at least one of three aspects: barriers, conditioning and facilitator factors, and the impact of health services as a determinant of migrants' health. The review considered studies that included economic migrants. We excluded studies with populations of migrants coming from developed countries, tourists, students and relatives of those economic migrants who constitute a separate category (family class/reunification) with different health statuses and behaviours.
Search strategy and data extraction
The initial search included Medline and CINAHL to identify text words contained in the title and the abstract as well as classify the appropriate descriptor/MeSH terms to be used. The next step used identified keywords and index terms in 13 electronic databases in Health and Social Sciences (see Table 1).
Table 1. Summary of the search strategy used for the systematic review
We located 3,025 potentially relevant papers and 120 (4.0%) of these were selected on title and abstract by the lead reviewer. This process was checked by a second reviewer. The full text of these papers was then reviewed and subsequently, after a first reading and application of inclusion/exclusion criteria, 35 (1.2%) studies were selected for critical appraisal. The decision of excluding 85 papers is based on different characteristics related mainly with the topic of the studies that are not related with barriers to accessibility to health services, for example: studies conducted in no-economic migrants, studies based in health providers' perspectives [23], studies in other topics such as: gender violence [24], other health determinants [25,26], health practices [27], culture and health [28], health knowledge [29] and recommendations for community-based strategies [30]. Two reviewers of the research team appraised papers independently. The process of complete data extraction is explained in Figure 1.
Figure 1. Exclusion and inclusion scheme.
Critical appraisal and studies' analysis
Appraisal of included papers for methodological quality was undertaken using a critical appraisal checklist and data extraction form for interpretive and critical research [31] (Table 2). Any disagreements that arose between reviewers were resolved through discussion with at least one other member of the research team and we discarded 8 papers [32-39]. The 27 (0.9%) selected articles were those satisfying at least 75% of the checklist of the critical appraisal [40-66].
The review followed the principles of meta-synthesis [67-70]. This process involved the aggregation of findings and categories to generate a set of synthesised statements that represented aggregation through categorisation of findings related in meaning. Initially, manual analysis was performed to identify categories related with accessibility to health services through several readings of the papers. Subsequently, data were entered into the JBI QARI software, which is designed to manage the synthesis of textual data as part of a systematic review of evidence [71]. Several triangulation strategies were employed to improve the quality of the data and conclusions; by source (the different migrant collectives studied and different health systems/welfare systems), different methodologies in the papers analysed, different conceptual frameworks and discussion by the research team. We identified from the papers the following information: First author (year), setting, data collection, participants, data analysis, services referred in the study, barriers to and determinants of access to health services for the migrant population, inputs and outputs in the access to health services and facilitative conditions and strategies for overcoming barriers. The extracted information of the studies are presented in different analysis categories following the Andersen's conceptual framework of access to, and use of, health services, the categories related with other studies conducted in migrants and new categories emerging from the different discourses extracted from the papers. All the advances of the process of this systematic review were discussed in academic meetings for the research team in other to guarantee the quality of the information and this paper has been elaborated considering the PRISMA guidelines for reporting systematic reviews [72].
Table 3 and Table 4 show the general characteristics of the studies considered in the metasynthesis. 12 studies (44.4%) were carried out in the U.S [40-51] and 6 (22.2%) in Canada [54-59]. 12 studies (44.4%) dealt with primary care services [40-45,52,56,59,63-65]. The participating population varied depending mainly on type of host country. The studies carried out in the USA focused mainly on the Latino population [40-43,45,48,49,51], two with Asian migrants [44,47] and Muslim population [46] with one specific study focusing on the indigenous population from one state in Mexico [50]. In case of other countries, some studies carried out in Australia, Canada and New Zealand are focused on Asian population [53-57,64]. Studies in Israel focused on Russian, Ethiopian and Arab migrants [60-62]. One study in Australia deals with a population from Brazil [52], and one study in Canada also included Romanian migrants [57]. One study carried out in Spain was explicit in mentioning the economic migrant population from five regions: the Maghreb, Sub-Saharan Africa, Asia, Latin America and Eastern Europe [65]; the other Spanish study was focused on Ecuadorian population living in Barcelona [66].
Table 3. Characteristics of the studies included in the review
Table 4. Characteristics of the studies included in the review
Figure 2 shows the summary of studies showing the identified barriers from the point of view of economic migrant and the elements that determine this access. In general terms, factors such as the knowledge of the health system in the host country, the health status or Migrants' own beliefs/knowledge about health are previous characteristics (inputs) and could constitute social determinants, previous to the utilization of health services in economic migrants. Secondly, migrants identified barriers that could be classified in those related with the structure or the social security/health system in the host country such as: economic barriers (cost of services), health services and insurance coverage, privatization of the services, and other related with the attitude and communicative abilities to the provider (health personnel) and barriers that belong to the migrant condition (language skills, cultural competence, religion). Discrimination appeared as an important social determinant of health services accessibility related with individual and structural characteristics. Lastly, the low/lack of utilization of health services could affect negatively the health profile of the economic migrants and caused the searching of alternative ways to improve their health (alternative medicine, self-medication).
