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Expanding the Reach and Impact of
|Table of Contents
|Executive Summary (Stand-Alone)
|Preface: A Vision of e-Health Benefits for All
|Executive Summary
|Chapter 1. Introduction
|Chapter 2. Mapping Diversity
to Understand Users' Requirements for
e-Health Tools
|Chapter 3. Assessing the Evidence Base for e-Health Tools for Diverse Users
|Chapter 4. Strategic Factors in Realizing the Potential of e-Health
|Chapter 5. Partnerships for Meaningful Access
|Appendix 1. Environmental Scan of 40 e-HealthTools
|Appendix 2. Project Interviewees, Experts Consulted, and Reviewers
|Appendix 3. Chapter 3 Literature Review Summary
|Appendix 4. A Comparison of Internet Use and Health Status of Populations That Experience Health Disparities
Chapter 2. Mapping Diversity to Understand Users' Requirements for e-Health Tools (Part 2)
User Characteristics That Influence e-Health Tool Use
Public health interventions typically rely on broad demographic categories to identify who is affected by an issue, risk factor, or disease. Those most affected become the targets for an intervention. These demographic categories—including race, ethnicity, gender, age, income and education levels, and disability status, among others—are the basis for much of the current debate on the nature and extent of health disparities (HHS 2000, 2005a).
One of the original purposes of the present study—a purpose that could not be wholly fulfilled because of a lack of existing research and publicly available data—was to identify and analyze factors in addition to demographics that affect the adoption of e-health tools by those population segments most affected by health disparities. As noted throughout the report, studies suggest that populations that experience health disparities are also likely to experience disparities in technology access and use. Beyond these broad observations, however, little information addresses factors related to users' motivation, engagement, and understanding of e-health tools and their relevance to strategies to promote greater use. The IOM Committee on Communication for Behavior Change in the 21st Century found that "data that provide a much deeper and more sophisticated understanding of how specific beliefs and behaviors and health status covary across the U.S. population and of how health behavior is shaped by sociocultural processes are not available. . . ." (IOM, 2002, p. 15).
Demographic characteristics or functional skills, such as low literacy, novice computer skills, and limited English proficiency, are the main factors that have been used to characterize user groups to date. Gender, education, income, and age are strong determinants of interest and behavior in health information-seeking across media, according to a review of prevention communication and media use (Lieberman, Benet, Lloyd-Kolkin, et al., 2004). Regardless of ethnicity, well-educated, affluent women under age 65 are the most active health information consumers.
Studies suggest that race and ethnicity have some association with communication processes, perhaps because of the ways that race can act as a marker or proxy for cultural factors. The literature review conducted for this study (see Chapter 3) found that few studies explicitly assessed the significance of race, ethnicity, or culture on participants' interaction with and response to technologies. A few studies did recruit participants on the basis of racial and ethnic characteristics, but they did not explore the significance of cultural influences.
Race and ethnicity are highly significant variables for health status, if only because of the impact of discrimination on health disparities. However, there is often more variation within traditional demographic categories than between them. Moreover, the IOM Committee on Communication for Behavior Change in the 21st Century cautions that the use of overly broad or rigid demographic characteristics can actually exacerbate inequities by reinforcing inaccurate assumptions and stereotypes. This Committee calls for a focus on "more meaningful ways of describing heterogeneity," focused on cultural processes, life experience, sociocultural environment, economic contexts, community resources, and beliefs (IOM, 2002).
From a communication perspective, people attribute meaning and make sense of the messages, interactions, situations, and media around them; and they interact with and shape both the tools and the environments in which they live. Interactive media, including e-health tools, make these processes more obvious because they provide new opportunities to act as engaged users instead of passive receivers of information, "link(ing), think(ing) and interact(ing)" with information and other users (Cole, 2004). Individuals become involved in shaping an environment of highly personalized and private engagement with the Internet, Web sites, and interactive components.
Some researchers conceptualize the Internet as a "hybrid" medium with features of mass and interpersonal communication (Cassell, Jackson, and Cheuvront, 1998). Some of the many communication factors relevant to the analysis of e-health tools are patterns of media or technology use, values, beliefs, intentions, expectations, preferences, perspectives, capacities, and access to information and technology (Neuhauser and Kreps, 2003). The characteristics of technology are important in terms of its fit with, value for, and usability by different user groups (Badre, 2002; Nielsen, 1999; Norman, 2002).
The lack of research on psychosocial variables other than health information-seeking as well as the lack of multivariate analyses of demographic and communication factors are major gaps in the literature (Lieberman et al., 2004). A few studies have examined the motivations or level of interest of potential or actual users of e-health tools—typically health information Web sites, online communities, or provider-patient e-mails. It is easier to know who, in demographic terms, is or is not using computers and the Internet than it is to know how individuals think about what they do online and how the interaction reinforces or changes their attitudes, beliefs, values, and preferences.
Despite the paucity of research, however, some things are known about factors that influence health communication processes and audiences' interactions with media. The most influential characteristics that have some evidence of their relevance are discussed briefly below.
Language Spoken
The relevance of language spoken to the use of e-health tools cannot be overstated. If individuals or groups use one language and the tool is based on a different language, users are very unlikely to make sense of the tool and the content. English-language materials dominate the Internet, which limits the utility of the content for those who read little or no English (The Children's Partnership, 2000).
Approximately 19 percent of the population speaks a language other than English, according to 2004 Census Bureau data (U.S. Census Bureau, 2004). The majority of persons in this category are Spanish speakers (62 percent); Chinese is a distant second. Data from the Census and the U.S. Department of Education suggest that the majority of persons who speak a language other than English at home consider themselves able to function "very well" in English (Greenberg et al., 2001; U.S. Census Bureau, 2000). Overall, the Census Bureau reports that 92 percent of the population over the age of 5 years report that they do not have difficulty functioning in English (U.S. Census Bureau, 2000). Census data indicate that approximately 4 percent of the population is "linguistically isolated" (U.S. Census Bureau, 2000). Despite this picture of English-language functioning, these data do not speak to issues of language preferences of different groups, the significance of language as an element of culture, or the role of language in perceptions of health and illness.
"Linguistic appropriateness" may seem straightforward, but it is not. Fulfilling the proviso that communication should be in the primary language of the target audience is not simple for large and diverse population groups, given the number of versions of a given language. For example, Spanish speakers present an interesting example of the complexities of linguistic appropriateness. This population segment is both culturally and linguistically diverse, coming primarily from multiple countries in Latin America and the Caribbean and with distinct cultural origins related primarily to Africa, indigenous America, and Europe. Despite the cultural relevance of slang, dialect, and vocabulary, there is often an imperative to identify a "common" Spanish that will function cross-culturally (Schroeder, Trowbridge, and Price, 2002). One of the few general studies of factors relevant for Hispanic groups' use of the Internet found that Hispanics encounter many barriers when trying to locate Spanish-language health information online (Schroeder et al., 2002).
At the same time, market research reports on Hispanics' Internet use indicate that they are going online faster than any other segment and are finding content of interest in the categories of communication (e.g., instant messages), entertainment (particularly music), and product information (Hispanic Market Weekly, 2006). When they perceive the relevance of the content, Hispanics are willing to go online to "compare prices, see features, learn about benefits, and then decide on a brand or purchase," according to the publisher of AOL Latino (cited in Hispanic Market Weekly, 2006).
Small-scale studies of the health information needs and preferences of Asian Americans, Native Hawaiians, Pacific Islanders, and Native Americans suggest that lack of content in the first languages of ethnic groups and inexperience with Internet resources are major barriers to greater use (Hsu, 2003a, 2003b). However, these factors have yet to be analyzed in terms of their contribution to overall lower rates of Internet usage and demand for e-health tools. For example, in a national survey of unpaid caregivers, only 5 percent reported that "finding non-English educational materials" was an unmet need (National Alliance for Caregiving and AARP, 2004).
In the scan of e-health tools conducted for this report (see Appendix 1), language and literacy emerged as two critical considerations in the design of successful tools. Even if developers did not report using any other methods to account for audience variations, they did mention creating understandable materials as design and content priorities. Designing for a stated reading grade level seemed to be the most popular strategy to make content more understandable. Providing content in Spanish was the most popular alternative to English.
Both these strategies have their own problems and raise a number of issues concerning the utility and comprehensibility of content. Even when content developers attempt translation, the quality of translations and the readability of materials can present problems. For example, translations can be of poor quality and reproduce problems, such as jargon and unfamiliar terms, that were features of the original text. Texts that meet a stated reading grade level can still make it difficult for users to understand the core meaning. Applying a health literacy approach that engages intended users in the development of the content from the beginning and focuses on assessing usability and understanding seems the most promising mechanism to address issues of language and literacy.
Socioeconomic Position
IOM proposes that the most important forms of diversity to pay attention to in health communication are those associated with "substantial disparities in health status and outcomes" that also represent differences in "health behavior and its antecedents" (IOM, 2002, p. 7). Individually and collectively, the components of socioeconomic position—including income, employment status, wealth, education, housing, and neighborhood environment—influence health, health behavior, and factors involved in health communication. IOM's Promoting Health report discusses the relationships among these factors (2000). Communication theory from the 1970s proposed the existence of a "knowledge gap," which represents the divide between higher socioeconomic persons who pay closer attention to and have greater access to information than lower socioeconomic persons (Tichenor, Donohue, and Olien, 1970). In the e-health arena, socioeconomic factors are major determinants of the elements of meaningful access, as discussed above.
Preliminary analysis of national data from the Health Information National Trends Survey, conducted by the National Cancer Institute (NCI), suggests that income and education levels, as well as gender and age, strongly influence the amount of attention people pay to health topics (Hesse, 2003). A study by Tu and Hargraves indicates that level of education is the most important predictor of health information-seeking; 55 percent of people with postgraduate education said they sought health information, compared with only 25 percent of those without a high school diploma (2003). Education level is also strongly associated with literacy skills, which are a component of health literacy. The relationship between education and literacy likely goes both ways: those who stay in school longer likely have stronger literacy skills, and those with stronger skills likely stay in school longer. This relationship indicates that there is much to learn about how both education and literacy affect people's access to, interest in, and engagement with health information and the pathways for development of communication capacities.
An estimated 54 million Americans—20 percent of the population—have disabilities (HHS, 2000). Disability, by definition, involves the interaction of impairments and environmental barriers; removing or reducing a barrier can reduce a disability. The types of impairments can include visual, hearing, mobility, cognitive, and learning disabilities. Each type of impairment corresponds to a set of accommodations needed to reach a particular audience segment with effective e-health resources. Disabilities affect people of all ages, but the proportion of the population affected increases with age; therefore, because the U.S. population is aging, the proportion of Americans with disabilities is growing (HHS, 2005b). There are many crossovers between the topics discussed in this section and those on the characteristics and communication needs of older adults and family caregivers, described below. Although people with disabilities are not necessarily in poor health, they are at increased risk of secondary conditions and may have less access to health services and medical care. Health promotion to improve functioning and reduce the incidence of secondary conditions has been shown to be effective (HHS, 2000).
A report by the Pew Internet & American Life Project includes a "special analysis" on Americans with disabilities (Lenhart et al., 2003). The research shows that 38 percent of Americans with disabilities use the Internet, compared to 58 percent of the entire population. Users with disabilities are more likely than the general population to have access only at home (58 percent versus 44 percent, respectively) as well as more likely to look for medical information online (75 percent versus 59 percent, respectively). The Pew research also yielded insights into the reasons persons with disabilities give for not going online—some of which, such as misconceptions about the Internet, are amenable to solution (Lenhart et al., 2003).
For people with disabilities, digital divide issues apply not only to Internet access but also to a broad set of assistive and adaptive technologies that increase accessibility of all kinds. Some of these technologies, which have been likened to "electronic curb cuts," enable access to the Internet and other digital resources for people with disabilities. Physical barriers to Internet use—or, alternatively, accommodations—can exist at many points, including the public access computing site, the computer terminal, the Web site, the Internet service provider, the browser, and the Web-based platform. Designing for persons with impairments was rare in the 40 e-health tools reviewed for this report (see Appendix 1). Only one makes specific accommodations for people with hearing or visual impairments.
Once physical access to computers and the Internet is achieved, the next set of issues relates to the design, content, and delivery of digital information resources. Paradoxically, although the Internet can reduce the isolation that can come with disability, it also presents its own barriers that must be overcome before it can be useful. The specific barrier, and thus the solution, varies with the impairment, and a detailed review of the often quite technical ways to achieve accessible Web design is beyond the scope of this brief overview. The creator of cascading style sheets, one such mechanism, points out that Web-based information involves the interaction of "content and presentation," and these have to be addressed separately in order to successfully communicate with people with visual and hearing disabilities (Bartlett, 2002).
The types of accommodations in content and presentation for people with disabilities can be beneficial to other e-health audience segments as well, such as seniors and people with limited literacy or English proficiency. The accommodations include multimedia presentation, breaking text into small chunks, and allowing users to control font size and other visual attributes. Techniques such as these, together with general principles of user-centered design and usability testing (described below), can result in e-health resources that are beneficial to all people, including those with disabilities.
The problem of inadequate research to guide design and content decisions figures in this context as it does elsewhere. Apart from the few references noted above, the present study found no empirical research on health communication issues for people with disabilities. This finding was confirmed by staff members of the National Center on Birth Defects and Developmental Disabilities, Centers for Disease Control and Prevention, who conducted an unsuccessful literature search on health communication and disability in preparation for a health promotion campaign for women with disabilities (J. Thierry, personal communication, October 2004).
Developers can draw on a combination of laws, guidelines, and evaluation tools in achieving and measuring accessibility. Federal law on accessibility is in Section 508 of the 1973 Rehabilitation Act (revised based on the Americans With Disabilities Act), which requires that Federal agencies' electronic and information technology be accessible to people with disabilities. An article in the Journal of Medical Internet Research reported on research that evaluated 108 Web sites for consumer health information according to disability accessibility guidelines; the researchers found that Government and educational sites are the most accessible, presumably at least partly because of Section 508 requirements for Government sites (www.section508.gov/). No site met all the criteria, however (Zeng and Parmento, 2004). Although the requirements only apply to Federal sites, some private Web developers choose to comply as well. (See Chiang and Starren, 2004, for another published evaluation of Web access for people with disabilities).
The World Wide Web Consortium (W3C) Web Accessibility Initiative has developed its own Web Content Accessibility Guidelines (WCAG) for determining Web page accessibility (www.w3.org/WAI/). The Web site of the International Center for Disability Resources on the Internet leads to a long chain of useful resources (www.icdri.org/prodserv.htm). The same is true of "Bobby," a Windows-based tool that provides a free service to analyze Web pages for their accessibility to people with disabilities, to identify and repair barriers to accessibility, and to facilitate compliance with accessibility guidelines such as Section 508 and W3C's WCAG (http://webxact.watchfire.com/). One expert reports that current Web accessibility guidelines do not address cognitive disabilities very well, as most of the focus to date has been on visual and sensory disabilities (R. Appleyard, personal communication, October 2004, citing Wehmeyer, 1998, 1999).
Age, Developmental, and Role Issues
As noted above, age is one of the most important factors affecting health status, information-seeking, media use, and Internet behaviors. Yet little attention has been paid to life course, roles (apart from parenting), and experiential variables that are often associated with age. Each phase of life has its own developmental perspective, obstacles and facilitating factors, and unique experiences that influence interests and capacities related to health communication. For example, unpaid caregiving by adults for adults is emerging as a critical policy issue as well as an experiential factor for millions of Americans. A survey by the National Alliance for Caregiving and AARP estimates that approximately 44 million adults provide unpaid care to other adults (National Alliance for Caregiving and AARP, 2004). The survey finds that "the typical caregiver is a 46-year-old woman who has at least some college experience and provides more than 20 hours of care each week to her mother." Approximately one-third of caregivers rely on the Internet for information to help them cope with their caregiving (National Alliance for Caregiving and AARP, 2004).
