text:
Exploring knowledge, attitudes, and practices related to alcohol in Mongolia: a national population-based survey
Health behavior, health promotion and society
The leading cause of mortality in Mongolia is Non-Communicable Disease. Alcohol is recognised by the World Health Organization as one of the four major disease drivers and so, in order to better understand and triangulate recent national burden-of-disease surveys and to inform policy responses to alcohol consumption in Mongolia, a national Knowledge, Attitudes and Practices survey was conducted. Focusing on Non-Communicable Diseases and their risk factors, this publication explores the alcohol-related findings of this national survey.
A door-to-door, household-based questionnaire was conducted on 3450 people from across Mongolia. Participants were recruited using a multi-stage random cluster sampling technique, and eligibility was granted to permanent residents of households who were aged between 15 and 64 years. A nationally representative sample size was calculated, based on methodologies aligned with the WHO STEPwise approach to Surveillance.
Approximately 50% of males and 30% of females were found to be current drinkers of alcohol. Moreover, nine in ten respondents agreed that heavy episodic drinking of alcohol is common among Mongolians, and the harms of daily alcohol consumption were generally perceived to be high. Indeed, 90% of respondents regarded daily alcohol consumption as either 'harmful' or 'very harmful'. Interestingly, morning drinking, suggestive of problematic drinking, was highest in rural men and was associated with lower-levels of education and unemployment.
This research suggests that Mongolia faces an epidemiological challenge in addressing the burden of alcohol use and related problems. Males, rural populations and those aged 25-34 years exhibited the highest levels of risky drinking practices, while urban populations exhibit higher levels of general alcohol consumption. These findings suggest a focus and context for public health measures addressing alcohol-related harm in Mongolia.
The World Health Organization (WHO) estimates that approximately 2 billion people worldwide consume alcohol, of whom almost 80 million are believed to be diagnosable with an Alcohol-Use Disorder (Endnote A). Globally, alcohol consumption has increased in recent decades, with most of that increase occurring in Low and Middle-Income Countries (LMIC)
However, the increase in alcohol consumption and related diseases in LMIC is likely underestimated as the majority of consumption goes unrecorded by monitoring efforts
Mongolia is a lower-middle income country with a population of about 2.6 million
Alcohol has a strong presence in Mongolian culture, predating, but exacerbated by Soviet rule
In 2005 and 2009, WHO STEPwise approach to Surveillance (STEPS) was conducted in Mongolia
However, the STEPS surveys have limitations; while they accurately assess disease prevalence and risk factor burden, they do not assess the knowledge, attitudes or detailed practices with regards to alcohol consumption. Hence, STEPS surveys cannot inform policy-makers on the population's level of awareness of the risks associated with heavy episodic drinking, or on the reasons for engaging in such patterns of alcohol consumption. For example, STEPS surveys cannot indicate if the majority of heavy consumption follows receiving income, and therefore cannot guide policies and regulations around pricing that may affect consumption behaviours
Given these limitations of STEPS surveys, a national Knowledge, Attitudes and Practices (KAP) survey was designed and implemented in Mongolia in 2010 to explore these issues in more detail.
This KAP survey aimed to explore five domains:
1. Prevalence of alcohol consumption.
2. Prevalence of risky drinking practices among Mongolians.
3. Risk perceptions towards daily alcohol consumption.
4. Awareness of heavy episodic drinking as a public health concern for Mongolia.
5. Major social, cultural and psychosocial drivers of heavy episodic drinking.
Setting and population
A door-to-door, household-based questionnaire was conducted on a nationally-representative sample. The full study protocol has been published
Forty-five local, trained field workers from the National Institute for Public Health administered the questionnaire, which explored a range of NCD and risk factor domains, including alcohol. Of the total 106 questions posed, 11 explored alcohol epidemiology. The wider questionnaire also included:
- Administrative demographic and geographic questions
- Risk factor specific sections covering broad NCD risk factor awareness
- Focused sections investigating public knowledge and attitudes towards specific diseases.
Definitions of the KAP survey domains
Prevalence of current drinkers of alcohol
Current drinkers of alcohol were those who reported having consumed any alcohol in the previous 12 months.
Prevalence of risky drinking practices
Participants who reported having consumed alcohol in the previous year were asked whether they had consumed alcohol in a morning period (between waking and midday) in the previous month. They were also asked whether they had ever felt the need to cut down their own alcohol intake.
Finally, participants who reported driving a car were asked if they had ever driven while under the influence of alcohol.
Risk perception
Participants perception of the health risk associated with alcohol consumption was investigated using a 4-level Likert scale mean (0/not harmful, 1/moderately-harmful, 2/harmful, 3/very-harmful).
Awareness of heavy episodic drinking as a public health concern
Awareness of the high prevalence of heavy episodic drinking among Mongolians was estimated using a four-level Likert scale. Participants were asked if they agreed that in general Mongolians drink large amounts of alcohol on single drinking occasions (strongly disagree, disagree, agree, strongly agree).
The major social, psychosocial and cultural drivers of drinking practices
Participants were asked to spontaneously list the most common reasons they consumed alcohol. Next, they were read a list of common social occasions and asked which of these would be associated with heavier drinking in Mongolian society.
Sampling methods and sample size
Sample size was calculated to obtain a nationally-representative sample and to allow disaggregated data analysis. The calculation of the nationally-representative sample was estimated considering a 95% confidence level. A design effect was adopted, based on methodologies used for the WHO STEPS. Accounting for an assumed non-response rate of 10%, final sample size was estimated at 3,854.