Figure 2. Barriers and determinants in health care access from the migrants' perspective*. * Summary of the results of the articles included in the metasynthesis.
The results and implications from the different studies are deeply presented below.
Barriers to and determinants of access to health services for the migrant population
First of all, the studies identify barriers based on factors operating at three different levels: firstly, the structural/political level (i.e. cultural, policy and resource considerations that determine the scale and configuration of services); secondly, the institutional factors (i.e. factors relating to service organisation and delivery) and the individual factors (i.e. the characteristics of migrants themselves and service providers, including socio-demographic characteristics, knowledge, communication skills and motivation).
In terms of the structural/political level, studies identified a range of obstacles, including the lack of coverage in health and social security programme, health insurance, or in some cases being unable to access private insurance due to a lack of resources and health service costs [40,44,46,48,49,52,57,64].
Also, elements were identified relating to the impact of social and economic policies on the privatisation of health services [52]; the lack of clarity in immigration legislation that hinders health care is also considered important [65].
Finally, the documented status (legal or illegal) of migrants in the host country affects their use of health services, restricts service availability and system coverage and insurance, and access to private health insurance [45,48,50,55,56,66].
With respect to the organisational factors, the characteristics of health care services, in terms of availability of human resources [57], interpreters and cultural mediators [47,48,62], opening hours and availability of medical and dental services [40], the lack of information about different programmes and services [51,63,66], and the perceived quality of the services provided [42,54] were all determinants of use health services amongst migrants taking part in the various studies analysed. In addition, geographical barriers and transport difficulties due to the location of health services with regard to their places of residence and work were also identified [47,48,57,64,66].
Individual factors constituted the third main type of obstacle that acted to exclude migrants from health services. Thus, a lack of social support networks left participants in a vulnerable and isolated situation in their communities and in the host country, with consequent impact upon health service use [51,52]. Elsewhere, studies reported barriers resulting from cultural aspects to do with belonging to a particular ethnic group [40,41,54,56,57,59,62], or for having a particular nationality or country of origin, religion [46] or sex [61]. In some cases, participants expressed feelings of inferiority in the health system of the host country or of not feeling welcome [51].
Further, many of the studies also identified language barriers [42,45,48-53,56,57,61,64] that hinder communication between service provider and patient, which led to feelings of insecurity among migrants [66].
Finally, discrimination in the health services from being an migrant, or for one's sexual condition [43], by institutions themselves and resulting from health care workers' attitudes [42,48,52-55,60,62-64], are a determinant that influences health practices and the utilisation of health services, and lead to feelings of mistrust by migrants towards organisations and health professionals [40,52].
Inputs and outputs in the access to health services
Inputs in access to health services refer to the information and characteristics that have an influence, as external determinants, on the barriers experienced by migrants. The qualitative studies identified elements such as prior attitudes and opinions regarding health services [41,57], beliefs, knowledge, values and attitudes about health [44,45,57,58,63,64], and the priority of health over other aspects relating to social and living conditions, or over legalising their current situation [40,45,50,65]. The degree of knowledge about the health system in the host country is also an influence [46,47,53,63,64,66].
Outputs refer to the implications of the determinants and barriers to migrants accessing health services, which affect their negative perception or lack of control over their health [49,52] and their feelings of social vulnerability [61]. The migrant population uses "alternative support ways" when they do not receive care from the health services. These support ways include using traditional Eastern medicine [55,56] home-made remedies [45,49] and self-medication [51] as well as obtaining health care in their countries of origin [51]. In this last aspect, migrants make a comparison between health systems, establishing that the treatment they receive from health professionals is better in their country of origin, and that the costs and the technology are higher in the host country [48,52,58,64].
Facilitative conditions
Some facilitative conditions and strategies "to overcome barriers" were found in the studies analysed. For example, recommendations are made by the participants in the studies, who recognise the role that support institutions and social networks play [47,51,66] in improving certain social and health conditions, as well as the contribution made by community organisations and health teams, which work in different neighbourhoods delivering education and health-promotion campaigns [45,47]. They also recognise family support as fundamental for making decisions and receiving health care [49,62]. Where language difficulties exist, relatives act as translators [51,62]. Preferences were also identified for professionals that speak the same language as the migrants [41]. Other recommendations for the health systems and health services are regarding strategies involving flexible payment for services provided [51]. Some studies identify positive aspects in health plans and services -such as for the obstetric population- [51] and the technical quality of health professionals [49,54]. One study revealed that migrants improved their health situation because of improvement of living standards in comparison to the origin country [58].