Internet use is inversely associated with age. Only 22 percent of people older than age 65 have been online (Fox, 2004), compared with 96 percent of children and adolescents age 8 to 18 (Rideout, Roberts, and Foehr, 2005). The higher percentage of young people online is to a great extent due to school-based access, whereas home access remains a concern for the large segment of low-income children. Home-based access is also important for older adults, who are more likely to be out of the workforce or homebound. Partly because of young people's greater exposure to technology, training, and technical assistance opportunities, they show greater comfort and facility with technology than older adults. (Indeed, some programs involve them as trainers, as seen in Chapter 5.) Older adults are more likely than persons in other age groups to have physical or cognitive impairments that further limit their ability to use computers and navigate the Internet (Morrell, Dailey, Feldman, et al., 2003; SPRY Foundation, n.d.).
However, both groups have shown considerable interest in health topics. Older adults use their Web access for health purposes more intensively than other age groups (Fox, 2004); and 68 percent of 15- to 24-year-olds and 50 percent of all 8- to 18-year-olds who have been online have used the Internet to get health information (Kaiser Family Foundation, 2001; Rideout et al., 2005).
One study is suggestive about the relationships among age, experience with both health and technology, and use of e-health tools. It examined participation and nonparticipation rates by primary care patients with type 2 diabetes in an Internet-based diabetes self-management support program (Feil, Glasgow, Boles, et al., 2000). The researchers found no significant differences in gender, insulin use, computer familiarity, or computer ownership. The significant differences between participants and nonparticipants were related to age and years since diagnosis; younger patients with more recent diagnoses were more likely to participate.
A relatively recent development of special relevance for older adults, including the significant percentage who are caregivers, is the growing use of disease management tools by healthcare organizations. Older adults have the largest incidence of costly chronic illnesses, and major institutions such as the Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Veterans Affairs (VA) are investing in the development of e-health tools to help patients manage their diseases. These programs provide training and sometimes the necessary equipment. If this trend continues, at least a small segment of older adults may be induced to become users of electronic communication and information for personal health management. In addition, the Web portal being developed for Medicare beneficiaries introduces them to an e-health tool that contains content of direct relevance.
Although the specifics vary considerably, both older and young age groups have style preferences, technology use characteristics, and health content interests that are often not served by standard e-health tool content, design, and architecture and that are best accommodated through targeted tools. The top priorities for meeting the needs of older and younger users include simplicity of design and content and the use of multimedia presentations. One example of applying good design practices and research-based knowledge of intended users is the Web site for older adults sponsored by the National Institutes of Health (www.nihseniorhealth.gov). The site is designed to accommodate limited literacy levels, cognitive and physical impairments, and different modes of learning (e.g., textual, visual, auditory). The Web site's approach closely matches the general principles of good Web design for all users promulgated by the Federal Government (see www.usability.gov and www.firstgov.gov/webcontent). Many e-health tools designed for young people have behavior change and prevention purposes; here the challenge is to make them interesting and attractive.
Interest in Health Information
Health information-seeking attitudes and behaviors, as well as attitudes and behaviors toward health care and healthcare providers, have been identified as a useful basis for segmentation with respect to e-health communication. Researchers and expert observers classify people in terms of their degree of independence and initiative in relation to health care and health information-seeking. For example, research by the communication firm Porter Novelli found that the public can be segmented into five health information types, based on two broad sets of characteristics—degree of reliance on physicians for health information and level of activity in seeking out such information (cited in Lieberman et al., 2004).
Long-time online health activist and analyst Dr. Tom Ferguson proposes a new vocabulary to capture the shift in individuals' orientation to information and their health. Instead of "consumers" or "patients," he sometimes speaks of "medical end users," "e-patients," and "prosumers," the last term coined by Alvin Toffler in The Third Wave to capture the blurring of the distinction between service providers and recipients (Ferguson, n.d.). Similar to the Porter Novelli categories, Ferguson divides patients and consumers into three groups—passive patients, concerned consumers, and health-active prosumers—and he predicts an increasing shift into the third group. In addition to information, he stresses the importance of communication among consumers, such as in online and face-to-face support groups.
Dr. Judith Hibbard has developed a multifaceted typology to assess levels of "health activation" in patients and consumers (Hibbard, 2003).2 Her work primarily concerns health behaviors, but it is highly relevant to health information-seeking and use. Hibbard's "activation measure" assesses patients along two axes, one listing actions the individual can take related to personal health and the other listing the capacities to be assessed with respect to those actions (Table 3).
Table 3. Domains for Measuring Activation Measure
Source: Judith Hibbard, Dr.P.H., University of Oregon. Slides presented at Center for Information Therapy conference, September 2003.
Hibbard states that consumers with higher activation are more likely to take such actions as read about possible complications when taking a new medication, seek out health information, visit a health Web site, and know about treatment guidelines for their condition. The relevance of her work for the present report is summarized in two questions she poses:
Attitudes About Privacy and the Protection of Personal Health Information
Since the initial framing of this project and drafting of the report, the issues of protecting personal privacy and ensuring the confidentiality of personal health information have moved to the top of the agenda in any discussion of consumer e-health tools, particularly personal health records. Numerous documents assert that there must be strong privacy protections for e-health tools that collect and store personal health information; the need for strong protections has been particularly noted in relation to personal health records (Markle Foundation, 2005; NCVHS, 2005a). Several national surveys have been conducted to gauge public understanding of privacy issues and the public's expectations about privacy protections in an e-health environment (California HealthCare Foundation, 2005; Markle Foundation, 2005; Westin, 2005). The findings are consistent that a majority expect strong privacy protections, whether through policies, laws, or technologies.
The findings of two surveys suggest, however, that as in most other areas, segments of the public can be distinguished on the basis of their attitudes toward privacy, and likely by their privacy-protecting behaviors as well (California HealthCare Foundation, 2005; Westin, 2005). As with other factors discussed in this chapter, attitudes about health information privacy and e-health tools have not been well studied. It is possible to infer from user behavior in online communities, however, that participants do not perceive all disclosures of personal information as equal. Participants often post highly personal and identifiable information in online chats and blogs; yet a disclosure of the same or similar information as a result of a security breach of a digital record system would likely be treated as a privacy violation.
In numerous hearings on personal health records, the National Committee on Vital and Health Statistics consistently heard testimony that the key factor for consumers is their ability to control their own information and records and protect their privacy (NCVHS, 2005a, 2005b). In light of the preceding discussion on the diversity in information-seeking behaviors and activation toward health, the need for control and sensitivity to disclosures also should be treated as having a range of values rather than dichotomous values of either total or no control and sensitivity to disclosure of personal information.
Designing for Diverse User Groups
Given the number of factors that must be considered when designing tools to meet the needs of diverse users, it is clear that a focused effort by developers is required. Engaging persons with low income or education, different ethnic groups, and adults with limited literacy skills in health communication requires sophisticated audience segmentation techniques that involve intended users of the information in interactive roles (Freimuth and Mettger, 1990). Targeting (audience segmentation) and tailoring on communication factors are considered promising strategies for user-centric design in the electronic environment (IOM, 2002). Both are employed to engage users by personalizing and individualizing information based on demographic, behavioral, motivational, psychosocial, or physical characteristics (Brug, Oenema, and Campbell, 2003).
Targeting or audience segmentation is selecting groups of users based on common characteristics related to behavior, health status, or some other common factor. The process of targeting generally happens in the following sequence. First, a target audience or market is identified, related to a healthcare or public health need or a business opportunity. Then, the audience is analyzed, and if necessary, segmented, to optimize service and impact. In some cases, specialized products and services are developed for existing audience segments or new target audiences. Some tools integrate tailoring capabilities that make it possible to accommodate individual differences. This sometimes involves "cultural tailoring," or tailoring to enhance the impact for individuals in targeted audience groups (IOM, 2002).
Tailoring is designed to simulate personal counseling in that the individual is surveyed and the responses are used to generate individualized information and feedback (Brug et al., 2003; IOM 2002).3 Tailored information has been shown to be more satisfying, read more deeply, seen as more personally relevant, and more often discussed with others (Brug et al., 2003). "First-generation" tailoring involves using a computer program to generate the individualized feedback that is presented to the user in a print-based format, such as a letter or newsletter. "Second-generation" tailoring takes advantage of the computer's ability to immediately deliver tailored information and eliminates the lag time incurred while waiting for printed, tailored information to be presented (Oenema, Brug, and Lechner, et al., 2001).
Dr. Victor Strecher and Dr. Kevin Wildenhaus at the University of Michigan are leading practitioners of computer-based tailoring in health communication. They prefer tailoring over targeting to enhance the effectiveness of health communication messages. When asked to identify the intended user groups or populations served by the e-tools his lab develops, Dr. Strecher stated, "Targeted messages miss the important variation in behavioral predictors that are often found within demographic or even psychographic groups. Tailoring identifies these predictors at an individual level and addresses them." He further stated, "Our most recent research suggests that deeply tailored materials seem to help the people who need them the most—those with low perceived capabilities in solving problems on their own. Tailoring may particularly help these individuals by providing a very individualized plan and by conveying information in a more vivid manner" (V. Strecher, personal communication, March 16, 2006). The National Cancer Institute (NCI) has funded Dr. Strecher's lab to work on identifying the "active ingredients" that make computer-based tailoring successful.
Enhancing the usability of Web sites is another strategy to make e-health tools more fully accessible to all users (Koyani, Bailey, and Nall, 2003). In the Government context, the HHS Web team and NCI have played a leading role in developing and implementing a usability approach to improve the navigation of Web sites (http://usability.gov). Usability testing can be used on its own or as part of a broader approach known as user-centered design.
User-centered design is an iterative process that assesses tools throughout the design life cycle in terms of users' preferences and performance. The process includes task and user analysis and participatory methods, such as focus groups and surveys, to determine the interests and capacities of prospective users. Later, usability testing determines how well users are able to use a given tool, with the goal of uncovering problems that can be fixed prior to launch. The Think Aloud protocol is a method in which users describe their thought processes as they make their way through a Web site. Other methods include contextual inquiry (observation and testing), interviews, journals, various forms of inspection, and performance measurement.
The major criteria are users' success in finding information, including accuracy and speed; related criteria are likability, learning, and retention. For example, in one small study, adults with low literacy were able to learn Web navigation skills easily and use interactive features such as active graphics and pull-down menus when the instructions were simple, direct, and noticeable (Zarcadoolas et al., 2002).
In an effort to identify the types of user-centric strategies currently in use by e-health developers in the field, project staff interviewed 54 developers and other experts about 40 e-health tools designed wholly or partly for diverse users (see Appendix 1). Each of the tools proved to be distinctive in the way it combines functions and features to serve intended users. The analysis of this set of tools suggests the number of user variables that can be considered and the many ways developers think about enhancing relevance and engagement. These developers report that they often consider literacy levels relevant to the use of e-health tools, although the literature review in the next chapter indicates that few studies have systematically included persons with limited literacy skills, designed tools as health literacy interventions, or assessed health literacy as part of the evaluation of the tool.
The scan of 40 e-health tools indicates that developers employ a variety of strategies to enhance the connection between the tools and their intended users. The main strategy appears to be one of targeting or segmentation. The findings align with the observations made in the IOM report, Speaking of Health: Assessing Health Communication Strategies for Diverse Populations, about the adaptation of health communication for diverse audiences (2002):
Often, tools are designed for large population segments based on public health priorities, such as kids with diabetes or adult smokers who are trying to quit. Several developers mentioned the economic impracticality of designing highly segmented or individually tailored tools. Many tools, such as public Web sites, serve anyone who finds the site on the Internet. Others may serve anyone in a more restricted but still heterogeneous group, such as members of a particular health plan or employees of a large organization. Targeting is often based on one or two dominant factors, such as shared health issues, gender, or age. Health condition, risk behavior, and age were the most popular factors for identifying intended users of e-health tools. Some developers stated that the most important characteristic in targeting was the shared health issue, such as people with cancer and their caregivers, rather than demographic factors. The implication is that shared health experience is the basis for coming together via technology. For the majority of the 40 tools, medical conditions (e.g., diabetes) or health-risk behaviors (e.g., smoking) define the audience.
In all, 19 of the 40 tools in the scan were described as having one or more special features for one or more diverse groups. Most consider multiple audience characteristics. The bases for audience segmentation among the tools (listed in order of frequency) are age, language, race/ethnicity, gender, income, geographic location, and disability or sensory impairment. The segments targeted by these tools include:
Added to these variations, several e-health tools have versions for intermediaries or adjunct users such as childcare providers, teachers, parents, school friends, and public health workers. The large group of healthcare tools (i.e., tools made available by healthcare providers or organizations for use by their consumers/patients) are also used by staff members of the healthcare organization, such as nurses, administrative staff, and personal physicians, and these are distinct user groups from the perspective of tool development and evaluation.
The interviews offer examples of developers who adapted a single basic program with multiple subprograms based on factors such as gender, age, or severity of disease. One company has 22 versions of its basic program. This finding suggests that the often-discussed potential of technology to create customized versions of generic interventions is starting to be realized in the marketplace through a variety of approaches.
This chapter identifies several concepts, factors, and strategies that can be used to design e-health tools for diverse users. The concepts of health literacy and meaningful access highlight the importance of ensuring physical access to information and technology and designing useful, understandable content. The IOM has already called for greater attention to communication factors in the design of health information, messages, and e-health tools. This chapter elaborates on many of the critical factors for user-centric design. If the vision of e-health tools for all is to be realized, these factors, along with others that have yet to be fully articulated, will require further research and integration into tool design and development. A scan of the current field of e-health tools indicates that developers are beginning to address issues of diversity, but do not yet have strategies and approaches that go much beyond traditional public health targeting based on demographic characteristics. Developers will need to engage consumers more fully in the research and design process and probe those factors that shape attitudes, beliefs, values, expectations, and experiences in relation to health and technology.
2This discussion is based on several of Dr. Hibbard's articles and on her slides, "Measuring and Improving Patient Activation," for a presentation to a September 2003 conference of the Center for Information Therapy. www.informationtherapy.org/conf_mat03/final_pres/Hibbard.pdf.
3For a book-length treatment on computer-based tailoring, see Kreuter, Farrell, Olevitch, et al., 2000.
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Aim for your best grade with this guide written specifically for the 2012 linear GCSE Geography for Edexcel A Specification. This guide will help you revise effectively in the way you want to, allowing you to plan and pace your revision according to your learning needs, and to adapt and personalise with your own notes. Written by an experienced author, teacher and examiner, you can be confident that this guide will cover the facts and ideas you will be expected to recall and be able to use in the exam. It accompanies the fourth edition of Tomorrow's Geography for Edexcel GCSE Specification A Student's Book. - Understand what is required in the exam with exam tips and guidance - Improve your examination skills with exam practice questions and model answers online - Check your understanding of the content and key terms with engaging activities and explanations of key concepts - Plan and pace your revision with My Revision PlannerAim for your best grade with this guide written specifically for the 2012 linear GCSE Geography for Edexcel A Specification.
|Tomorrow's Geography for Edexcel Gcse, Specification a
|Steph Warren, Mike Harcourt
|- 2013-09
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subset: commoncrawl