Participants were recruited using a multi-stage cluster sampling technique across 42 locations. Sampling used proportional population to size methods for primary and secondary sampling units, followed with simple random sampling from household lists for tertiary sampling units. Finally, a Kish method was used for participant selection within households
Only permanent residents of the households sampled were eligible for recruitment and had to be aged between 15 and 64 years. In total, 3540 participants completed the survey.
While this survey does not sample the same participants as the 2009 WHO STEPS survey, both methodologies are aligned, and both nationally-representative samples are from the same broader population.
Quality control
In order to maximise scientific rigour in this research, a number of processes were adopted in the questionnaire methodologies
1. Translation and back translation
2. Peer and expert review
3. Pretesting using a Cognitive Interviewing
4. Piloting.
Analysis was undertaken using the statistical software package SPSS (IBM SPSS 20.0.0 Statistics). Sampling error, which could potentially affect the accuracy of this survey's results, was estimated from the standard error of variables computed taking the cluster sampling technique into account.
Multiple regression models were constructed to explore the relationship between knowledge, risk attitudes and disease or demographic parameters comparing means from Likert scale measures. Binary outcome or categorical variable questions were analysed using logistic regression expressed as bivariate or multivariate (adjusted) odds ratios (OR). Co-variables included in multivariate analysis were gender, rurality, age, education and employment.
Limitations of methods
It should be recognised that the findings of this KAP survey may under-estimate the true burden of alcohol-related behaviours due to recall and observation bias
This survey adapted the CAGE clinical tool for use in a population-based survey. The CAGE questionnaire is used for the screening and diagnosis of alcohol related disorders, with an estimated sensitivity of 70%
Finally, recognizing the limited impact of knowledge on health behaviours
Ethics approval
This study was conducted according to the principles of the Helsinki declaration and approved by the Mongolian National Ministry of Health's Medical Ethical Committee on the 06 October 2010.
3450 of the sampled 3,854 participants agreed to take part in the study and were included in the analyses (89.5%). Of these participants, approximately 40% were male, while 50% were from urban areas (Additional file
Additional file 1: Table S1
Descriptive information on sample population, disaggregated by age, sex, urbanicity, educational level and employment status.
Click here for file
The median overall age of participants was 33 years. No significant difference was found between the median age of rural and urban participants (32 and 34 years respectively, p = 0.08), Female median age was 3 years older than male counterparts (p <0.05).
Approximately two-thirds of participants were educated to a secondary school level with 30% having been to university, 6% having received only a primary school education, and 21% being students, of which half were women. Significantly more urban participants had received secondary or tertiary education, with 2% having received only primary education in urban areas and 11% in rural areas.
By employment status, two-fifths of participants reported to be employed and 15% unemployed. One-fifth of participants were retired or home-makers, of which 75% were women. Finally, there were no significant differences in relation to employment status between rural and urban populations.
Domain one: prevalence of alcohol consumption
This survey reveals that approximately 50% of males and 30% of females were current drinkers of alcohol (MOR 3.6), confirming the findings of the 2009 STEPS (Additional file
Additional file 2: Table S2
Prevalence of current-drinkers of alcohol within the Mongolian population.
Click here for file
Disaggregated by age, the highest alcohol consumption rates were observed among those 25-34 years at 52% (MOR 2.1). The occurrence of youth drinking (15-24 years) was lower than in older age groups, with approximately one in five younger Mongolians drinking alcohol. Interestingly, drinking rates in the youngest urban populations were almost twice as high as compared to rural counterparts. Indeed, 34.8% (28.8-40.8) of males and 24.9% (20.0-30.0) of females were current drinkers, as compared to 19.5% (14.7-24.3) of males and 11.0% (7.5-14.5) of females in this age group in rural areas (data not shown).
Domain two: prevalence of risky drinking practices among Mongolians
Following, current drinkers were questioned on risky drinking practices. Questions based on the CAGE clinical assessment tool probed alcohol consumption in the morning, and explored the participants' own perceptions around their need to reduce their alcohol intake
Additional file 3: Table S3
Practices relating to risky drinking of alcohol.
Click here for file
With an increase in road traffic accidents in Mongolia
Additional file 4: Table S4
Self-reported driving while alcohol-affected among non-abstaining drivers.
Click here for file
To further gauge the level of risky practices, and reflecting the CAGE clinical tool for assessing problematic alcohol consumption, current drinkers were asked two additional questions: whether they had consumed alcohol between waking in the morning and lunchtime in the past month, and whether they had considered the need to reduce their own alcohol intake (Additional file
Additional file 5: Table S5
Morning drinking in the past month, and problematic drinking among current drinkers.
Click here for file
Among males, almost one-third of current drinkers reported morning drinking in the past month, compared with one in eleven women (p < 0.01). When questioned about their need to reduce their alcohol intake, 24% of all males and 6% of females current drinkers reported both morning drinking and the perception that they needed to cut down their alcohol intake (MOR 5.0, p < 0.01).
Comparing urban and rural men, morning drinking was more prevalent among the former at 25.0% (21.3 - 28.7) and 16.2% (13.6 - 18.6) respectively (p < 0.05), and whilst highest in the oldest age group (25%, 18.7 – 31.3), the 25-34 year age group was most at-risk when other variables were controlled (MOR 2.0, P = 0.04).
Domain three: risk perceptions of the general public towards daily drinking
The harms of daily alcohol consumption were generally perceived to be high among participants of this survey. More than 90% of respondents stated that they regard daily alcohol consumption as either 'harmful' or 'very-harmful' to health (data not shown).
