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Defining culturally safe primary care for people who use substances: a participatory concept mapping study
Karen Urbanoski ORCID: orcid.org/0000-0001-7017-35461,2,
Bernadette Pauly1,3,
Dakota Inglis1,
Fred Cameron4,
Troy Haddad4,
Jack Phillips4,
Paige Phillips4,
Conor Rosen5,
Grant Schlotter4 na1,
Elizabeth Hartney6 &
Bruce Wallace1,7
BMC Health Services Research volume 20, Article number: 1060 (2020) Cite this article
People who use substances experience high levels of substance-related stigma, both within and outside of health care settings, which can prevent people from help-seeking and contribute further to health inequities. Recognizing and respecting how political, social, economic, and historical conditions influence health and health care, cultural safety, with origins in addressing Indigenous racism, is a potential strategy for mitigating stigma and marginalization in health care. Using a participatory research approach, we applied the concept of cultural safety to develop a model of safe primary care from the perspective of people who use substances.
People who use or used substances were involved in all phases of the research and led data collection. Study participants (n = 75) were 42.5 years old on average; half identified as female and one quarter as Indigenous. All were currently using or had previous experience with substances (alcohol and/or other drugs) and were recruited through two local peer-run support agencies. Concept mapping with hierarchical cluster analysis was used to develop the model of safe primary care, with data collected over three rounds of focus groups.
Participants identified 73 unique statements to complete the focus prompt: "I would feel safe going to the doctor if …" The final model consisted of 8 clusters that cover a wide range of topics, from being treated with respect and not being red-flagged for substance use, to preserving confidentiality, advocacy for good care and systems change, and appropriate accommodations for anxiety and the effects of poverty and criminalization.
Developing a definition of safe care (from the patient perspective) is the necessary first step in creating space for positive interactions and, in turn, improve care processes. This model provides numerous concrete suggestions for providers, as well as serving as starting point for the development of interventions designed to foster system change.
Over the past few years, many countries have been experiencing large increases in fatal and non-fatal drug overdoses, largely attributable to the increased presence of synthetic opioids in the illicit drug supply [1,2,3,4]. In Canada, there were over 15,000 apparent deaths linked to overdoses between 2016 and 2019, with 77% of these fatal overdoses involving fentanyl or fentanyl analogues [5]. Among the lessons being learned as policy makers, service providers, researchers, and the public navigate this crisis is an appreciation of the extent to which the existing system of services for people who use substances falls short of meeting population needs.
Primary care has an important role to play as a key point of entry to the health care system. Many people who use substances, particularly when substance use is combined with structurally produced disadvantages, such as poverty and homelessness, do not have access to primary care [6, 7]. Among an array of patient, provider, and system-level factors, the stigma of substance use is a barrier to timely and effective health care. To inform ongoing efforts to improve the quality of health care for people who use substances, we used the concept of cultural safety to guide an investigation of what constitutes safe, accessible, and acceptable primary care for this population.
Impact of stigma on help-seeking and health outcomes
The stigma associated with substance use is deeply embedded in health and social systems as a result of current policies that criminalize drug use and neo-liberal beliefs that people who use substances are solely to blame for their problems. Illicit drug use, in particular, is highly stigmatized, especially when coupled with structural disadvantages (e.g., homelessness, colonialism, racism, classism, sex and gender discrimination, poverty) and other marginalized health conditions (e.g., HIV/AIDS, HCV) [8,9,10,11,12,13]. Socioeconomic disadvantages and associated processes of social exclusion contribute to inadequate access to health care [8, 9, 14,15,16,17,18,19]. Feelings of not being safe in health care settings, due to fear of judgements and stereotyping, can lead people to delay and avoid seeking the health care they require [13, 20,21,22,23].
Studies have shown that many primary care providers including physicians, community health workers, and nurses hold negative and stigmatizing beliefs towards people who use and experience harms related drugs and alcohol [22, 24, 25]. Lack of trust has been identified as a key concern that impacts access to primary care [21, 23, 26]. While harm reduction services (e.g., needle and pipe distribution, supervised consumption sites) are often more trusted as a source of care [27, 28], their capacity to provide primary care is limited by the lack of integration with primary care services. For people who use substances, particularly illicit drugs in combination with structurally produced disadvantages, the overall impact is one of reduced access to primary care in general and lack of safety when accessing primary care.