With the results of this review it was possible to consider the obstacles that economic migrants face when accessing health services, by using the participants' discourse to define a typology of barriers that encompass structural/political, organisational and individual factors [6-8]. Thus, macro-level social and economic policies, including immigration policies and the privatisation of health services, influenced the availability and configuration of health services for migrants [9]. Also, the organisation and delivery of health services at a local level, including service opening hours, the geographical siting of services and the availability of translators influenced health service use amongst migrants [15]. In addition, a range of individual factors, residing in the migrants themselves (e.g. socio-demographic characteristics, knowledge and motivation) and in the service providers (e.g. staff attitudes) informed health service use amongst migrants [15].
The studies included were carried out in seven countries (Australia, Canada, USA, Israel, New Zealand, Netherlands and Spain), the first four of which have a longstanding tradition of immigration dating back to the 1980s and the phenomenon is much more recent in New Zealand and Spain [73-76]. This is significant because access barriers must be analysed within the context of the host countries and their reforms concerning to health systems.
According to the overall performance report by the World Health Organization (2000) that compare the health system of the countries [77], Spain was in 7th place in health system performance, Netherlands was 17th, Israel 28th, Canada 30th, Australia 32nd, USA 37th and New Zealand 41st. This includes factors such as general level of health, response capacity and how financial contributions are spread. For economic migrants, inequalities in access to health services would be explained not only by their socioeconomic level [78] but also by factors relating to the countries' overall policies and strategies [77].
Many of the studies were carried out in the USA, where the health system is run by various private entities, and operates different health programmes that vary by State. In this regard, the US literature reports that 15% of the population have no insurance [79] and structural barriers exist that lead to inequalities in care among vulnerable collectives, such as the lack of a regular health care resource, a lack of funding, and geographic barriers [14,16,80].
The Canadian health system, meanwhile, is universal and is both publicly and privately financed [81]. However, access barriers exist due to the length of time one must spend as a resident in the country in order to access health care services, the complexity of the system [82] and the high cost of private insurance services [83], and the reduction of economic benefits [23]. Australia has a universal public insurance system, but the studies show difficulties in terms of access to programmes and services for the undocumented (illegal) population [84], and barriers relating to service cost [36]. New Zealand has a mixed system, with public insurance funded through taxation, which does not cover some services, such as dental care -only for children and under 18 s- [85]; some migrants access private services to request a quicker and more timely service in comparison with public services, and for some medical and dental procedures and treatment, with the inconvenience of high costs [86]. In Israel, the insurance system is universal and works with various government institutions [87-89], and the impact of insurance policies (National Health Insurance Law) on minority groups in Israeli society, such as Arabs [61], Ethiopians [62] and Russians [60], has been discussed. Healthcare in the Netherlands is financed by a dual system and several reforms have been carried out [77]. Lastly, in case of Spain, the insurance system is universal and the guarantee of health care in similar conditions to the autochthonous people, nevertheless could exist administrative bureaucratic difficulties affecting the use of health services for instance a lack of knowledge of the Spanish system organization and the different requirements for accessing [90,91].
In general terms, the barriers experienced by the migrant population described in the various studies are in relation to the insurance system of the host country, with differences depending on each country's context. In addition, it is important to take in account the models of social welfare and the capacity of the states to provide welfare services and benefits in social security, health care, housing, education and social services for all people and in case of the present review, for the migrants [92,93].
The barriers expressed by the participants with regard to language difficulties and belonging to different ethnic groups related to the migrants' values system and beliefs within a particular culture [15], as well as the culturalisation processes of groups in the host societies, which hinder proper integration and thus affect how health services are used [94]. In some cases, this means feeling discriminated against by different institutions [95], feeling unaccepted and misunderstood or perceiving a certain attitude towards them by health professionals [15]. Legal status is also a factor contributing to greater vulnerability, due to a precarious social and employment situation, despite the fact that, in some contexts, health care is universal [96,97]. This suggests that health services should adapt to the social and economic context, offering medical attention according to individuals' particular needs and cultural aspects.
Barriers to accessing health services have implications in both the subjective perception of a poor state of health [98] and in the use of alternative health systems to resolve a health need. This situation depends on cultural aspects and on social inequalities between groups, leading to increased social vulnerability [2].
One of the strengths of this review (despite the fact that it deals with heterogeneous studies from different countries) is that this is the first time that findings describing determinants and barriers affecting access to health services have been synthesised in this way, analysing the discourses and perceptions of those directly involved in the process. There is increasing interest in qualitative research in the field of public health [99]. Awareness among the international scientific community should therefore be raised with regard to the importance of recognising participants' discourse as a research objective. There is still certain timidity in qualitative studies, given that they mention sample size and the impossibility of generalising results as limiting factors. Qualitative research does not aim to be statistically representative, but rather as an approach that has proved to be useful in filling "gaps" that are not resolved by quantitative research, in particular examining issues such as understanding and motivation.
This systematic review has limitations that should be highlighted. Although studies were selected by an exhaustive search of scientific and grey literature databases, there may be unpublished reports. The systematic search and the initial process of extracted data was in charge of the review leader, however, the process was supervised for a second reviewer in order to evaluate the accordance of the selected articles for further analysis. We have used an instrument to evaluate the quality of qualitative research, and although this has proven to be effective in other studies, it is important to recognise that evaluating the literature of qualitative studies depends on the subjective evaluation of the researchers, although throughout the process the consensus and agreement among the research group was guaranteed. More information is needed on inequalities access to health care, considering aspects such as gender and social class and further research is needed into strategies that help migrants to minimise the negative effects of access barriers. It seems important to research the impact of health reforms on vulnerable collectives.