There was no significant difference in mean perceived risk by age, education level or sex; nevertheless, urban dwellers on average regarded daily drinking to be more harmful than their rural counterparts. This urban-rural difference in perceived risk of daily drinking was small, but significant (harmful with a mean of 2.0 and moderately-harmful of 1.8 respectively, p < 0.01).
Finally, exploring the relationship between risk perception and risky drinking practices (represented by morning drinking), current drinkers who felt daily alcohol drinking was slightly harmful, as compared with very harmful, were more likely to engage in risky drinking practices (MOR 3.7, 1.1 – 12.3) (Additional file
Additional file 6: Table S6
Relationship between morning drinking of alcohol and risk perceptions of daily alcohol drinking.
Click here for file
Domain four: awareness of heavy episodic drinking as a public health concern
Nine out of ten respondents either agreed or strongly agreed that heavy episodic drinking of alcohol is common among Mongolians.
There was no significant difference in awareness for men and women or across age groups (Additional file
Additional file 7: Table S7
Awareness of heavy episodic drinking as a public health concern.
Click here for file
Domain five: the major social, cultural and psychosocial drivers of heavy episodic drinking
'Celebrations' (91%, 89.5 - 92.2) as well as 'Drinking with friends or family' (87.1%, 85.4 – 88.3) were the most common reason for engaging in heavy episodic drinking among respondents. There were no significant differences between men and women (Additional file
Additional file 8: Table S8
Social and cultural drivers of heavy episodic drinking amongst Mongolians.
Click here for file
Rural Mongolians were more likely than their urban counterparts to drink following receiving income at 51.6% (49.2 – 54.0) and 47.5% (45.1 – 49.1) respectively, while urban Mongolians tended to more commonly do so 'with friends or family' and during 'celebrations'.
In terms of age, youth (15-24 years) were most likely to cite 'customs or traditions' as the reason for engaging in heavy episodic drinking, as volunteered by 67.1% (64.3 – 69.9) of these participants.
Participants were also asked, in an unprompted fashion, to list commonly used methods for psychological stress management in their everyday life (Additional file
Additional file 9: Table S9
Participants listing alcohol as an utilised stress reduction method.
Click here for file
This KAP survey reflects and builds on existing STEPS findings, confirming high levels of alcohol consumption in Mongolia. Indeed, up to 80% of urban Mongolian men were found to have consumed alcohol in the previous year, compared to 70% and 20% of men in China and India respectively
Applying the findings of this research to Public Health practice, three clear populations with distinct health risks and needs emerge: rural Mongolian men; urban Mongolians; and young Mongolians (Additional file
Additional file 10: Table S10
Translating KAP findings into public health practice.
Click here for file
This national KAPS survey revealed a high level of health knowledge, particularly among urban participants, regarding the risks of daily alcohol consumption and awareness about the heavy episodic drinking prevalence in Mongolia. This is also the group with the highest prevalence of such behaviours. Combined, these findings support the notion that high levels of awareness alone may have little impact on healthy-behavioural outcomes in a population, findings which are echoed in other populations globally
These findings support the need for legislative policy responses such as harsher blood alcohol concentration laws, closer enforcement of such laws including sobriety checkpoints, and limitations to access for alcohol, rather than solely education or public awareness campaigns in urban Mongolia
Findings also show that urban drinking was associated with celebrations and social events. In the context of the rapid urbanisation as well as the increasing Western-style branding and marketing of alcohol in recent decades, this may represent a changing social paradigm around drinking, where advertising and marketing of alcohol promote its association with festivities and celebrations, leading to higher levels of alcohol consumption in such settings. If identified as a threat to public health in Mongolia, this association may indicate the need for more stringent regulation of alcohol advertising as is seen in other nations
In contrast, rural participants were less aware of heavy episodic drinking as a national health issue and of the risks posed by drinking. While reporting a lower drinking prevalence, higher levels of dangerous drinking behaviours were reported. These findings were particularly evident among men. This echoes similar studies from China and India, where risky alcohol consumption is also linked to male-gender and rural dwelling
Looking across the lifespan, low youth drinking rates with a peak in the late-twenties suggests that most Mongolians begin consuming alcohol during their second decade of life, a practice that peaks in middle-age. This is in contrast to many developed nations, where drinking uptake usually peaks in the teenage years
Finally, findings reveal that drinking and heavy drinking were less common among the oldest Mongolians. As alcohol in some form has been part of the Mongolian culture for many centuries, this supports the theory that the high burden of drinking in early-middle age may not be linked to the long-standing Mongolian cultural norms. Instead, a new practice, possibly associated with rapid recent socio-economic changes and urbanisation in Mongolia
In the aftermath of the 2011 High-Level Meeting on NCDs, which prioritised alcohol-harm reduction, this national survey adds to and refines existing knowledge around factors driving alcohol-related harm in Mongolia. Findings on drinking and risky-drinking prevalence, and on knowledge, risk perceptions and related attitudes towards alcohol all combine to better inform policies and programs to address this burden.
This research confirms a high prevalence of drinking among Mongolians, as well as risky drinking practices including binge drinking and morning drinking. It furthermore suggests that, in general, Mongolians hold a high level of knowledge around the harms of alcohol consumption and risky-drinking practices.