Cultural safety was originally developed by Indigenous nurse scholars to address racism and improve health care practice for Indigenous peoples in New Zealand [29,30,31]. The Nursing Council of New Zealand has outlined cultural safety as an approach to care that requires health care providers at all organizational levels to 1) reflect on their own, often unconsciously held, attitudes and beliefs about others; 2) examine ways in which history, social relations, and politics continue to shape peoples' health needs and access and responses to care, and 3) demonstrate flexibility in how they relate with others, especially those who are different from themselves. In the Canadian context, cultural safety is relevant to understanding the impact of historical trauma and ongoing institutionalized racism impacting Indigenous peoples' health, health care experiences and access to health care [32,33,34]. It has been proposed as a strategy for mitigating stigma, discrimination, and other forms of marginalization in health care for both Indigenous and non-Indigenous people [35, 36] and has been applied more broadly to other groups experiencing marginalization and differences in power and privilege [13].
Conceptually, cultural safety emphasizes recognition and respect for how political, social, economic, and historical conditions influence and shape health, health care, and health inequities [35, 37, 38]. Cultural safety extends beyond cultural sensitivity and competency, by focusing attention on power imbalances, systemic discrimination, social contexts, and impacts on health inequities [38, 39]. It is defined from the perspective of those receiving care, in terms of what makes them feel safe or unsafe in a health care setting. Because it is defined by care recipients, it challenges care providers to reflect on their own cultural identity, positions of privilege and power, and how these influence (often unconscious) assumptions about health and health care practice. Cultural safety offers a lens through which people's health can be seen as influenced by their historical, socio-political, and socioeconomic contexts, and accordingly though which health care providers can work towards equity and social justice within their professions [37, 38].
Given the impacts of substance-related stigma and social marginalization on health and health care inequities, cultural safety is a potentially useful concept to guide the study of how to improve care and care experiences for people who use substances. Prior work has examined how negative constructions of illicit drug use (e.g., as an individual failing, criminal activity, or disease) impacted on patients' experiences and nurses' abilities to provide culturally safe care in hospital [13]. To date, however, there has been no systematic exploration of the meaning of culturally safe primary care from the perspective of people who use substances. Developing a definition of safe care (from the patient perspective) is the necessary first step in creating space for positive interactions and, in turn, improve care processes.
As part of a broader research agenda focused on developing recommendations to reduce stigma and foster greater inclusion of people who use substances in health care planning and research, we conducted a concept mapping study to investigate how people who use substances understand cultural safety in primary care. The study and its approach were developed by a project team that includes people who use or have used drugs, academic researchers, health planners, and health care providers.
This study followed a participatory community-based research approach, which "integrates education and social action [into research] to improve health and reduce health disparities" (p. 312 [40]). People who use or used substances were involved in all phases of the research, and the research process itself had a goal of social action related to reducing stigma in primary care settings. The initial study was conceptualized through a collaboration of people with lived experience, academic researchers, health planners, administrators, and providers. The core research team was composed of community researchers (people who use or used substances) and academic researchers with the remainder of the initial planning team acting as advisors and contributing to knowledge translation. The community researchers were affiliated with two local peer-run organizations that provide support, advocacy, and outreach services to people who use substances and who also experience various forms of structural disadvantages related to poverty and homelessness, racialization, criminalization, and discrimination. The two peer-run organizations operate from different philosophies, with one working from a harm reduction philosophy and the other (at least historically) embracing a more abstinence-based understanding of recovery.
We used concept mapping to develop a model of safe primary care for people who use substances [41, 42]. We chose concept mapping for this study since the concept of culturally safe primary care has not been previously described for this population. The approach involved five steps, detailed below. Data were collected in three rounds of focus groups with people who use or used substances, led by the community researchers with assistance from the academic researchers. Data collection took place from October 2017 to January 2018. Ethical approval for this study was obtained from the institutional Research Ethics Boards at the University of Victoria and the Vancouver Island Health Authority.
Preparation and participant recruitment
The first step in concept mapping consists of establishing a focused prompt and identifying a plan for recruitment and data collection [42]. The focus prompt refers to a statement or question to be completed or answered by participants in step 2, serving as the basis for the concept to be defined. We developed the focus prompt, recruitment, and data collection strategies in a series of face-to-face research meetings of the core research team. The final focus prompt for mapping the concept of culturally safe primary care was: "I would feel safe going to the doctor if …" Relevant health care settings included doctors' offices, walk-in clinics, and other community health clinics, but excluded emergency and acute care settings. Prospective participants were people who use or used substances (alcohol and/or other drugs) and who experience structural disadvantages (as described above). The sample was recruited by the community researchers via word-of-mouth through their networks, and attention was given to recruiting people who were diverse in terms of gender, age, and current use of substances (abstinent and non-abstinent). Written informed consent was obtained at the first data collection point, with the assistance of a video recording in which one of the community researchers described the study and meaning of consent.