Furthermore, it is important to recognise the difficulty in selecting studies dealing with economic migrant populations. This metasynthesis focuses on populations that are migrants for economic and work-related reasons, and the literature is based mainly on belonging to a minority ethnic group in the destination country being a proxy of migrant status, and although they are similar, they are not equivalent [100,101] given that, in the current context, the second or third generations of migrants tend to acquire nationality of the destination country. There are also migrants for political or social reasons, who may have differing characteristics to the economic-type.
The results of the studies analysed are circumscribed by a number of factors including, study design, the characteristics of the populations interviewed and the data-gathering techniques used. These include heterogeneous and variable data analysed with regard to the populations chosen [40]; limiting findings to a particular geographic, social and political context [40,50,57]; difficulty in generalising results by the sample used in the studies -not random-, and by participant selection [41-46,48,49,51,53,55,56,62,64]; and by the characteristics of the qualitative techniques -interview and focus group, among others- [65]; cultural background and language difficulties of participants, which can hinder field work [42,46].
Dealing with social inequalities in the migrant population requires greater knowledge of the social determinants and the relationships that occur within social inequalities, in order to provide health-equality strategies in plans and policies, in terms of health as a universal right [102], a better handling of health care resources, strengthening public and universal health care systems and improving living conditions for vulnerable collectives.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
All the authors contribute with the data analysis, the written of the manuscript and the approbation of the final version to be submitted to the journal.
This project has received funding from the following sources: Carolina Foundation (Spain), Mario Benedetti Foundation of the University of Alicante, Regional Ministry of Education (Generalitat Valenciana) (BEST/2009/003). Healthcare Research Fund of the Spanish Ministry of Health and Social Policy (PI 0790470).
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By Reuven Cohen | Article Rating: |
June 17, 2009 07:30 AM EDT | Reads: |
23,560 |
Well IBM has gone and done it, they've announced a cloud offering yet again. Actually what's interesting about this go, is not that they're getting into the cloud business (again) but instead this time they're serious about it. And like it or not, they're approach actually does kind of make sense for, assuming you're within their target demographic (the large enterprise looking to save a few bucks).
My summary of the "Big Blue Cloud" is as follows: It's not what you can do for the cloud, but what the cloud can do for you. Or simply, it's about the application, duh?
In a statement earlier today in the New York Times, IBM CEO Sam Palmisano said, "The information technology infrastructure is under stress --- and the data flood is just accelerating."
Palmisano isn't alone in this thinking, earlier this week Cisco Systems, the mobile networking giant, released a report suggesting that global Internet traffic is growing exponentially. Scientific American said that Cisco needed a newer term -- zettabyte, or one trillion gigabytes -- to measure both the amount of uploading and downloading traffic on the Web and the bandwidth required to accommodate it. At the heart of IBM's cloud announcement is this forth coming growth in internet usage and the battle to control the flow of information in this new zettabyte age.
More to the point, the Cisco report has a lot of interesting statistics, including the prediction that the Web will nearly quadruple in size over the next four years. Cisco claims that, by 2013, what amounts to 10 billion DVDs will cross the Internet each month. Or to put it another way, it will take over a million years to watch just one month's worth of Web video traffic. The findings point to "consumer hyperactivity" -- that with Web-enabled phones and mobile devices, more powerful computers, and multitasking, growth will only increase. For such a surge in volume, networks must be able to accommodate the growth. Whether the private or public clouds for many companies cloud computing may help solve this problem.
One of IBM customers at the Interior Department's National Business Center, a service center that handles payroll, human relations, financial reporting, contracting services and other computing tasks for dozens of federal agencies spelt out the opportunity. "For us, like other data centers, the volume of data continues to explode," Douglas J. Bourgeois said. "We want to solve some of those problems with cloud computing, so we don't have to build another $20 million data center.
Although not exactly sexy, IBM is hitting at the heart of the opportunity for big businesses looking at getting into cloud computing. First and foremost they're looking to address the issue of security and trust, secondly cost and thirdly massive exponential growth in network / internet based capacity. Turns out a lot of businesses aren't very comfortable handing over their data center and application management infrastructure to some up-start company or bookseller. The old saying "No manager ever got fired to choosing IBM" is as strong as ever. This statement is especially true of cloud computing. (And IBM knows it)
Here are the highlights of IBM's announcement:
- Smart Business Test Cloud — A private cloud behind the client's firewall. Basically IBM is offering to install "private clouds" for companies in-house, behind their firewalls built on a suit of existing IBM software with some IBM magic on top.
- Smart Business Development & Test on the IBM Cloud, a bundle of development and test tools that can be used on IBM's cloud -- a network running on 13 datacenters located around the globe.