Finally, this KAP identifies three Mongolian sub-populations with distinct alcohol-related program and policy response needs, and outlines possible public health approaches for which there is an evidence-base. Indeed, despite better harm-related knowledge, urban populations exhibited higher prevalence of alcohol consumption and heavy-episodic drinking compared to rural populations. Given the speed at which Mongolia is urbanising, this may represent a growing trend and a focus for public health responses. While higher consumption prevalence was associated with urbanicity, rurality and male-gender was an independent predictor for poorer health knowledge, and was associated with morning drinking of alcohol, a predictor of chronic alcohol misuse. Finally, this research suggests that alcohol drinking peaks in the late 20s and is associated with celebrations and social activities, rendering youth a potentially important third target group for strategies on alcohol-harm reduction.
a Alcohol-Use Disorder is defined by DSM-5 criteria of the American Psychiatric Association, 2012.
b Current drinkers are defined as participants who report having ever consumed alcohol in the previous 12 months.
c For the KAPS 2009, heavy episodic drinking was 4 or more drinks in a single occasion. For the purposes of this study and article, heavy episodic drinking was redefined for lay participants as "drinking large amounts of alcohol on a single occasion".
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
AD and DM drafted the manuscript. AD, OD, PA and MdC participated in the design of the study. OD obtained funding for the project. All authors read and commented on manuscript drafts. All authors read and approved the final manuscript.
This study is funded by the Millennium Challenge Account - Mongolia Health Project. The authors of this paper would like to acknowledge Kyra-Bae Snell for her editorial support in drafting.
UN high-level meeting on Non-communicable diseases: addressing four questions
Urban transition in mongolia: pursuing sustainability in a unique environment, environment
China: alcohol today
The dual nature of alcohol use and abuse in Mongolia: reflections through policy
Widespread alcohol abuse clouds Mongolia's future
Effectiveness and cost-eff ectiveness of policies and programmes to reduce the harm caused by alcohol
Protocol for a national, mixed-methods knowledge, attitudes and practices survey on non-communicable diseases
A procedure for objective respondent selection within the household
Cognitive interviewing techniques: in the lab and in the field
Social desirability biases in self-reported alcohol consumption and harms
Gender differences in social desirability and social approval bias in dietary self-report
Reassessment of the CAGE questionnaire by ROC/Taguchi methods
Screening for alcohol problems in the U.S. General population: comparison of the CAGE, RAPS4, and RAPS4-QF by gender, ethnicity, and service utilization
Internet-based brief personalized feedback intervention in a non-treatment-seeking population of adult heavy drinkers: a randomized controlled trial
Alcohol use on the rise in India
Alcohol-impaired driving among U.S. Adults, 1993–2002
Reviews of evidence regarding interventions to reduce alcohol-impaired driving
Interventions to reduce harm associated with adolescent substance use
Regular use of alcohol and tobacco in India and its association with age, gender, and poverty
Drinking and drinking patterns and health status in the general population of five areas of china
PrimaryCare intervention to reduce alcohol misuse: ranking its health impact and cost effectiveness
Local wisdom and health promotion: barrier or catalyst?
Taking up binge drinking in college: the influences of person, social group, and environment
Teenage drinking and the onset of alcohol dependence: a cohort study over seven years
Harm minimization in school drug education: final results of the school health and alcohol harm reduction project (SHAHRP)
Pre-publication history
The pre-publication history for this paper can be accessed here:


text:
Software for Scheduling your Staff
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subset: commoncrawl


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text:
One of the happiness-project resolutions that has added most to my happiness is my resolution to Join or start a group.
Being part of a group is a terrific way to make new friends, deepen existing friendships, have fun, create a sense of belonging, and spend time thinking about a subject that interests you. It sounds odd to talk about "efficiency" in the context of friendship, but belonging to a group is a very efficient way to build and strengthen relationships (especially if you're pressed for time).
I've heard from lots of people who want to launch or join groups for people doing happiness projects together, so I created the starter kit, to help them get the ball rolling. (If you want a copy, email me at grubin at gretchenrubin dot com.)
In answer to my plea, many people already in Happiness Project groups completed the survey about their groups. (If you're in a group and haven't filled it out, please take a second to answer these six quick questions!)
Thanks to those responses, I now have a list of the existing groups. At last, if you want to know if there's a group in your area, you can look it up. You can see the current list here or on Facebook here. If you want to start a new group in your area, start a Discussion Topic under the Discussions tab in the left-hand column on Facebook.
One important note: it takes work to start a group, and once a group has started, it takes work to help keep it going. It's enormously rewarding, but it demands some effort.
My three children's literature reading groups are among the lights of my life. (Yes, it's true, I'm in three of these groups.) Nevertheless, they take a lot of work. Tonight, for instance, one of the groups was supposed to meet at a member's apartment, but at the last minute, he couldn't do it. So I said I'd host instead. I was about to start the frantic pre-guest preparations, when another member bowed out, sick, then someone had an emergency business meeting, and it was a bad night to begin with for a few other folks — and so in the end, we've had to reschedule. This took a lot of emails, logistics, calendar coordination…not much fun. (In case you're wondering: book choices are Raskin's The Westing Game and Sleator's House of Stairs.)
The thing is, being in this group is so worth the effort. It absolutely is. But it's not effortless.
As Samuel Johnson (one of the patron saints of my happiness project) observed: "The production of something, where nothing was before, is an act of greater energy than the expansion or decoration of the thing produced." And while it takes special energy to start something, it also takes energy to keep something going. Just acknowledging that to myself helps me expend the energy more readily.
Have you found that it takes effort to be in a group? And did the group make you happy, nevertheless?
* I love the site Brainpickings, but I'd missed the post on DrawHappy: Ongoing global art project on happiness until a thoughtful reader pointed it out to me.
* Sign up for the Moment of Happiness, and every weekday morning, you'll get a happiness quotation in your email inbox. Sign up here, or email me at gretchenrubin1 at gmail dot com.