Participants were 42.5 years old on average (SD = 12.1). Half identified as female and one quarter as Indigenous (i.e., First Nations, Inuit, or Métis) (Table 1). Three quarters had at least some post-secondary education. Most (61.3%) lived in a rented house or apartment, and 73.6% described their housing situation as stable. All participants were people who were actively or had formerly used substances, had experienced substance-related harms or problems, and were known to the two peer-run support agencies involved in the study.
Table 1 Sample description (n = 62)
In the second step participants are asked to brainstorm as many ideas as possible to complete the focused prompt. This step was also completed during the first round of focus groups. Each focus group was facilitated by at least one community researcher and one academic researcher. A total of 68 participants attended 16 focus groups (3–8 people per group). Participants' ideas were recorded on a flip chart by the academic researcher and transcribed after the groups. In addition to stipends, food was available at the focus groups for participants. A total of 754 statements were generated, including duplicates generated in different groups. Participants also completed an anonymous questionnaire providing sociodemographic information. After the groups were completed, the core research team reviewed the statements and removed duplicates. Through extensive discussion, similar ideas were collapsed and synthesized to create the final list of statements. The team reached consensus on a final set of 73 statements that represented all of the ideas voiced by participants in the focus groups.
In the second round of focus groups, participants sorted the statements into groups based on conceptual similarity. A total of 56 people participated in this round of focus groups, including 54 of the 68 recruited initially (79.4%) with the addition of 2 new participants. The statements were printed on sets of index cards, which the participants individually sorted into physical piles. They were instructed to create as many piles of cards as they wanted to represent the concept of cultural safety. The number of piles per participant varied from 2 to 20. In these groups, participants were also asked to reflect on whether the 73 statements accurately captured the discussions from the first focus groups, and whether any ideas were missing. No new statements were suggested.
Data were entered for analysis in Concept Systems. The analysis involved generating a 73 × 73 matrix in which the cells contained the number of times participants grouped each pair of statements together. The matrix was analyzed using multi-dimensional scaling (MDS) to produce a 2-dimensional point map of statements. Statements grouped together more often appear closer together on the point map. Goodness of fit between the 2-dimensional configuration and the original input matrix was assessed using a measure of stress. The stress value is a normalized residual variance after accounting for the association between the configuration and input matrices, and thus provides a measure of the extent to which the produced configuration is random or without structure [43, 44]. Values range from 0 to 1, with lower values indicating better fit. After 19 iterations the stress value provided for this study was 0.325, which falls within the recommended range (> 0.39).
We then used hierarchical cluster analysis to identify discrete clusters of statements based on the point map. To decide on the optimal number of clusters, the core research team reviewed the output from analyses producing 4 to 12 clusters of statements in a face-to-face meeting. Starting with the 12-cluster solution, we examined the groups of statements and reflected on participants' discussions of statement meaning in the focus groups. We worked successively through the cluster maps with n-1 clusters, considering the conceptual meaning of the clusters as they merged, until further merges were felt to result in a loss of meaning and specificity. In this way, consensus was reached for the 8-cluster solution as a comprehensive and meaningful representation of the data.
In the third and final round of focus groups, study participants were asked to review the 8-cluster solution and cluster map, and to identify the key ideas that were conveyed by each cluster. A total of 48 people participated in this round of focus groups, including 43 of the 68 recruited initially (63.2%) and 5 new participants (75 people participated in the study overall; 72% participated in more than one round of focus groups, and 57.3% participated in all three). In addition to identifying key themes for each cluster, participants also rated each of the 73 statements in terms of importance, on a scale from 1 (not important) to 5 (very important). The statement ratings were entered into Concept Systems, and the mean and standard deviation calculated for individual statements and clusters (i.e., mean and SD for all statements within a cluster).
Participants drew from both positive and negative experiences to relate their ideas of culturally safe primary care; that is, they recalled examples of both safe and unsafe health care experiences. The 73 statements, grouped by cluster, are shown in Table 2 along with the mean ratings (and SD) of importance. Figure 1 shows the cluster map (the point map with the 8-clusters superimposed).