- IBM CloudBurst — 42-unit server cabinet that comes preloaded with hardware, storage, virtualization, networking and service management software. Think of this as managed outsourced private cloud housed in an IBM data center.
I will say there are some glaring holes in IBM newly reinvented cloud offering. One in particular is IBM seems to have put together a combination of several existing products, rather then re-imagining the data center, they seem to have found a new way to market what they already had, which I'm not saying is bad, just nothing new. This is in direct contrast to IBM's rivals such as Amazon Web Services, Google and even Microsoft who have managed to create a totally new and integrated stack of cloud components. IBM's hodgepodge approach may be indicative of future acquisitions they may need to make to fully realise there cloud ambitions. (IBM Rightscale or IBM SOASTA CloudTest anyone?) Regardless, this latest move firmly places IBM in the center of the hottest land grab in IT.
Published June 17, 2009 Reads 23,560
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February 20, 2015 11:58 am | by Alicia Chang and John Rogers, AP Science Writers | News | CommentsAn 18-year-old student is struggling to survive after he was infected by a superbug outbreak tied to contaminated medical instruments at a Los Angeles hospital, his attorney said.
Five Winning Pediatric Device Innovators Receive Seed Funds
February 20, 2015 11:51 am | by Children's National Health System | News | Comments$250,000 given to winners at second annual National Capital Consortium for Pediatric Device Innovation (NCC-PDI) Competition.
Clorox Healthcare™ 4% CHG Skin Cleansing Kit
February 20, 2015 11:15 am | by Clorox Healthcare | Product Releases | CommentsThe Clorox Healthcare™ 4% CHG Skin Cleansing Kit is a kit for pre-procedural skin cleansing designed to help improve patient compliance.


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Mark Leftly: Seven reasons to be cheerful, plus Asil Nadir for fun
Just don't worry about the FTSE 100 or talk of double-dip recession – the good times are back
Sunday 29 August 2010
Don't panic. Fears that the US might fall back into recession pushed the FTSE 100 to a seven-week low on Wednesday, but City bigwigs can return from their August holidays at their most optimistic since the pre-credit crunch days of 2006.
Even forgetting that low trading exaggerated the FTSE fall and ignoring the encouraging economic growth data from the Office for National Statistics on Friday, there is compelling anecdotal evidence that the Square Mile is in a confident mood. Here are seven reasons why.
One: M&A mania. BHP's $39bn (£25bn) offer for the extravagantly named Potash Corporation of Saskatchewan is only likely to get higher, while China's growing interest could set up a major takeover battle. Plenty of other deals are in the pipeline and bankers will be licking their lips at the possibility of RSA returning with an improved offer for the best bits of Aviva's general insurance business.
Two: sovereign saviours. Ever since the credit crunch, industries from property to power have been holding out for sovereign wealth fund (SWF) money. They have been disappointed – until now. The $112bn Malaysian Employees Provident fund is scouring Europe for assets and Norway's SWF is about to embark on a shopping spree of London's office landmarks.
Three: dividend dough. Most firms that reported in last week's results bonanza increased their dividend payments to investors. More good news is likely to follow this week.
Four: proper politics. The drawn-out Labour leadership election enters its final month. With the LibDems sacrificing principles for power there has been an opposition vacuum that one of the Miliband brothers will finally fill at the end of next month. Spending cuts were needed, but they are dangerously severe and every government needs a strong opponent to pick holes in even the most well-considered of plans.
Five: lucrative listings. There are some big London share offers in the works. Glencore, the commodities trader, has announced plans to spin off its $5bn gold business and banks are close to being picked for the 2011 flotation of the whole group. Morgan Stanley, Credit Suisse, Bank of America, Merrill Lynch and Citi might all win juicy advisory roles some time next month. North Sea oil group Fairfield and Madame Tussauds owner Merlin Entertainments could revisit flotation plans.
Six: inspiring ideas. The New City Initiative's proposal for regulations to force advisers to disclose whether or not they are investing in assets beside their clients is being taken seriously by the coalition. The City has taken a battering, but is coming back with ideas like these that are demanding – and getting – respect.
Seven: Polly Peck palaver. Asil Nadir, the tycoon who fled to northern Cyprus when his Polly Peck empire failed in1990, is back in the UK, trying to clear his name in court. He's wearing an electronic tag. That has nothing to do with City optimism, but it entertains the hell out of me.
After three long years, it might be time to turn that frown upside down.
Fears of tears? London may miss out on 2012 Olympics
Paula Radcliffe's tears flowed after she missed out on the Olympic crown in Beijing, four years after spectacularly failing in Athens. Remarkably, Radcliffe is likely to have a final run for gold in 2012 at the grand old age of 39.