text:
Dr. Ramon Pla Jr MD Patient Reviews
- Internal Medicine Clinton, IA
Overall Rating
21 Patient Reviews
- Friendly Staff
- Promptness
- Spends Time With Patients
- Bedside Manner
- Fair and Accurate Diagnosis
- Easy Appointments
- Wait Time 32.3 minutes
- Appropriate Followup
Showing 1 - 12 reviews
5.0 of 5
November 5th, 2016
Very pleased patient
I didn't wait long to be seen. He was nice, listened and took time with me. I felt he was concerned about my situation and will be taking steps allowed by a dr. to help me resolve my health issue(s). I can't speak for anybody else but I am happy with his services.
5.0 of 5
September 12th, 2016
Great Doctor
Dr. P listens to the patient and spends time with the patient. Does not "talk down" and is a refreshing change from the standard self-important types. And he knows what he is doing! What's not to like?
1.0 of 5
December 21st, 2015
I should have known...
I had to go to Dr. Playing because he was the house doctor of the Nursing home I reside in. The very first time I met him he didn't even introduce himself, but just called me fat! From that point on any diagnosis was my obesity caused the problem, not the other way around! Finally two weeks ago I asked my nurse to see him as I had this persistent cough that was really bothering me. The next day he told my nurse "it's always something with him" and refused to see me! Fortunately there is another Doctor that visits the Nursing home, and I am now on the way to healing. Dr. Playing is rude, abrasive and condescending to his patients, at least he was to.me. In my opinion, his HUGE EGO prevents him from being an effective physician. He is arrogant to his patients, nurses and CNA' s alike. I realize he could probably care less that I changed doctors, but I assure you, dear reader, that I am releaved to be done with him!
5.0 of 5
November 12th, 2015
I was very impressed with Dr Pla. So thankful he accepted me as his patient
1.0 of 5
January 24th, 2015
He calls his patients FAT and chastise them. His bedside manner and personality are something to be desired.Someday Dr. Pla will be on the other side of the line of scrimmage and I hope he gets a doctor that treats him as badly as he treats his patients.
5.0 of 5
September 26th, 2014
Great doctor
I've found Dr. Pla to be very thorough, following up with a phone call to discuss his concerns. He has never been impolite or rushed through my appointment. Probably one of the nicest doctors I've known. I would highly recommend him.
5.0 of 5
September 25th, 2014
Dr. Pla
I have seen Dr. Pla in Clinton and found him to be a very caring doctor. He was efficient and knowledgeable with my medical condition. I thought he was friendly and welcomed all my questions . He was very thorough in his assessments. I felt comfortable in his office and disagree with the other reviews about him acting "god like". I will certainly be seeing Dr. Pla in the years to come. Caring, friendly, and professional doctor.
1.0 of 5
August 14th, 2014
Regarding care of diabetic patient he lacks correct knowledge on a couple of topics. He comes across knowledgeable but I've been able to discount what he has said. I agree with the other review he does have a god complex and I felt chastised for asking questions. He even mentioned if I was 80 he wouldn't be mentioning anything about the diabetes care. His time he gives or allows is about two minutes. He doesn't even make rounds we have to come to him in an empty room which is wrong.
1.0 of 5
February 28th, 2014
Dr. Pla definitely has a God complex. I was treated with disrespect and chastised. He does not take time to review the chart and is quick to form opinions based on zero knowledge of his patient. I will not be going back, and I will do my level best to inform the public of his shortcomings and simply awful bedside manner.
5.0 of 5
March 28th, 2009
a caring doctor
Dr. Ramon Pla is an amazing doctor that never leaves a single stone unturn. He give great care and has wonder bedside manners. He care about his patients and makes you feel unrushed gives you time to explain and is a great listener. Thanks for the amazing care you have give our family for so many years.
5.0 of 5
April 24th, 2017
1.0 of 5
April 4th, 2017
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The Significance of Body Language
Body language is one thing many writers take for granted. It's also the reason that many people hate reading in first person. First person authors often write with historical or psychological information. Historical: Where did we come from? Who did this before? What happened yesterday? Psychological: Why I'm feeling this way. How my heart beats. What my tears feel like. Third person authors also miss out on great opportunities to capitalize on body language, but they write about it more often. Body language includes: Lack of eye contact. Sitting on…Read More


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4 Things Bacteria Need To Survive
Kandis K.
#1 Food
How to prevent bacteria: Keep all work surfaces, dishtowels, utensils, and containers clean. Info: Bacteria "eat" anything from sugar, starch, sunlight, sulfur, and iron.
#2 Moisture
How to prevent bacteria: Store food with moisture corecctly. Info: The moisture bacteria needs can be found on many foods.
#3 Warmth
How to prevent bacteria: Your frige tempature should be kept 5 degrees celsius. Your freezer tempature should be kept below -18 degrees celsius. Info: Harmful bacteria grow readily from 5 degrees celsius to 63 degrees celsius. Most bacteria grow the quickest at around 37 degrees celsius.
#4 Time
How to prevent bactaria: Get perishable, chilled, and frozen foods home and properly stored as fast as possible. Eat food by the due dates.
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We feel a major streaming marathon coming on! Today, we're thrilled to announce that Google Play Movies & TV has been added to our expansive Channel Store in the U.S., U.K., Ireland and Canada. With the addition of Google Play Movies & TV, you now have more options than ever to watch the entertainment you love on your Roku player.