Table 2 Clusters and statementsa
Cluster mapa. aNumbers correspond to the statements listed in Table 2
Cluster 1: Act to prevent stigma: Don't treat me like crap! The seven statements in this cluster (light orange on the cluster map) defined aspects of safety that had to do with not feeling judged, stigmatized, or treated poorly because of substance use. They are fairly closely grouped together, indicating a high degree of conceptual similarity within the cluster. Statements reflect both external stigma (being judged by others) and internalized stigma (feeling embarrassed or ashamed). This cluster reveals how keenly the stigma of substance use is felt by people who use substances, who fear being labeled as threatening and being shamed or embarrassed in primary care settings.
Cluster 2: Hey I'm human. Treat me right! Closely related to the above is another tightly grouped cluster of nine statements (red) that reflects the importance people placed on being treated fairly and with compassion from the first point onward. People highlighted the importance of being trusted as a patient (in terms of being taken seriously and having their knowledge of their own health recognized). They wanted to know that they could ask questions and that their provider would provide explanations about their health and health issues. These were understood as elements of safety that came with knowing you would be respected as a person and treated "right" (like a human). Although closely aligned with Cluster 1 (as indicated by the close positioning of the two clusters on the cluster map), the statements in Cluster 2 speak generally to being treated with respect and dignity, while those in Cluster 1 more explicitly address fears of judgment, labeling, and stigma.
Cluster 3: Uphold professional standards. Cluster 3 (light green) contains nine tightly connected statements that concern professional competencies, particularly as they relate to substance use, addiction, medications, and related health issues (especially pain management). A central element in this cluster revolved around how important it was that providers recognize people's claims of pain as credible and legitimate, and that pain be adequately managed. Closely related to this was being included in care planning and decision-making. Together, these were seen as key elements of professional competency that translated into feeling safe at the doctor's office.
Cluster 4: Do you care about me? Located below these three clusters on the map, Cluster 4 (dark green) contained eight tightly connected statements that speak to the safety that is felt when care is personalized, when there is continuity of care, rapport, and trust between the physician and patient. People noted challenges related to not being able to see the same physician at each visit and feeling rushed during appointments. Attention to these details was seen as demonstrating care, which in turn contributed to people's sense of safety.
Cluster 5: Maintain my confidentiality in a welcoming and comfortable environment. Next to these was a larger cluster of 12 statements (grey) that were not as tightly connected as in previous clusters. Of particular concern were the waiting room environment and general clinic practices and protocols. People described safe primary care environments as welcoming and comfortable with a chief priority being maintenance of confidentiality by all in the clinic setting. For example, needing to provide a reason for their visit in a crowded waiting room that could be overheard by others, and overhearing providers and/or office staff having conversations about other patients constituted negative and unsafe experiences. People feared that they would be being misdiagnosed, that their information would not be recorded correctly, or that physicians would not communicate with each other about their health conditions. Concrete suggestions for creating safety included accommodations around these issues included not being asked questions in the waiting room, being able to speak with the doctor on the phone or being able to see their own medical records were provided by participants.
Cluster 6: Be a champion for advocacy. Somewhat separated off from the other clusters was a small cluster of six tightly connected statements (dark orange) that address the accessibility of services and the possible supports needed to reduce anxiety and improve perceived safety in accessing care. Examples included allowing people to bring an advocate or friend with them to appointments, having doctors of the same gender as the patient, providing care in discrete and accessible locations, and having system supports in place (e.g., avoiding situations in which people are not covered by insurance). It was noted that, in Indigenous communities, doctors are part of one's family circle. These issues were all seen to reflect a possible role for primary care providers as advocates for people who use substances, both clinically and systemically to ensure culturally safe primary care.
Cluster 7: Acknowledge and accommodate my needs and circumstances. Above these was another larger (more dispersed) cluster of 10 statements (purple) that highlight socioeconomic and other circumstances that affect the ability of people who use substances to navigate health and social service systems. The statements reflect the importance of primary care providers understanding and accommodating patient circumstances and assisting in mitigating negative consequences. Perceptions of safety were linked to provider recognition that people living on low incomes may not have the resources to execute plans of care, or that life circumstances and demands make following plans of care difficult. Examples of concrete suggestions for improving perceived safety included forgiving charges for missed appointments, not punishing people for missing appointments or labelling them as non-compliant, explicitly asking to ensure patient consent for procedures, and recognizing and accommodating fears of losing child custody or being criminalized if drug use is disclosed. This cluster indicates the need for a public health approach to primary care that recognizes the structural (economic, gendered, and socio-legal) conditions that impact people's lives and involves accommodations to ensure they can access services.