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Would You Eat A Football Made Of Bologna?
Forget seven-layer dip: this is the Best. Super Bowl Snack. Ever.
It's a near regulation-size football made of Lebanon bologna that comes with real laces and threads.The sweet, smoked sausage inside the casing gets its name from Lebanon County, Pa, where it is often produced.
This packed pigskin is available at Dietrich's Meats in Krumsville, Pa., northwest of Philadelphia and just outside the Pennsylvania Dutch Country. No wonder there aren't any Amish dudes in the NFL. Who wants to run, pass or kick a football when you can eat it?
Anyway, the Magill Report Fantasy Football League, and presumably other fantasy football leagues, honor their annual champs with a feast of the meat football. But why wait till next year when the Big Game is this Sunday? Get yours now.
The most manly thing to do is to buy one, take a bite at kickoff and pass that ball around until it's gone. You may want to provide a mustard laced with blood pressure meds and Lipitor so your guests can enjoy… responsibly.
[Via Magill Report]


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Explosion.com's Dave Walsh looks at historical search data for both the Call of Duty and Battlefield series and details how Battlefield was once king before Call of Duty 4: Modern Warfare came out and the challenges that the series faces against the Call of Duty juggernaut now.
"Uphill battle"? What uphill battle?
You're deluded if you think Battlefield is 'struggling', and even more so if you think Battlefield 4 has anything to prove to Call of Duty: Ghosts - about which we currently know very little, might I add...
This article couldn't be more subjective if it tried.
CoD: Ghosts isn't due out for another 6-7 months yet...expect an article like this at least once a day until then...just like GTA5 *yawn* '137 reasons this will be the best GTA EVAR!'