London itself, though, gets only one crack at Olympic glory, and there is a growing feeling in the City that 2012 will be a golden opportunity missed. Grant Hearn of hotel group Travelodge says there is "no real plan to make the most of the commercial benefits that the Games can offer tourism". He should have gone further: unless there is sufficient buzz around the Games, people will not get behind British athletes and that will hurt UK plc. Besides hotel chains, firms to miss out include pub groups, which will be hoping for beer-guzzling supporters cheering on British medallists, and housebuilders, that want to snaffle buyers keen to live near a historic event.
Few will shed tears for the City failing to make some coin. But it doesn't help anyone if the country's employers don't make money out of a golden opportunity.
Svanberg must take the risk: Goodyear is too good not to be on BP's board
Carl-Henric Svanberg has one hell of a dilemma: keep his job or hire the best. The BP chairman was criticised, not least in this column, for his handling of the Gulf of Mexico oil disaster, and particularly for appearing to fail his embattled chief executive, Tony Hayward. Now, as head of BP's nominations committee, Svanberg must choose two new non-executive directors, and his choice will be telling.
The best businessman on the market is arguably London-based Yank Charles "Chip" Goodyear, the successful former head of BHP Billiton, which he turned into the world's biggest mining company.
Goodyear is looking for executive work. As a geologist, it would be hard for him to resist a plum job at BP. Svanberg's problem is that everyone will believe that Goodyear was being groomed for the chairmanship. And most would think that, despite his unceremonious departure from Singaporean sovereign wealth fund Temasek Holdings last year, Goodyear would make a better chairman that Svanberg.
Goodyear is ambitious. He rebuffed approaches last year from Russian steel group Metalloinvest to take over ahead of a potential London flotation. Spin doctors denied this, but sources close to the company and the American have repeatedly confirmed that he wanted to be at a group with a truly international reach.
So, Goodyear ticks all BP's boxes: hugely successful, respected businessman; available; experience of running a group that geographical resembles an empire more than a company; hungry for an important job. He has to be approached.
Svanberg might be able to argue that it is inappropriate to have two miners on the non-executive board: Anglo American boss Cynthia Carroll is already a non-exec at BP.
Svanberg could add that the resulting speculation over the chairmanship would be divisive. But, if he is still the canny character who led telecoms giant Ericsson so well for six years, he'll take the risk and ask Goodyear to come to the table.
- 1 Home Office says Nigerian asylum-seeker can't be a lesbian as she's got children
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The City of the Monkey God: Archaeologists claim to have found city lost for 1,000 years in remote Honduran jungle
Turkish Airlines flight TK 726 crash-lands on Nepal runway amid dense fog
Japanese island overrun with cats after population explodes
Bubonic plague-carrying fleas found on New York City rats
London property boom built on dirty money
'Jihadi John': CAGE representative storms off Sky News accusing Kay Burley of Islamophobia
Nearly 100,000 of Britain's poorest children go hungry after parents' benefits are cut
Durham Free School: 'Creationism taught at' free school facing closure
Ukip would cut billions from Scottish budget to fund English tax cuts
End of the licence fee: BBC to back radical overhaul of how it is funded
Ukraine crisis: Top Chinese diplomat backs Putin and says West should 'abandon zero-sum mentality'
Legendary isle of nights
The festival that made rock'n'roll history boasts a star-studded line up.
Crowdfunding: The end-end solution for business success.
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Senior Member
Just to throw it out there, but sometimes you have to hit the tanks because they're the only ones you can safely reach <_< And to add to the parodies...you have missed some important points. 1) Be as aggressive as possible in lane. Disregard things like champion matchup, summoner spells, items, and minion aggro. Kill the other fool. They won't expect a Kassadin to try and 1v1 a Cassiopeia at level 1, and you're garunteed to take them out with ease. 2) If you die to the enemy in lane, make sure to inform them how lucky they were in all chat. Use all caps and call them a scrub to drive the point home. This psychological warfare tactic will make killing them easier when you return to lane. Repeat step 1. 3) If your opponent cheats enough and kills you a whole bunch of times, remember to ping your lane like crazy and direct your jungler to gank by saying in all chat 'OMG NOOB JUNGLE NEVER GANKS GG'. Make sure to inform him how trash he is (in all chat)when he attempts to gank your lane to shut you up, only to give the enemy laner a double kill. It's not like the enemy champion is fed and you're weak or anything, you need to inform your jungler to step up his game and this is the best way. 4) When your scrub team mates inevitably start losing the game for you, spam 'GG NOOB TEAM' in all chat while berating individual team mates for every mistake. This lulls the enemy team into a false sense of security. Your own team will recognise the sheer masterfulness of your plans and will play along, asking the enemy team to report you and end it quicky. 5) Save your skills for landing killing blows. Getting many kills is important as it shows you're good at the game. Be sure to rub this in at every opportunity. Ignore the assists counter, as it has nothing to do with your amazing kill score. Freaking noob supports 0/1/28, l2p. 6) If you win, spam 'GG GET GOOD SCRUBS' or other witty one liners, to establish your dominance of the entire game. If you lose, be sure to spam 'BG' and blame everyone else. You were not the one at fault, and this needs to be communicated.