Cluster 8: Don't red flag me: Recognize addiction as a health issue. The final cluster (brown), at the top of the point map, contains 12 statements that link safety to physician views that addiction is a legitimate health issue, not a criminal behavior. This included aspects of physician knowledge (about addiction and available services and supports), acceptance of the reality of drug use, and openness to harm reduction strategies. People indicated that in order to feel safe accessing primary care they did not want to be red-flagged by the health care system as a drug user for fear this would impact their ability to receive ongoing physical and mental health care.
On the 5-point scale (ranging from 1 to 5), mean ratings of statement importance ranged from 2.58 to 4.57. The top 5 ratings (all over 4.5) were for statements in clusters "Maintain my confidentiality in a welcoming and comfortable environment," "Hey, I'm human. Treat me right!" "Acknowledge and accommodate patient needs and circumstances," and "Live up to professional standards." Only three statements were rated below 3.00 (the mid-point) in importance, including two from "Be a champion for advocacy" cluster and one from "Maintain my confidentiality in a welcoming and comfortable environment." All clusters had statements rated above 3.00 and there was no obvious pattern to average ratings across the clusters, suggesting relatively equal contributions to the overall concept of culturally safe primary care.
This study provides a structured conceptualization of culturally safe primary care for people who use substances. Culturally safe primary care for people who use substances recognizes is respectful care, provided with explicit attention to confidentiality, professional standards, and the impacts of structural conditions (including criminalization and poverty). The eight themes that we identified comprise a comprehensive overview that can be used as a starting point for the development of interventions designed to foster system change, and for systematic evaluation of the facilitators and barriers to implementing quality improvement initiatives. Participants were readily able to describe their understandings of safe primary care, covering a wide range of topics from features of the care provided to the characteristics of physicians, other clinic staff, and the clinic environment. There was relatively restricted variability in ratings of importance across topics, features, and ideas, underscoring their shared contributions to the meaning culturally safe primary care. The purpose of this study was not to evaluate the accuracy of peoples' past experiences of stigma or safe/unsafe health care, but to relay what people perceive to be key aspects of safety in health care, in the context of a cultural identity that is highly marginalized and even criminalized. Planning and delivering culturally safe health care requires that providers and policy makers reflect on their own power and positioning, and how forms of structural disadvantage and violence are reproduced in health care settings and policies. It is worth nothing that interactions with health care providers may be experienced by patients as unsafe despite the intentions of providers or their impressions of the encounter and quality of care [34]. Within the eight themes that comprise this model of cultural safety, there are numerous concrete suggestions for providers who are looking to explore ways to improve access and service delivery for people who use substances. Findings offer various potential accommodations that may be tested in future research for their effectiveness in improving access and outcomes among people who use substances. As part of our knowledge exchange strategy, we have translated findings into an anti-stigma workshop for primary care providers, and have created a post card summarizing study findings, for use by community members in advocating for their own care.
In terms of serving as a driver for systems change, it is relevant that our findings are strongly consistent with prior studies describing the key components of equity-oriented primary care, which include being responsive to inequities and the social determinants of health, being trauma-and violence-informed, and being tailored to peoples' social and cultural contexts [7, 45]. Likewise, a role for advocacy is aligned with recommendations to find places to disrupt. A number of specific strategies identified in prior work to enhance these components of equity-oriented primary care were echoed by participants in our study (e.g., actively working to counter oppression and promote equity, allowing for more time in appointments, building a rapport, allowing for flexibility in scheduling, tailoring care to the individual and the contexts in which they live) [7]. The consistency across studies speaks to the credibility of these findings.
Also consistent with prior findings are the experiences of stigma, labeling, and stereotyping that people who use substances reported in describing their interactions with physicians and other clinic staff, including receptionists and office assistants [7]. While participants relayed past experiences with both culturally safe and unsafe care, it is the case that the majority of experiences were negative. Participants were mindful of their own role in contributing to these negative experiences, and many expressed some sympathy with physicians on the difficulty of their profession. It is clear that participants were highly attuned to potentially dismissive or stigmatizing attitudes and behaviors of physicians and clinic staff, and that past negative experiences affected the ways in which they approached health care interactions. Similar processes have been noted by other socially marginalized groups, including people who identify as Indigenous [34, 46], and speak to the need for care providers to be mindful of past traumas and other experiences of their patients. Many of the elements of this model of culturally safe primary care align with broader definitions of health care quality (for instance, receiving care that aligns with professional standards or having confidentiality maintained). That is, the elements of safe care described here are not unique to people who use substances, but reflect more widely shared expectations of primary care. The fact that such issues were raised explicitly speaks to the sizable amount of work that is required to achieve equity-oriented primary care for people who use substances.