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Team Treatment Helps Depression, Chronic Disease
Dec. 29, 2010 — More than 40% of older Americans have multiple chronic conditions, such as diabetes and heart disease, and many also suffer from depression.
These patients have the highest health care costs and the worst outcomes, but a new study suggests that a team-based approach to managing care could improve outcomes and potentially save taxpayers billions.
Researchers at the University of Washington and the Seattle-based managed care organization Group Health Cooperative published their findings in the Dec. 30 issue of The New England Journal of Medicine.
The intervention involves specially trained nurses who work closely with patients to coordinate their health care needs, paying specific attention to optimizing the treatment of depression, blood pressure, blood sugar, and cholesterol.
One year after entering the trial, patients who worked with the nurse coaches had less depression and better control of their diabetes and heart disease risk factors than patients who got standard care.
Sixty-two-year-old Dennis Revoyr, of Lynnwood, Wash., who has depression and diabetes, was one of these patients.
"I don't just feel better, I am better," Revoyr tells WebMD. "The biggest difference was that I have one person who knows everything that is going on with me."
Depression and Chronic Disease
Depression is common in older patients with chronic conditions like diabetes and heart disease, but its impact on these diseases is not well understood.
In earlier research, University of Washington psychiatry professor Wayne J. Katon, MD, and colleagues followed nearly 5,000 diabetes patients for about a decade, finding that one in four suffered from depression.
Diabetes patients with depression also experienced more complications related to their disease, including heart attacks, strokes, and kidney disease.
Katon and colleagues found that patients benefited from having a nurse case manager whose role was to integrate depression and diabetes treatment.
In their latest study, they examined an even more comprehensive treatment approach. "We hypothesized that treating depression is a necessary first step, but it alone is not sufficient to improve chronic disease outcomes," Katon tells WebMD.
The new trial included 214 patients with poorly managed diabetes and/or heart disease, randomly assigned to either standard care or the collaborative care intervention, called TEAMcare. The average age of the patients was 60, and about half were eligible for Medicare.
The TEAMcare patients were assigned a doctor-supervised nurse coach who coordinated their medical care. The nurses screened the patients for depression and recommended adjustments in blood pressure, blood sugar, cholesterol, and depression medications as needed.
Nurse coaches also worked with patients to set and achieve attainable health goals.
During the yearlong study, patients with the nurse coaches had more frequent adjustments in insulin and in medications for depression, blood pressure, cholesterol, and blood sugar than patients who got standard care.
They also achieved better control of their depression, diabetes, and heart disease and reported better quality of life and more satisfaction with medical care.
Nurse coach Susan Ruedebusch, RN, who has been a diabetes educator with Group Health for 27 years, says she has rarely seen such dramatic improvements in patients.
She ended up coaching several of her previous patients who had never made much progress before entering the study.
"We entered into a totally different relationship, where the patients set the agenda for the goals they wanted to achieve," she says. "The improvement I saw was amazing."


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A report out of the Wall Street Journal has us thinking differently about the Nexus program. According to the report, Google may be going all-in on their new Nexus strategy, partnering with not one, but multiple OEMs on Nexus devices that Google would sell directly to customers similar to its recent Galaxy Nexus offering. Google hopes to have a full portfolio of devices available by Thanksgiving, and is working on giving multiple OEM partners early access to the next version of Android, currently codenamed Jelly Bean.
This marks a stark change from Google's previous strategy, where Google exclusively partnered with one key manufacturer to provide the flagship device for its latest OS. Sources for The Wall Street Journal believe this strategy is being taken to provide Google with greater control over the operating system and apps that run on it, thus reducing the impacts wireless carriers have over devices. We assume this will be because the Nexus devices will launch with stock Android, as opposed to the custom skins manufacturers are keen on putting on their devices.
Many are speculating that the move is a response to appease manufacturers concerned with Google's acquisition of Motorola and what that means for the rest of the Android industry. Taking the potential for Google to play favorites off the table will likely persuade these manufacturers to keep producing and innovating with Android devices.
This story is obviously developing, and Google was unavailable for comment at the time the WSJ story went live. We've reached out to Google as well, and will update you as we learn more of the expanded Nexus line rumored for later this year.