DC when you die first blood.
Anytime someone else gets a kill and you see it: /all STUPD KS NOOOB!!!11
one more: If you have an ability that pushes people away, use it to knock enemies away from your group to safty. If people complain about it copy and paste this: /ALL NOOBZ! U HAFTA ERN UR KILLZ lLOLZ! NO1 KS MEH! B RO!!1`
If you decide to play tank make sure to stay back as long as you can in team fights. Otherwise they will try to kill you. Also, real tanks dont need armor. Just build straight health, once you get over 4000 HP you are invincible.
Or you end up like me and have instalock ashe mid with revive... That happened about 5 times


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Prayer Circles
Read Prayers. |
LindaLou58 2/16/2006 21:26 |
Lorrie, |
roaming2736 3/27/2006 05:34 |
Dear Lord, |
roaming2736 3/27/2006 05:37 |
Others have prayed for you too, check out the chronic pain support forum at Beliefnet: click me |
Has problems James J 02/12/2008
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My marriage Kat Mounce 02/12/2008
A good friends mother, who has cancer everyone who needs prayer universal 02/12/2008
Pray for Michelle and Carlos N. 07/08/2008
"This prayer is to help us sell our home."
Pray for Donald H. 07/07/2008
"The love of my life has cancer."
Pray for Amanda B. 07/06/2008
"Please pray for my daughter and her unborn child."
Pray for Janice A. 07/05/2008
"One of my most favorite people in the whole world needs your prayers today. Please spread this and include Janice in your daily prayer."
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Sarah Lancaster
Position At NOLS: Special Events & Recruitment Coordinator NOLS Course: Brooks Range Backpacking & Rafting, 2002 WMI Certification: Wilderness EMT
Sarah Lancaster can't recall exactly how she first came to know about NOLS. Growing up outside of Cleveland, Ohio, she always had a passion for spending time in the outdoors. Each summer her family would travel to Colorado to spend time in the Rockies, while fishing, camping and hiking. Her desire to be outdoors was only increased by her love for horses. You could go as far as to say that Sarah grew up on the back of a horse, where she rode competitively for 13 years.
In 2002, Sarah traveled north into Alaska to take a 40-day Brooks Range Backpacking and Rafting course. Although she had some experience prior to her course, she enrolled to become a more competent and capable outdoor enthusiast. "I chose to take a course in Alaska because I never thought I'd be able to go there again," remarks Sarah. "It was new and exciting and different from everything I'd ever done."
An extended taste of the Rocky Mountains came while working on her undergraduate degree in Art History with a minor in Anthropology at the University of Denver. Following her graduation, Sarah was on the job hunt and ran across a position with the marketing department of an organization she'd become passionate about a few years prior, NOLS. This, combined with easily accessible outdoor areas, brought her right to the heart of the organization, Lander, WY.
Sarah has been an integral part of the NOLS Marketing Department since her acceptance of a Student Services Representative position in January 2006. She has served on the front lines, answering phone calls and e-mails from prospective students, enrolled students, parents, and everyone in between. "One of my favorite things about working in our department is that I have the opportunity to chat with students and their families all the way through their NOLS experience," expresses Sarah. "I'm there from their first inquiry, to choosing a course, applying for that course, preparing for it and finally keeping them connected as NOLS alumni."
As the current Special Events and Recruitment Coordinator, Sarah thrives in a constantly challenging environment. Booking events at expos, conferences, study abroad fairs and the like, Sarah ensures that NOLS has a presence in the frontcountry. "Not only am I challenged (and supported) to be the best I can at my job, but I also have to seek new and different avenues to get the word out about NOLS."
In January 2009, Sarah enrolled herself on a Wilderness EMT course offered by the Wilderness Medicine Institute of NOLS. "I've always been interested in medicine and it seemed like the perfect opportunity to explore," says Sarah. "I hope to do regular volunteering within the NOLS and Lander communities and put my knowledge to use."
Sarah is working on becoming a tri-athlete and loving it. Her passion for the outdoors is ever increasing, especially when it comes to spending time with her dog, Cleo. She hopes to one day own a solo canoe and spend extended periods of time on the water.
"Spending time in the backcountry was something I always considered a hobby before I started at NOLS," comments Sarah. "Now, it's a passion I share with the people I work with."
Request a Catalog or call 1-800-710-6657 NOLS, 284 Lincoln Street, Lander, WY 82520-2848, USA Copyright © 2015 National Outdoor Leadership School. All rights reserved. NOLS is a 501(c)3 nonprofit educational institution.


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Book your room at Hotel Okura Tokyo Bay
Please enter your travel dates.
Luxury Urayasu hotel in Maihama, near Disneyland® Tokyo
Located in Maihama, this luxury hotel is 0.4 mi (0.7 km) from Tokyo DisneySea® and within 3 mi (5 km) of Disneyland® Tokyo and Tokyo Sea Life Park. Kasai Rinkai Park is 2.3 mi (3.7 km) away.