From the hottest new releases to iconic classics, there's a world of movies at your fingertips with Google Play Movies & TV. Get new releases like 22 Jump Street, Into the Storm and Let's Be Cops in SD or HD before they are available on DVD.
Also, don't miss the "Gift from Google" section for a complimentary HD copy of of X-Men, when you sign up for a Google Play account. Check back next week, you never know what new title will pop up!
If you're a TV lover, you can catch up on last night's episode or past seasons of can't miss TV, laugh out loud comedies, nail biting dramas, notable documentaries and more, when it's most convenient for you. You can even get a season pass to have the latest episodes added automatically to your library the day after they air.
Looking for a new drama series to binge-watch? Don't know where to start? Google Play Movies & TV makes it easy to browse TV shows and movies by genre.
Another cool feature to look out for when you're watching a TV show or movie is Google Play's Info Cards. Can't remember that actor's name? Press pause when he is on screen and voilà – his name will pop-up on screen!
You can find Google Play Movies & TV in the Channel Store now on *current-generation Roku players and Roku TV models.
Roku TV support is coming soon.
Stream on!
*Current generation players are those introduced after June 2011 and include Roku 3 (4200X), Roku 2 (2720X), Roku 1 (2710X), Roku Streaming Stick, both HDMI (3500X) and Roku Ready (3400X, 3420X) versions, Roku LT (2400X, 2450X, 2700X), Roku 2 HD (3000X), Roku 2 XD (3050X), Roku 2 XS (3100X) and the Roku HD (2500X).


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All we need do is vote
The Global Post, an online news journal out of Boston, has posted an amazing series of 7 photographs taken in Aleppo, Syria, a couple days ago. Here is the instant that a tank shell explodes among a small group of rebels holding one of the forward street corners in the city against the Syrian army. Yes, all three are being instantly killed in this photo - even though their bodies have not yet begun to be blown back.
Why post this? To just plain remind people that democracy is a dream for most people in the world. We have it but we seem to find reasons to pout and not vote. At times, a majority of registered voters ignore voting. And that does not count the many who refuse to register for any number of selfish and inane reasons. We should all vote intelligently. Vote only for those offices and candidates we know enough about. These fellows were seeking to have the right to vote and hoped and expected to live to do so. Democracy is precious, scarce and fragile.
A note on the Global Post. It is an amazing online only news journal started in 2009. It focuses on International news. I am adding a permanent link to them in the right side column.
Comments by Readers
Todd Granger
And 74% in Syria got a democracy a long time ago.
John Servais
Sad. Don't bother following the link. It is a numbing spiel about republics that I have listened to a hundred times since the 1950s and it is just nuts. This reasoning connects two dots and cannot connect three dots. The link gives no clue about 74% nor about Syria ever having had democracy. It is a total non sequitur.
These three Syrians died fighting to gain democracy for their country. It is sad that others start parsing and cautioning that democracy is something bad. Arguing with the concept in this link is like arguing with an Ayn Rand true believer. These true believers see the world as black and white. Shades of gray do not exist, much less color. They simply cannot fathom a complex civilization nor a complex government.
Paul deArmond
Three comrades lost. Hope is not necessary to persevere.
Todd Granger
Since the 50's John?
Actually Truman's 1948, was an interesting year in many of these local neighborhood's too
"The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants. It is it's natural manure."
THOMAS JEFFERSON, letter to William Stephens Smith, November 13, 1787.—The Papers of Thomas Jefferson, ed. Julian P. Boyd, vol. 12, p. 356 (1955).
A related idea was later expressed by Bertrand Barère de Vieuzac in a speech to the French national assembly, January 16, 1793: "L'arbre de la liberté… croît lorsqu'il est arrosé du sang de toute espèce de tyrans (The tree of liberty grows only when watered by the blood of tyrants)," Archives Parliamentaires de 1787 à 1860, vol. 57, p. 368 (1900).
"In the early ages of the world, according to the scripture chronology there were no kings; the consequence of which was, there were no wars; it is the pride of kings which throws mankind into confusion. Holland, without a king hath enjoyed more peace for this last century than any of the monarchical governments in Europe. Antiquity favours the same remark; for the quiet and rural lives of the first Patriarchs have a snappy something in them, which vanishes when we come to the history of Jewish royalty.
Government by kings was first introduced into the world by the Heathens, from whom the children of Israel copied the custom. It was the most prosperous invention the Devil ever set on foot for the promotion of idolatry. The Heathens paid divine honours to their deceased kings, and the Christian World hath improved on the plan by doing the same to their living ones. How impious is the title of sacred Majesty applied to a worm, who in the midst of his splendor is crumbling into dust!
As the exalting one man so greatly above the rest cannot be justified on the equal rights of nature, so neither can it be defended on the authority of scripture; for the will of the Almighty as declared by Gideon, and the prophet Samuel, expressly disapproves of government by Kings…"
Common Sense Thomas Paine
Todd Granger
"...It murders itself." Samuel Adams
According to Subhi Hadidi, a Syrian dissident, "The Ba'ath (1947) is in complete disarray. [...] It's like a dead body. It's no longer a party in any normal sense of the word."
Todd Granger
Democracy Now!
Walk like an Egyptian?
Paul deArmond
The bizarre notion of republicanism being opposed by democracy is a very recent bit of propaganda that dates to to post-WWII counter subversion hysteria. There are no contemporary sources showing any such debate among the founders, either at the time of the Articles of Confederation or the debates between the Federalists and Anti-federalists during the Constitutional Convention or the debates over ratification.
During the post-WWII attempts to rehabilitate the political reputations of American fascists and their fellow travellers, there were numerous attempts to subvert the anti-facist and anti-racialist policies of the Rooseveldt and Truman administrations.