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Lockable Noticeboards
Adboards Metropolitan Tamperproof Noticeboards with Covered secure doors for protection of displays and fire resistant tamperproof noticeboards. Browse our selection of internal, external lockable display boards, Adboards is one of the leading whiteboard, display signs supplier in the UK. Adboards offer a wide range of lockable internal glazed notice boards. All tamperproof boards have either a top or side hinged door with a wide choice of felt & woven fabric colours or magnetic backing. Buy buy discount available.
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Water Fun Theme Exterior Noticeboards4 variations
Dolphin 2 x A4 £330.00 £396.00 Fish 6 x A4 £370.00 £444.00 Star Fish 6 x A4 £501.00 £601.20 Turtle 4 x A4 £370.00 £444.00


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UMKC and MSU Collaborate to Provide Doctor of Pharmacy Program in Springfield
Program designed to increase numbers of pharmacy professionals in southern Missouri
SPRINGFIELD, Mo. – Missouri Governor Jay Nixon was joined by leaders from the University of Missouri-Kansas City (UMKC) and Missouri State University (MSU) today in Springfield to announce the signing of an agreement that will allow students on the MSU campus to enroll in UMKC's Doctor of Pharmacy (Pharm.D.) degree program. The announcement was made at a special ceremony at the MSU Brick City Gallery in downtown Springfield, where representatives from the two universities signed a Memorandum of Understanding to expand the program to the MSU campus.
"From small towns to big cities, Missouri needs more pharmacists," said Gov. Nixon. "When we launched the Caring for Missourians program in 2009, this was exactly the sort of collaboration and innovation we had in mind. This initiative is helping prepare our students with the education and skills they need to have a successful career in a health care field that is in demand. Working together with our universities and colleges, we're continuing to invest in our workforce to grow our economy and move Missouri in the right direction."
The UMKC Pharm.D. program expansion to MSU was developed in response to current and projected shortages of pharmacy professionals in the state, particularly in underserved rural areas. With support from Gov. Nixon's Caring for Missourians initiative, this collaboration will train pharmacy professionals to serve pharmacy healthcare needs in the southern region of Missouri. The location of the program in Springfield at MSU makes the UMKC pharmacy program more accessible for students living in the southwest region of Missouri
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About this Story
Campus: UMKC
Key words: Innovation, KC Campus, Teaching, UM System,
County: Greene


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Courtesy of: Pat Lutterman, Edina Realty-Marshall
502 Continental St Thinking of building a home....choose Carr Estates. No special assessments. Tar roads,curb&gutter,city water & sewer, underground utilities,natural gas. Sidewalk paid by homeowner.Disclosure--Broker is principal to transaction.
Listing Source - ListHub
Copyright © 2018 West Central Association of Realtors - MN. All rights reserved. All information provided by the listing agent/broker is deemed reliable but is not guaranteed and should be independently verified.


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Today's guest blogger is Richard Hatch, a featured performer of our Magic! exhibition, as well as an instructor of the Museum's Adult Magic classes. He will be performing a special evening of magic and music with his wife, violinist Rosemary Kimura, accompanied by pianist Jo Ellen Hubert, in Houston on June 12.
The Magic! exhibition currently featured at HMNS is unique in having secured the services of some of the world's leading magicians to act as "living artifacts," giving performances both close up and on the stage as an integral part of the exhibit. According to HMNS President Joel Bartsch, "As fascinating as the artifacts are by themselves, we became convinced that they were only "complete" when they were accompanied by performances—in our case both live and taped. It is only when these artifacts are animated and brought to life by talented magicians that the dialogue loop between the artifact and the museum visitor is completed."
The first performer to headline on the exhibit's stage was John Carney, one of the world's greatest sleight of hand artists. John performed at the Museum for the first two weeks, then returned after a two week break to perform for another two weeks. Tomorrow evening, May 18, John will be the featured performer on CBS's popular "Late Show with David Letterman" which is celebrating a week of close-up magic. In the meantime, a video of John performing his original "invisible" coin routine may be viewed online here and is featured in the Magic! exhibit.
Currently featured as headliner on the exhibit stage is Canadian born magician Christopher Hart, winner of many magic competitions and probably best known for his role as "Thing" in the three Addams Family movies: The Addams Family (1991), Addams Family Values (1993) and Addams Family Reunion (1998). Ironically, Christopher's stage performance has long featured a vignette with a disembodied hand, which both predates his Addams family role and was independent of his casting in that role. Even more ironic, given his Addams family casting, as a teenager he actually worked as a gravedigger and was nicknamed "Lurch" due to his lanky frame!
Christopher is currently closing his stage performances with this signature piece involving the disembodied hand that comes to life. Other highlights of his current performances at the Museum are his superb card manipulation and a demonstration of pure digital dexterity in which the entire audience is invited to participate! Christopher will only be at the Museum through June 6 so make reservations soon to come see him! He truly is "the real Thing"!
For a full listing of the performance schedule, check out the Live Show site.
To read Richard Hatch's previous blog click here.
Don't miss your chance to see Magic!, open now at HMNS.


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SANFORD — After suffering a narrow loss to South Portland earlier in the week, the Sanford High girls basketball team improved its record to 7-3 with relatively easy wins over Westbrook and Thornton Academy on Friday and Monday.
On Friday, Sanford jumped out to a 16-6 first quarter lead and increased it to 33-19 at the half on the way to a 56-36 win over the Blue Blazes at the Memorial Gymnasium.
Taylor Littlefield led Sanford with 15 points, scoring seven in the second quarter and six in the third. Morgan Fogg added 13 and Sam Adams scored 10, including a pair of 3 pointers.
Other Sanford scorers included Heather LeBlanc with seven, Janelle Cannon with six and Shelby Paiement with five.
Sanford opened up a 17-7 halftime lead and never looked back in this one. The teams played even basketball in the third quarter, each scoring eight, but Sanford topped things off in fine style, outscoring Thornton 17-8 in the final quarter to take the easy win.
Sam Adams continued her fine outside shooting, tossing in four more from behind the arc while leading Sanford with a 16-point performance. Morgan Fogg added 15 to Sanford's total followed by Taylor Littlefield with six and Heather LeBlanc and Shelby Paiement with two points each.
Sanford will play a 7 p.m. game at Massabesic on Friday, then will travel to Marshwood on Monday for a 2 p.m. game with the Hawks. On Friday, January 25, the girls will play at Scarborough.


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The combination of fabrics on the boots makes them durable, strong and practical. There's split suede leather, nylon (900 denier, super strong) covered in Mossy Oak Break-Up® camouflage, and a rubber vamp that protects the toe area. A molded foam collar provides an extra bit of comfort.
If you want women's insulated and waterproof boots that can stand up to harsh winters, get these BlizzardStalker boots from Rocky.
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At Unigo, our primary goal is to help students find free money for college. That's why we provide a quality scholarship search service ... but did you know that we are also a scholarship provider? Each month, Unigo awards a scholarship to one student who can best answer a short essay prompt in 250 words or less. We think our scholarships are pretty fun (and easy, too!). So, put on your thinking cap and apply today!
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Since there are six regular figures shown, I think this is how Jabba will be divided up.
I seriously hope you are correct though I think the reason folks are speculating on more than six pieces is due to the view from the back:Quote from: DSJ on October 24, 2009, 03:35 AMI completely agree with you on the separation of Jabba from his tail. Seven base pieces though, possibly two pieces for the rail (joint near the corner). Who knows?
I think it's pretty clear from the info Medicom has released that we're getting 1x figure and 1x Jabba piece in each box. The Medicom website clearly (well, as clear as broken English-Japanese translations can be) says:"When the bonus part which belongs to each box is combined 'JABBA THE HUTT (TM)' you complete!"
Could be a month or 2 till this set shows up on HLJ & hopefully NCS...
Hi, yes we will stock the upcoming Kubrick Star Wars Deluxe Series 1 and we should begin preorders within the next 2 months. Since the toys will be released in the summer of 2010, Medicom is expected to start their preorder campaign in January. Thanks.
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I come back to this game often and almost always get burned out by hearing an seeing the same 3 things.
Drg is for procs
Subpar DD
Drg mage still has no place in parties
Has the situation improved, or gotten worse since the level 99 update? Do I need the Mythic polearm to do well? I always wanted Gungnir more :( . I doubt I ever get either because I will mostly be doing everything solo. If I want to get seals should I be leveling another job to get into parties to get said seals? Is maining any single job even possible, or are my hopes of being a DRG all for not D: ?
If the hard news is just level WAR if you want to melee DD, or level WHM/BLM if you want to be desirable, please say so, I always knew I was taking a hard path only taking DRG past 50, but its time to actualy get into parties an see some of the game this time >.>


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U.S. stocks were little changed, after erasing earlier losses, as a drop in jobless claims and Warren Buffett's deal for H.J. Heinz Co. tempered concern over shrinking economies in Europe and Japan.
Heinz surged 20 percent after Buffett's Berkshire Hathaway Inc. and 3G Capital agreed to buy the company in a deal valued at about $23 billion. Constellation Brands Inc. soared 38% after Anheuser-Busch InBev NV offered to cede full control of U.S. distribution for Corona beer in a bid to salvage its deal for Grupo Modelo. US Airways Group Inc. dropped 8.5% after agreeing to an $11 billion merger with AMR Corp.'s American Airlines.
The S&P 500 rose 0.1 percent to 1,521.95 at 2:59 p.m. in New York, after slumping as much as 0.4% earlier. The Dow Jones Industrial Average dropped 3.17 points, or less than 0.1%, to 13,979.74. Trading in S&P 500 companies was 14% above the 30-day average at this time of day.
"There is global economic weakness and we're still constrained growth-wise," Scott Armiger, a money manager at Christiana Trust in Greenville, Delaware, said in a telephone interview. His firm has $15 billion in client assets. "It's an environment where it's easier to buy growth than trying to grow organically."
Data today showed the recession in the euro area deepened, with the worst performance in almost four years. In Japan, gross domestic product shrank an annualized 0.4%, amid falling exports and a business-investment slump.
U.S. jobless claims decreased by 27,000, the most in a month, to 341,000 in the week ended Feb. 9, Labor Department figures showed. The level of filings trailed any projection in a Bloomberg survey in which the median forecast was 360,000.
Approaching Record
The S&P 500 has climbed 6.7% in 2013 as U.S. lawmakers reached a budget compromise. It has more than doubled since bottoming in March 2009 as the Federal Reserve conducted three rounds of bond buying to lower interest rates and boost economic growth. The gauge is about 3 percent below its record of 1,565.15 reached in October 2007.
Six out of the 10 industry groups advanced in the S&P 500 as energy companies gained the most, rising 0.7%. The Chicago Board Options Exchange Volatility Index, which measures the cost of using options as insurance against declines in the S&P 500, fell 2.1% to 12.71.
Copyright 2014 Bloomberg. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.
Copyright 2014 Bloomberg. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.