Nearest Transport Options
Nearest Airports
Hotel Features
This hotel features an indoor pool, a health club, and a bar/lounge. Free WiFi in public areas and train station pick-up are also provided. Other amenities include a coffee shop/café, a sauna, and self parking.
Room Amenities
All 427 rooms offer refrigerators, minibars, and plasma TVs with digital channels. Room service, separate bathtubs and showers, and free newspapers are among the other amenities available to guests.
Information missing or incorrect? Tell us!Hotel Amenities
Hotel Amenities
In addition to an indoor pool, Hotel Okura Tokyo Bay provides a health club and a sauna. The hotel offers a coffee shop/café. A bar/lounge is on site where guests can unwind with a drink. High-speed wireless Internet access is complimentary.
Event facilities include conference space and meeting rooms. This luxury hotel also offers tour/ticket assistance, gift shops/newsstands, and dry cleaning/laundry services. For a surcharge, a roundtrip airport shuttle at scheduled times is offered to guests. Parking is available onsite for a surcharge.
- Bar/lounge
- Airport transportation (surcharge)
- Safe-deposit box at front desk
- Total number of rooms - 427
- Hair salon
- Number of floors - 12
- 24-hour front desk
- Coffee shop or café
- Conference space
- Dry cleaning/laundry service
- Elevator/lift
- Gift shops or newsstand
- Health club
- Tours/ticket assistance
- Spa treatment room(s)
- Meeting rooms
- Self parking (surcharge)
- Year Built 1988
- Number of meeting rooms - 4
- Sauna
- Number of buildings/towers - 11
- Breakfast available (surcharge)
- Wedding services
- Free WiFi
- Free train station pickup
- Indoor pool
Family Friendly Amenities
- Indoor pool
- Free Wi-Fi
- Rollaway/extra beds available
- Refrigerator
Available in some public areas: Free WiFi
Self parking (surcharge)
Room Amenities
- Free newspaper
- Air conditioning
- Refrigerator
- Minibar
- Daily housekeeping
- Private bathroom
- Designer toiletries
- Hair dryer
- Bidet
- In-room massage available
- Slippers
- Separate bathtub and shower
- Iron/ironing board (on request)
- Desk
- Rollaway/extra beds available
- Cribs/infant beds available
- Blackout drapes/curtains
- Plasma TV
- Digital TV service
- Room service (limited hours)
Where to Eat
Cooked-to-order breakfasts are available for a surcharge and are served each morning.
Restraint Fontana - This restaurant specializes in French cuisine and serves breakfast, lunch, and dinner.
Hagoromo - This restaurant specializes in Japanese cuisine and serves breakfast, lunch, and dinner.
Toh-Ka-Lin - This restaurant specializes in Chinese cuisine and serves lunch and dinner.
Cafe resturant terrace - This café specializes in fusion cuisine and serves breakfast, lunch, and dinner.
Room service (during limited hours) is available.
Nearby Things to Do
Recreational amenities at the hotel include an indoor pool, a health club, and a sauna.
The recreational activities listed below are available either on site or nearby; fees may apply.
- Aerobics on site
Spa Services
- Body treatments
- Facial treatments
To make requests for specific accessibility needs, complete the "Special or Accessibility Requests" section of "Trip Preferences" when you book your hotel.
- Accessible parking
- In-room accessibility
Hotel Policies
Check-in time starts at 3 PM
Minimum check-in age is 20
Check-out time is noon
Payment types
You need to know
Extra-person charges may apply and vary depending on hotel policy.
Government-issued photo identification and a credit card or cash deposit are required at check-in for incidental charges.
Special requests are subject to availability upon check-in and may incur additional charges. Special requests cannot be guaranteed.
- Minimum Spring Break check-in age is 20 years old.
No pets or service animals allowed
- Breakfast fee: JPY 3200 for adults and JPY 1550 for children (approximately)
- Airport shuttle fee: JPY 830 per person (one way)
- Airport shuttle fee per child: JPY 420 (one way), (from 6 to 12 years old)
- Self parking fee: JPY 2600 per day (in/out privileges)
We should mention
Only registered guests are allowed in the guestrooms. The Japanese Ministry of Health, Labour, and Welfare requires all international visitors to submit their passport number and nationality when registering at any lodging facility (inns, hotels, motels, etc. ). Additionally, lodging proprietors are required to photocopy passports for all registering guests and keep the photocopy on file. No pets and no service animals are allowed at this property.


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Taxation without representationSubmitted by Taxman a comin (not verified) on Wed, 04/04/2012 - 5:21pm.
Ahh the sound of tax dollars sucked in by the city to pay for fiscal irresponsibility. Services ..what a joke, County Fire paid for by NHCo, EMS paid for by NHRMC, Sheriff's Dept. paid for by NHCo, Water and Sewer via CFPU, Garbage via Waste Management..what lousy City Services are needed ? Just siphon off more tax dollars at the expense of working people. NHCo does just fine with their services. »
Reply |


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