Two of the most notorious forgeries and distortions are the Pinkney diary fraud (http://www.adl.org/special_reports/franklin_prophecy/print.asp)and the representation of Jefferson's opinions (written to his agent in England, William Smith) about Shay's Rebellion while he was Ambassador to France.
Smith was in fact a British double-agent and he forwarded a copy of the letter to the pro-British loyalists who sought refuge in the Federalist Party, much the same as Nazis, racialists, and international fascists sought refuge with the Republican Party:
See Russ Bellant's Old Nazis and the New Republican Party (http://www.publiceye.org/bellant/old_nazis.html); Goldwater and the Dixiecrats (http://en.wikipedia.org/wiki/Southern_strategy); and The World Anti-Communist League (http://www.scribd.com/doc/94287848/Inside-the-League-World-Anti-Communist-League(http://www.scribd.com/doc/94287848/Inside-the-League-World-Anti-Communist-League).
Jefferson's "Tree of Liberty" letter is actually a defense of the Federalist killing of tax protesters. Jefferson was an Anti-Federalist at the time and was much defamed by the Federalists as a supporter of the French revolution, as an atheist, in fact a Diest much like a Unitarian-Universalist today (http://en.wikipedia.org/wiki/Deism), and as a subversive linked to the Bavarian Illuminatti (http://www.goodreads.com/review/show/326115667).
It is an embarrassment to see these canards repeated in the present, when they are merely echoes of past tyrannies and their fuglemen. It is even more despicable that the spirit of such lickspittles would be so trollishly spewed on the anniversary of the infamous attack on American freedom by the descendants and inheritors of absolutism and imperial authoritarianisn.
We need to do far more than vote, an act reduced to the mere consumption and commodification of propaganda by power elites. We need to manufacture a new politics where power devolves to the public, the 99% who have been betrayed, oppressed and ripped off by the banksters, the manufacturers of consent and the hereditary aristocracy of the pseudo-centrists and the pseudo-conservatives.
When Jefferson wrote, "Wonderful is the effect of impudent & persevering lying. The British ministry have so long hired their gazetteers to repeat and model into every form lies about our being in anarchy, that the world has at length believed them, the English nation has believed them, the ministers themselves have come to believe them, & what is more wonderful, we have believed them ourselves." He is speaking directly to and about the conspiracy-mongering wackos who have dominated the right wing of American politics—fabricating conspiracy out of grass-roots sovereignty, creating faction out of debate and and labeling dissent as treason.
The spirit of Jefferson's letter is alive (though bleeding from numerous wounds of added exemptions) in the Washington Public Disclosure Act, which states, "It is hereby declared by the sovereign people to be the public policy of the state of Washington:
"It is hereby declared by the sovereign people to be the public policy of the state of Washington:
(1) That political campaign and lobbying contributions and expenditures be fully disclosed to the public and that secrecy is to be avoided.
(2) That the people have the right to expect from their elected representatives at all levels of government the utmost of integrity, honesty, and fairness in their dealings.
(3) That the people shall be assured that the private financial dealings of their public officials, and of candidates for those offices, present no conflict of interest between the public trust and private interest.
(4) That our representative form of government is founded on a belief that those entrusted with the offices of government have nothing to fear from full public disclosure of their financial and business holdings, provided those officials deal honestly and fairly with the people.
(5) That public confidence in government at all levels is essential and must be promoted by all possible means.
(6) That public confidence in government at all levels can best be sustained by assuring the people of the impartiality and honesty of the officials in all public transactions and decisions.
(7) That the concept of attempting to increase financial participation of individual contributors in political campaigns is encouraged by the passage of the Revenue Act of 1971 by the Congress of the United States, and in consequence thereof, it is desirable to have implementing legislation at the state level.
(8) That the concepts of disclosure and limitation of election campaign financing are established by the passage of the Federal Election Campaign Act of 1971 by the Congress of the United States, and in consequence thereof it is desirable to have implementing legislation at the state level.
(9) That small contributions by individual contributors are to be encouraged, and that not requiring the reporting of small contributions may tend to encourage such contributions.
(10) That the public's right to know of the financing of political campaigns and lobbying and the financial affairs of elected officials and candidates far outweighs any right that these matters remain secret and private.
(11) That, mindful of the right of individuals to privacy and of the desirability of the efficient administration of government, full access to information concerning the conduct of government on every level must be assured as a fundamental and necessary precondition to the sound governance of a free society.
The provisions of this chapter shall be liberally construed to promote complete disclosure of all information respecting the financing of political campaigns and lobbying, and the financial affairs of elected officials and candidates, and full access to public records so as to assure continuing public confidence of fairness of elections and governmental processes, and so as to assure that the public interest will be fully protected. In promoting such complete disclosure, however, this chapter shall be enforced so as to insure that the information disclosed will not be misused for arbitrary and capricious purposes and to insure that all persons reporting under this chapter will be protected from harassment and unfounded allegations based on information they have freely disclosed."
Todd Granger
And to this democracy for which it stands…
Todd Granger
William Eaton(R), a former school teacher, and Jefferson's U.S. Ambassador to Libya…seems he made it back home, that complex civilization of red, white and blue, didn't make shades grey.
Print more money, like Greece today a complex civilization, where Plato's Republic was lost long ago, their complex civilization also on fire today.
Pay us the tribute money, we love you democrats for democracy!