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Combine besan and spices in a medium mixing bowl. Add just enough water to make a smooth paste. Gradually add more water until it is the consistency of a thick pancake batter. Add gingerroot and mix well.
Drop by teaspoonfuls into hot oil (350-375°) and fry until golden brown on all sides. When done, remove with slotted spoon and set to drain on absorbent paper towels. Let oil heat up again between batches. For a nice variation, chop an eggplant into 1/2" dice, coat with batter, and fry as above. Now add the pakoras to the cooking curry sauce and simmer for 10 minutes.


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Jack Palmer, byRené Pétillon
Self-taught artist René Pétillon made illustrations for magazines like Planète, Plexus, L'Enragé, Week-End, Vingt Ans and Penthouse before he began a collaboration with the magazine Pilote in 1972. From then on, Pétillon devoted himself completely to comics and produced a series of strips with 'Docteur Miracle'. In 1974, he created his series about detective 'Jack Palmer'. This became his most important character. 'Jack Palmer' was published in several magazines, including l'Echo des Savanes and Pilote.
Le Prince de la BD (1989)
In addition to this detective story, Pétillon drew 'Le Chien des Basketville' in L'Écho des Savanes and created science fiction stories for Métal Hurlant and Pilote. Several of his short stories were collected in albums like 'Les Carottes sont Cuites' (Humanoïdes Associés, 1980) and 'Les Aventures de Douglas Ferbanc et Vaseline' (Dargaud, 1982). Petillon also worked for Fluide Glacial (since 1975), À Suivre (since 1978) and Chic (since 1984).
Jack Palmer, by René Pétillon
For L'Echo des Savanes he wrote the scripts for 'Le Baron Noir', a comic drawn by Yves Got. As a scriptwriter, he has also worked with Jean-Marc Rochette ('Panique à Londres', 'Scandale à New York') and Florence Cestac ('Super Catho'). He was present with V.S.D. and has drawn 'Les Animous' in Le Point. René Pétillon is mostly known nowadays as an editorial cartoonist in the satirical weekly Le Canard Enchaîné.


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"I don't know what happened to North Street," Town Clerk Eileen Lowney said, looking at the 4�-inch thick book of deeds. "But it's not in here."
FAIRHAVEN — North Street, which runs between Adams and Cherry streets, looks like any other in Fairhaven. It's a quiet road with few passing cars where Christmas lights and lawn reindeer have just begun to make their appearances. It's paved, is plowed in the winter, and it receives postal and trash pickup services, just like any other public street.
Except North Street technically isn't a public street.
Six years ago, when the Department of Public Works wanted to use state funding to repave the road, officials did what the town always has to do when using state funds: Prove that the street is town-owned by looking it up in a 4�-inch thick book of deeds in the Town Clerk's Office.
"It was a formality, just to double check," Town Planner Bill Roth recalled.
But when he looked in the book, North Street was nowhere to be found. It had never been formally accepted by the town and was therefore not a public road.
"I don't know what happened to North Street," Town Clerk Eileen Lowney said Thursday, looking at the same 4�-inch thick book. "But it's not in here. If it was accepted, it would be."
Town officials hope that's all about to change. An article to officially accept North Street is on the warrant for special Town Meeting, to be held Tuesday, and Roth said there is no reason why the article should not pass.
Roth said the article would have appeared before Town Meeting six years ago when the oversight was first discovered, but that the town did not have money to conduct the required surveying until this year.
How North Street was overlooked is a mystery that has flummoxed town officials.
"It's a bit ironic, because North Street is one of the oldest streets in town," Executive Secretary Jeffrey Osuch said. "When the settlers came here, I don't think they paid much attention to the formalization of roadways. They just cut down trees and created the easiest way to get from Point A to Point B."
Back in the late 1700s, Fairhaven comprised two villages within the town of Dartmouth: Fairhaven Village in the south, and Oxford Village in the north, according to Tourism Director Christopher Richard. A river leading to a pond in what is now Cushman Park separated the two villages. To get from one to the other, residents had to walk up Adams Street, and then cross North Street.
"North Street is the oldest road going east to west above what is now Route 6," Richard said. The street is also of historical importance because it is home to the Old Stone School House, where John Manjiro received his education.
Today, residents are tickled by the idea that they've been living on an unrecognized street for so long.
"No kidding," chuckled Walter Medeiros on Thursday afternoon. "My house was built in 1865 — how was I supposed to know this wasn't a real street?"
Tony Vasques said he has lived on the street for 19 years without being aware of its status.
"It's just a nice quiet neighborhood," he said. "I had no idea."
But, that's the mystery of North Street, Roth said.
"It acts like a street," he said. "If it looks like a duck and quacks like a duck, it's a duck, right? Well, in this case, not yet."


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LocationWhite Lake, MI
8285 Highland Road
White Lake, MI 48386
New 2018 Keystone RV Passport 2920BH Grand Touring
Pack up the kids, and a few extra friends and enjoy traveling in this Passport Grand Touring travel trailer by Keystone RV. Model 2920BH features a rear bunkhouse that the kids will want to claim, a large slide out, and an outside kitchen for the chef in the bunch!
Step inside and find a front bedroom with queen size bed. There are dual wardrobes, one on either side of the bed along with overhead cabinets too.
In the main living space notice the entertainment center on the interior half wall. There is a slide out fold-down sofa and large u-shaped dinette along the road side wall. The sofa offers additional storage above and they both can be made into sleeping space for extra family or guests.
The kitchen provides all that you need to prepare and cook food for a hungry crew. There is a double kitchen sink on the L-shaped countertop that makes cleanup easy, a three burner range and refrigerator on the curb side wall. A small pantry for dry good storage is located just off the dinette slide.
A convenient bath features a tub/shower, toilet, and vanity with sink, plus overhead storage.
Lastly, the rear bunkhouse is where you will likely find the kids hanging out. There are quad bunks that are 32" x 74" including a wardrobe with TV shelf above.
Enjoy exterior storage with a front pass-through compartment, and rear road side storage too. The outdoor kitchen along the curbside features a refrigerator, single sink, double cook top, and counter workspace also.
All this and more makes this Passport Grand Touring trailer the perfect unit for a larger family!
Like most: I ask that you give Jill all the credit in the world for presenting your products in a low key, no pressure, fun and informative matter. She is the difference in your business department. Rusty is a huge asset to General RV and is worth whatever you pay him and more!! It is because of people like Rusty and Jill that will make your company successful. - Nick from Saginaw, MI
You Save: $8,347
Sale Price: $23,999
Stock# 175389
|32 ft 10 in
|Ext Width
|8 ft
|Ext Height
|10 ft 8 in
|Hitch Weight
|625 lbs
|Dry Weight
|5680 lbs
|Fresh Water Capacity
|43 gals
|Grey Water Capacity
|38 gals
|Black Water Capacity
|38 gals
|Tire Size
|Furnace BTU
|30000 btu
|Number Of Bunks
|Available Beds
|Refrigerator Type
|Double Door RV
|Refrigerator Size
|6 cu ft
|Cooktop Burners
|Number of Awnings
|LP Tank Capacity
|20 lbs.
|Water Heater Capacity
|6 gal.
|Water Heater Type
|DSI Gas/Electric
|13500 btu
|TV Info
|Awning Info
|Axle Count
|Number of LP Tanks
|Shower Type
|Tub/Shower Combo
When Cole Davis founded Keystone RV in 1996 his vision was clear: Build a quality RV loaded with features priced thousands less than other RVs on the market. To accomplish his goal, Cole would recruit and build a strong team, focus on keeping overhead low, and empower the people closest to the customer to make decisions.
Within a few short months after opening the doors, Keystone produced its very first camper. Delivering big on quality, features and value, the public fell in love with it. A star was born! As the appetite for the camper increased, new Keystone models were added to satisfy growing customer demand. Along with this tremendous growth came the need for expanded production. To meet this need more manufacturing plants were built and staffed.
From new floor plan designs to patented inventions, Keystone leads the way in product innovation. One reason is our mission to stay close to the customer. When talking with campers or visiting dealerships, our sales, product development, and service teams, are always looking for ways to improve the camping experience. And we don't stop there.
Every member of the Keystone family is encouraged to contribute to making our campers absolutely the best possible. Through something we call Kamp Keystone, our employees camp free of charge at local campgrounds in the Keystone trailers we supply. Each year hundreds of our production workers, administrative staff and service team enjoy a day (or a week) at Kamp Keystone. Their evaluation of the experience and the feedback they provide results in continued product improvements. Ask us if we use our RVs...the answer is YES!
General RV works hard to ensure the accuracy of all its listings however we are not responsible for any misprints, typos, or errors found in our website pages. Any price listed excludes sales tax, registration tags, and delivery fees. Manufacturer-provided pictures, specifications and features may be used as needed. Inventory shown may be only a partial listing of the entire inventory. Please contact us at 888-436-7578 for availability as our inventory changes rapidly. All calculated payments are an estimate only and do not constitute a commitment that financing or a specific interest rate or term is available.