When Jefferson became president in 1801 he refused to accede to Tripoli's demands for an immediate payment of $225,000 and an annual payment of $25,000. The pasha of Tripoli then declared war on the United States. Although as secretary of state and vice president he had opposed developing an American navy capable of anything more than coastal defense, President Jefferson dispatched a squadron of naval vessels to the Mediterranean. As he declared in his first annual message to Congress: "To this state of general peace with which we have been blessed, one only exception exists. Tripoli, the least considerable of the Barbary States, had come forward with demands unfounded either in right or in compact, and had permitted itself to denounce war, on our failure to comply before a given day. The style of the demand admitted but one answer. I sent a small squadron of frigates into the Mediterranean. . . ."
The American show of force quickly awed Tunis and Algiers into breaking their alliance with Tripoli. The humiliating loss of the frigate Philadelphia and the capture of her captain and crew in Tripoli in 1803, criticism from his political opponents, and even opposition within his own cabinet did not deter Jefferson from his chosen course during four years of war. The aggressive action of Commodore Edward Preble (1803-4) forced Morocco out of the fight and his five bombardments of Tripoli restored some order to the Mediterranean. However, it was not until 1805, when an American fleet under Commodore John Rogers and a land force raised by an American naval agent to the Barbary powers, Captain William Eaton, threatened to capture Tripoli and install the brother of Tripoli's pasha on the throne, that a treaty brought an end to the hostilities. Negotiated by Tobias Lear, former secretary to President Washington and now consul general in Algiers, the treaty of 1805 still required the United States to pay a ransom of $60,000 for each of the sailors held by the dey of Algiers, and so it went without Senatorial consent until April 1806. Nevertheless, Jefferson was able to report in his sixth annual message to Congress in December 1806 that in addition to the successful completion of the Lewis and Clark expedition, "The states on the coast of Barbary seem generally disposed at present to respect our peace and friendship."
In fact, it was not until the second war with Algiers, in 1815, that naval victories by Commodores William Bainbridge and Stephen Decatur led to treaties ending all tribute payments by the United States. European nations continued annual payments until the 1830s. However, international piracy in Atlantic and Mediterranean waters declined during this time under pressure from the Euro-American nations, who no longer viewed pirate states as mere annoyances during peacetime and potential allies during war.


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Designer Brand Printing Backpack Women's PU Leather
Item Type: BackpacksBackpacks Type: SoftbackBrand Name: worthfindCarrying System: Arcuate Shoulder StrapTechnics: JacquardExterior: NoneRain Cover: NoInterior: Interior Slot PocketHandle/Strap Type: Soft HandleClosure Type: ZipperDecoration: RivetGender: WomenPattern Type: SolidStyle: FashionLining Material: PolyesterMain...> See more product detail
Item Type: Backpacks
Backpacks Type: Softback
Brand Name: worthfind
Carrying System: Arcuate Shoulder Strap
Technics: Jacquard
Exterior: None
Rain Cover: No
Interior: Interior Slot Pocket
Handle/Strap Type: Soft Handle
Closure Type: Zipper
Decoration: Rivet
Gender: Women
Pattern Type: Solid
Style: Fashion
Lining Material: Polyester
Main Material: PU
Capacity: Below 20 Litre
Model Number: printing backpack ou0121136
Material: PU Leather
Color: White,Black,Pink,Gold,Silver
Size: L25*H20*W12 CM
Style: Backpack,school bags,shoulder bags
Backpack Usage: Daily Backpack
Capacity: Below 20 Litre
How long will my order take to arrive?
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|AVAILABLE, dispatched immediately
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|AVAILABLE, dispatched within (specified) days
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|AVAILABLE, from Overseas
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|15 to 60 Days
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Goods may be returned only when defective, damaged or if the product supplied is not the same product as what was ordered. If the Goods are defective in any way this must be reported as soon as reasonably possible after the product having been delivered to you and must be returned to us within a period of 180 days after delivery. If the Goods are not the same as what was ordered this must be reported within 24 hours of delivery. Any damage must also be immediately reported, within 24 hours of delivery.
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Students of Education studies need not worry about paying for over-priced textbooks anymore – renting textbooks is an option! Education textbooks – for example NCLEX-RN® Review (Nclex-Rn Review (Mcgraw-Hill)) by [Margaret Dahlhauser], and Study Guide to Accompany Fundamentals of Nursing by [Geralyn Ochs, Patricia A. Castaldi, Patricia A. Potter, Anne G. Perry] – are often some of the most frequently updated books by Publishing companies. The field of Education is constantly changing, and new editions can come yearly and at a huge cost to students who continually buy new books. So why buy when you can rent cheap textbooks? There are plenty of Education books to rent – BookRenter has of them all!
Used book sales can be a cheap option as well, but often can be more expensive than textbook rentals. However, there are very few return policies with used books, and especially when taking Education classes, buying a used book can be dangerous and costly.
RentList Price:$44.95
RentList Price:$19.95
RentList Price:$86.95
RentList Price:$24.95


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Enterprise class JIRA and HPE ALM/QC integration
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Version 1.0.0 • JIRA Server 4.0 - 7.2.10 • Released 2016-05-10
Update for JIRA 7 version compatibility


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This little wheelbarrow is the tool of choice for hauling flowers, grass clippings, toys, and other treasures. Not only
does it look like a real wheelbarrow, it is a real wheelbarrow, with a red steel tray, a black triangular steel
undercarriage, and finished hardwood handles. The tray has no-scratch edges and is 20 inches long, 16 inches wide, and 4
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inches from the floor and is 32 inches from the front of the tray to the ends of handles. The whole thing weighs a
little more than 7 pounds. --Louise Carter