text: Homes for Lease Near Me Post by Mrs. House Plans | September 18, 2017 | 1 Bedroom, 2 Bedroom, 3 Bedroom, 4 Bedroom, House For Rent, House For sale, Rental Agencies Near Me, TownHouse For Rent | 3854 Views | No Comments Homes for Lease Near Me – When you're looking for rentals, it helps to know where to start. You're in luck. All homes for sale near me has the rentals you are considering Continue Reading →


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downunder "Now a few epoxy coats and with a PU varnish, some EVA inside or even neoprene, strap and that is it! Hoping for less than 220g. Light as feather"!dragnfly wrote:Wouldnt you want some padding in there??
This looks awesome, Is there any thoughts of drainage holes, so it doesn't bucket?downunder wrote:plummet wrote:looks a bit wrinkly at the back?
swap the Double bias glass out of 1/3 weight db carbon and booya! sub 200G.
Dammit maybe I need to make my own helmet.
PS. Good choice of carbon/Kevlar. that will give you good impact resistance and strength.
PSS Have you considered that there may need to be a certain amount of flex in the helmet to absorb the impact? Super stiff may transfer the force rather than absorb it?
It's got channels at the back which makes it extremely difficult to make it perfect. The inside is fuuurfect. Which makes me think to reverse the mold to a female one. Easy peasy.
For a first run I am more than happy. A few epoxy coats and won't be visible:)
There is a flex, no probs with that. There will be more of it when cut to a final shape with more open forehead, like ie. Gath. The idea is a skin helmet, tho. With the ears protection as well (a new mold).
The absorption should come from some inner linings, foam, eva, etc.
Cheers for suggestions. Duno how to finish edges which are sharp now?
Do it! You know you can!


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When I lived in Tucson, AZ I worked in a gourmet sandwich shop that had the most delicious Tuna salad. They kept the exact recipe a secret but it was packed with fresh dill, sweet pickle and sliced almonds were scattered over top. One of the things I miss the most about Tucson is their unique sandwiches. I have been recreating them in my own ways since.
This tuna is as close as I'm ever going to get with some of my own touches added in, namely the onion and cranberries. It's insanely delicious made into a melt with wheat bread, swiss cheese and lots of crispy almonds. I bid you to make this tonight for your brown bag lunch tomorrow, you will look forward to it all morning long. If it lasts that long. You might just hear it calling to you during the night. A tasty midnight snack!
Gourmet Tuna Salad
(by Reeni)
1 (5 ounce) can solid white albacore tuna, drained
Mayonnaise (the amount based on your personal taste)
1 tablespoon fresh chopped dill or 1 teaspoon dried
1 tablespoon diced sweet pickle
1 tablespoon diced red onion
1 tablespoon dried cranberries
1 tablespoon sliced Almonds
Salt and fresh cracked pepper, to taste
Flake your drained tuna in a medium bowl using a fork. Add the mayo, dill, pickle,
onion, and cranberries. Combine and season with salt and pepper.
Serve over a salad, on a sandwich or all on its own.
Sprinkle the almonds on top.


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For growers who demand more flexibility and maneuverability during planting, Case IH is expanding its lineup of Early Riser 1250 planters.
New offerings include 12- and 16-row, front fold Early Riser planters available in a wide variety of configurations. Producers can spec their planter with the latest high-end precision farming features or as a basic value version or somewhere in between.
"These new models are the hard-working little brothers of the Case IH Early Riser 1250 24-row front-fold planter we introduced in 2007," says Alan Forbes, Case IH marketing manager for planters. And just like the 24-row 1250, the new 12- and 16-row units have an exceptionally narrow transport width of only 11 feet, 11 inches. "That width allows outstanding maneuverability during transport, even on the narrowest country roads," says Forbes.
"These new planters also offer great flexibility, with a wing flex of 21 degrees up and 21 degrees down, for excellent performance on hilly grounds and heavily terraced areas," Forbes adds. "In addition, they come equipped with our industry-exclusive Early Riser row units, which provide superior seed-to-soil contact, for earlier, more even emergence."
Another industry exclusive on all Early Riser planters: the Case IH Advanced Seed Metering system.
This highly advanced vacuum metering system features a larger diameter seed disk, providing unmatched accuracy over a wider range of seed sizes, regardless of seed type — large, small, flat or round — even at faster than normal speeds.
"This set-up is the best of both worlds," Forbes says. "Growers get the best row unit, which gets the crop out of the ground early and even.
"And the best metering system for consistent seed placement, spacing and superior depth control — all of which leads to higher yield potential."
On the new 12-row and 16-row Early Riser planters, growers can choose either on-row or bulk-fill seed hoppers. The large-capacity bulk fill option — a Case IH innovation that has become an industry standard — features two 50-bushel hoppers for hours of in-field operation between refills.
An optional 600-gallon liquid fertilizer tank is available on the 16-row model, while the 12-row planter has an optional 400-gallon capacity tank when equipped with 1.9 bushel on-row seed hoppers.
Growers also can choose from a mechanical or hydraulic transmission, with an advanced AFS Pro 600 touch screen display or a basic Early Riser IV monitor.
"Whether you want advanced technological features for prescription farming or a planter with just the essentials, the new 1250 Early Riser planters fit the bill," Forbes says.
For more information, call 1-877-4CASEIH or visit the World Wide Web at http://www.caseih.com.


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Fulfill Their Destiny
With turkey day behind us, we're heading full-force into Christmas. Many evergreens have been cut – most of them many months ago – to become holiday trees that we decorate. For me, this is a yearly reminder about an episode of the television show "Friends." In an episode around Christmas, Phoebe explains that all trees, no matter how scrawny or decrepit, need to fulfill their destiny to become an actual Christmas tree.
This idea causes me to think about the many, many scraps found around the Popular Woodworking Magazine shop and my home shop (more so in my home shop). By leaving these scraps piled in corners or sitting atop benches, or even if you neatly sort and stack your leftovers, are we allowing them to fulfill their destiny?
It's my opinion that we should release these scraps. Let them achieve their destiny. While that could be a small holiday project (gifts) such as those found in the book "Wood Stash Project Book," by Kerry Pierce, I'm willing to bet that destiny for most of these scraps is going to be as fuel. That's right, burn them for heat. (That's way better than ending up in landfills.)
Of course, burning scrap isn't always just for heat. Sometimes it's just for fun, or to destroy evidence, as shown below.
It you have questions about the object in the bonfire, post your comment. Mr. Bender will be watching closely.


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February 1, 2014
I'm writing to express what I believe to be fraud by The John Stewart Co., which manages the Martin Luther King Marcus Garvey Square cooperative apartments where I lived for 26 years. I was evicted for having a care provider in my home. To demand a thorough investigation of the fraud at King-Garvey, I'm asking all who read this to call HUD Operations Director Angela M. Corcoran: (415) 489-6400.


text: Sure.. I thouht I miss to configure something. Let me do this and if I will come across something like this, I will be more than happy to share with you guys. Thank you, Regards - Chirag On 9/6/05, Allen, Brandon <Brandon.Allen@xxxxxxxxxxx> wrote: > > I know - it's kind of a pain. Search Metalink for index_stats and you > should find a script that you can run which will create a stored procedure > and generate a secondary script to run validate structure on each index and > then insert the values from index_stats into a secondary table, e.g. > all_index_stats. > > -----Original Message----- > *From:* oracle-l-bounce@xxxxxxxxxxxxx [mailto: > oracle-l-bounce@xxxxxxxxxxxxx]*On Behalf Of *Chirag DBA > *Sent:* Tuesday, September 06, 2005 10:07 AM > *To:* Chirag DBA > *Cc:* Oracle-L Freelists > *Subject:* Re: When to rebuild the index? > > While you do the validate structure with indexes, it shows the stats only > for the last index. > How can I see the list of all the indexes who needs to get rebuild now. > I can see the results only for 1 index and that is the last one in > valudate structure. > Regards - Chirag > > On 9/6/05, Chirag DBA <chiragdba@xxxxxxxxx> wrote: > > > > Hi Guys, > > I think that even select statement will make the index split and > > require the rebuilding. Am I true? I think I am. > > And there is a view called index_stats with column height. > > I have read that when the value of this column is >= 4, u need to > > rebuild the indexes. > > But after analyzing the particular schema, I don see any value to get > > populated in this view. > > I can see last analyzed value changed in dba_indexes when I analyze the > > schema with DBMS_STATS. ANALYZE_SCHEMA package. > > Why this is so? > > Regards - Chirag > > > > Privileged/Confidential Information may be contained in this message or > attachments hereto. Please advise immediately if you or your employer do not > consent to Internet email for messages of this kind. Opinions, conclusions > and other information in this message that do not relate to the official > business of this company shall be understood as neither given nor endorsed > by it. >


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NEW YORK (AP) — Stock futures are rising after a volatile week in which major U.S. averages set record highs.
Dow Jones industrial futures are up 46 points to 15,523. S&P futures have gained 3.5 points to 1,754 50. Nasdaq futures are up 10.25 points to 3,379.25.
Even with consecutive days of losses after the U.S. Federal Reserve said that the economy is still struggling, it appeared Friday that the week will end in positive territory.
The Institute for Supply Management will release its report on U.S. manufacturing activity in October. Economists fear that the 16-day partial government shutdown slowed activity in the sector, and they're projecting a decline for the index to 55.1 from 56.2 in the previous month.
The automakers are also releasing auto sales figures for October.


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Why is Mike Wallace viewed as the top free agent receiver on the market? Is re-signing Brian Hartline a priority for the Miami Dolphins? What is tight end Anthony Fasano's future in the NFL?
Those are the issues we'll tackle in today's installment of "What's Chirping," where I expound on Dolphins related questions for twitter.
@MooreALJMoore: I see Anthony Fasano putting up good numbers if he goes to a team like the Atlanta Falcons » Fasano's still a good tight end. He's just more of an H-back, red zone threat than seam threat option.
MY TAKE: Re-signing Fasano to serve as the starting H-back, Miami's second tight end, should be a priority considering he's scored 23 touchdowns the past five seasons. That's my opinion based on how he played the H-back position in the final month of the year, once Charles Clay was sidelined by his knee injury. Fasano's protection was amazing, and it kept Ryan Tannehill's pocket clean. And he was a better option coming out the backfield as a receiver than he was working off the line of scrimmage.
It is clear to everyone that Fasano, who will turn 29 in April, has lost some speed, which hinders his ability to create separation from linebackers. However, he's still one of the NFL's best in-line blocking tight ends, and that has value. Because of that skill Fasano will probably have a role in the NFL for the next four to five seasons.
Pair him with a legit seam threat like Dustin Keller and that unit could blossom just like Fasano did when he played alongside David Martin, setting franchise records for the position in 2008. Keep in mind that Fasano was the H-back in that relationship.


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By Margarita Antidze
TBILISI (Reuters) - A Georgian court sentenced a former prime minister on Monday to five years in prison for corruption in a verdict that the opposition branded as part of a government witch-hunt against its foes.
Vano Merabishvili was convicted of abuse of power and other crimes at the trial in the western city of Kutaisi. He served as prime minister for less than four months in 2012 under Georgia's then-president, Mikheil Saakashvili, until their United National Movement (UNM) lost a parliamentary election.
Defense lawyers said they would appeal against the verdict.
"It is obvious that the judge failed to withstand pressure from the government," UNM member Giga Bokeria told reporters.
"It is a very bad day not only for justice, but also for Georgia's democratic traditions."
Western countries have aired concerns that the new government has used selective justice and political persecution against opponents in the mountainous ex-Soviet republic, which is a pivot of geopolitical rivalry between Russia and the West.
Merabishvili, also a secretary general of the UNM, is the highest ex-official to be convicted since billionaire Bidzina Ivanishvili led his coalition to victory in the 2012 parliamentary election, ending nine years of dominance by Saakashvili. His term as president ended last year.
The judge ruled that the actions of former health minister Zurab Chiaberashvili, a co-defendant of Merabishvili, constituted neglect of official duty rather than abuse of power and ordered him to pay a fine of 50,000 lari ($29,000).
The first case against Merabishvili and Chiaberashvili involved allegations that they funneled over 5.2 million lari of public funds to the UNM's election campaign ahead of the parliamentary election in 2012.
The second case involved allegations that Merabishvili misappropriated a seaside villa from its private owner and used over 157,000 lari of interior ministry funds to refurbish it in 2009. He denies all allegations of wrongdoing.
Merabishvili is also on trial on separate charges involving "aggravated abuse of office" in connection to the break up a protest rally in May 2011, when he was the interior minister.
In addition he faces criminal charges, that he also denies, involving alleged abuse of office, in connection to a murder case of a Georgian banker in 2006.
($1=1.73 lari)
(Reporting by Margarita Antidze; Editing by)


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Nightlights for Baby and Kid Rooms
10 Lights to Keep the Nights Bright
10 Lights to Keep the Nights Bright
Good night. Sleep tight. Don't let the bed bugs bite. MOM! Please turn on the light! When youngsters have a tough time getting shut-eye in a pitch black room, they will appreciate a lil light being shed on them. Save some tears and energy by keeping the overhead switch off and introducing one of these luminous friends to your tot.
0previous images
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A co-owner of an archery and taxidermy company in China Grove was killed June 29 after an explosion and fire at the business.
The Charlotte Observer reported that friends and family identified the victim as 46-year old Sonya Graham, who, along with her twin sister, Sie, operated S&S Graham Archery on North Main Street.
The Graham sisters were among five employees and customers in the building Friday evening.
Sonya Graham had gone into a bathroom as part of prep work for mounting a boar when the explosion occurred, said David Nance, a store employee. He said others inside the building tried to rescue her but couldn't.
The fire was reported about 9:30 p.m. Friday, and it took emergency crews about 45 minutes to extinguish the blaze.
The owners and archery store were well known among hunters and within the community.
For the full report, click here.


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- Mercedes news
Mercedes trusts driver rivalry won't boil over
- Drivers:
- Ross Brawn
- |
- Lewis Hamilton
- |
- Nico Rosberg
- Teams:
- Mercedes
Mercedes is prepared for a disagreement between Nico Rosberg and Lewis Hamilton at some point this season, but is confident it won't derail the team's progress.
The Mercedes team-mates are good friends away from the circuit and so far this season have been closely matched in qualifying and races. One flashpoint came in Malaysia when Rosberg was ordered to remain behind Hamilton by the pit wall, but the incident does not appear to have affected the relationship between the drivers.
However, team principal Ross Brawn said it is inevitable the two will have disagreements at some point this season, but he is confident it won't distract the team.
"Our drivers get on well, they have raced together before, they have got some nice history together, but we all know there will be events and incidents where they get angry with each other," he said. "But that's natural, they are competitors and it's important that we recover from those very quickly so it doesn't become damaging. But they will have their moments for sure."
Brawn said so far the relationship between his drivers has helped push the team forward.
"I think with any driver you need the pace and speed, because without that you are not going to succeed - the first thing any top F1 driver needs is the pace. Then you need an intelligent approach and if you both drivers working in harmony to improve the car and the way the team works, then you've got an ideal situation.
"Our drivers work very well together as team-mates, they want to beat each other and they are very quick and that's combination that we are enjoying at the moment."


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so excited about this new community.
Gonna riot soon?
I am so worried that Moral Mondays will not be effective. The arrests have dropped. If we can't get 150+ …
Thanks for all the great images over the years (including this one!) You will be missed.
Some UK Essex girl would pay highly for a dip in the tanning pool....!
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Duo Duel: Part II
Southpaws Aaron Laffey and Brian Mazone matched up in a terrific pitcher's duel just 11 days ago. In Lehigh Valley, Laffey bested Mazone in a 2-0 Bisons win. Buffalo's lefty fanned nine in eight innings of four-hit baseball. Mazone allowed just a solo home run (OF Todd Linden) in his six innings. Mazone struck out eight but suffered the defeat.
TODAY'S GAME: Tonight, the Buffalo Bisons host the Lehigh Valley IronPigs in the third game of a four-game series at Dunn Tire Park (7:05 p.m.). Last night's 10-1 win has given the Herd four victories in their last five games. The Bisons is currently 4-2 on their eight-game homestand that will conclude on Thursday. Taking the hill for the Herd this evening is LHP Aaron Laffey. The southpaw pitched six strong innings against Rochester on Friday and allowed just two unearned runs and struck out five. Lehigh Valley will counter with LHP Brian Mazone.
TODAY'S STARTER:Aaron Laffey
-Last Game: 8/15 vROC: (W, 6.0IP, 3H, 2R, 0ER, 4BB, 5K), Bisons' 14-7 win.
-2008 w/ Bisons: (4-1, 2.70ERA)(7GS, 40.0IP, 35H, 13R, 12ER, 10BB, 33K).
-2008 w/ Cleveland: (5-7, 4.23)(93.2IP, 103H, 52R, 44ER, 31BB, 41K).
-2007 w/ Bisons: (9-3, 3.3.08)(16G, 96.1IP, 89H, 36R, 33ER, 23BB, 75K).
-2007 Bisons Warren Spahn Most Valuable Pitcher (Buffalo 13-3 when he pitched).
-2007 Indians Bob Feller Minor League Pitcher of the Year (13-4, 2.88ERA).
-Selected in the 16th round (468th overall) of the 2003 First-Year Player Draft
NO LAUGHING MATTER: LHP Aaron Laffey is 2-0 with a 1.80ERA since returning to Buffalo on August 4. The southpaw has pitched six or more innings in his last three starts and hasn't allowed an earned run in his last two trips to the mound. Laffey who is 5-1 with a 2.35ERA on the season with the Herd, hasn't allowed an earned run in five of his eight starts. At Dunn Tire Park this season, Laffey is 2-0 with a 2.70ERA in three starts. He hasn't lost in Buffalo since May 22, 2007 (11 starts, 8-0).
RECORD SETTING: Last night, OF Jason Cooper set the record for most games played (401) in a Bisons uniform in the modern era. Cooper entered the game in the top of the eighth and then doubled in his only plate appearance. Cooper now has 81 career doubles as a Bisons, 2nd in the modern era. Other notable categories Cooper ranks in the Bisons Modern Era are 2nd in RBI (218), 3rd in walks (167), T3rd in triples (18), 4th in runs (202), and 6th in hits (322) and home runs (49).
REHAB UPDATES: DH Travis Hafner is expected to continue his major league rehab assignment this evening. Monday night, Hafner singled and doubled as part of a 2-3 performance. The DH has been out of Cleveland's lineup since May 25 nursing a sore right shoulder. C Victor Martinez will rest today after going 1-2 with a run and two RBI last night.