Findings suggest that interventions designed to support the development of positive relationships between primary care providers and people who use substances are warranted. Although more work is needed to establish effective ways to achieve this, there is some evidence to support the effectiveness of interventions in which people with lived experience of substance use engage with and educate health care providers in improving care relationships [47, 48]. In particular, there is a critical need to attend to the building of trust in relationships between individuals and with groups in health care [21]. Others have moved beyond the micro-level of individual providers to design organizational-level interventions that attend to the ways in local and system contexts affect equity in primary care (both in terms of front-end access and processes of service delivery) [45]. The theoretical model guiding such efforts posits that, by attending to and tailoring activities to fit the organizational contexts in which care is delivered, interventions will be more successful at fostering organizational structures and policies that support equity-oriented care and, in turn, more equitable health outcomes in the population.
We also recognize that supportive structures and policies need to be in place in order for physicians and other primary care providers to be able to deliver culturally safe primary care, and that some of the accommodations and strategies outlined in this study will require significant systems change (e.g., changes to funding and remuneration, educational curricula). In Canada, primary care is covered by universal provincial health insurance; although challenges related to keeping up-to-date identification cards and maintaining active registration can also affect coverage among members of marginalized groups (e.g., people who are homeless) [18]. This accounts in part for statements reflecting a fear of being turned-away or not being covered by insurance, despite universal health care coverage. Spending adequate time with patients is also a major challenge for primary care physicians practicing in Canada, many of whom are paid primarily through a fee-for-service structure associated with the universal health insurance plan. Successful implementation of culturally safe primary care requires critical reflection not only by health care providers, but also by decision-makers and health planners. In this sense, the present study provides evidence that may be useful to physicians, other providers, and their representative organizations as a tool for advocacy efforts. As noted earlier, cultural safety provides a potentially useful lens through which health care providers can work towards equity and social justice within their professions [37, 38].
Part of the value of the concept of cultural safety lies in the fact that it is defined by the care recipients, and therefore requires meaningful involvement of patients in defining and interpreting what is considered to be safe care. The stigma of substance use, particularly illicit drug use, is one way through which people who use substances are excluded from social structures where decisions are made around the design and implementation of health services [16, 49,50,51]. When people are excluded from decision-making processes (whether for their own health care or for the design and implementation of services), stigma can be unintentionally reproduced and opportunities to provide health care are missed. Capacity-building among people who use substances is critical for facilitating the collective efficacy and political voice necessary to raise awareness and address stigma in health care [52, 53]. As a precedent, many innovations in harm reduction services and policies have been driven by people who use illicit drugs with the goal of promoting the health and safety of their peers [54,55,56,57,58].
We made efforts to maximize the credibility of our findings; for instance, by giving participants the opportunity at each data collection point to review the statements and clusters and make any required changes to better reflect their perceptions of cultural safety. We were also successful at recruiting a diverse sample of people who use substances through the contributions and work of the community researchers. That said, our study is limited by a number of factors. Not all of those who were recruited could be located for the second and third rounds of focus groups, such that the sample differed slightly across time points. While the sample includes representation from Indigenous peoples including women, and their perspectives informed study conclusions, these findings are not explicit to their needs and preferences. We did not obtain representation of those with diverse gender identities or sexual orientations, or youth who use substances. Further work is needed to explore cultural safety in these populations. A small number of participants experienced difficulties completing the task of sorting the statements. In these cases, a member of the research team provided assistance, by reading the statements out loud and asking for direction on what piles to create and where to put each statement. The study was conducted in one community and, therefore, may reflect how stigma and primary care are experienced locally. Relatedly, it is needs to be acknowledged that this study was conducted within the context of an escalating public health emergency related to illicit drug overdoses. This context is shaped by the fact that harm reduction is official provincial policy in British Columbia, Canada, and that public campaigns to reduce stigma were ongoing during the period of data collection as part of strategy to reduce overdoses.
Cultural safety is recognized as a key aspect of health care, particularly as it relates to Indigenous peoples [46]. This study makes a valuable contribution to understandings of culturally safe primary care for people who are often socially marginalized and stigmatized by their substance use. A major strength of the study is the inclusion of community researchers who work in both harm reduction and abstinence-based services. Findings highlight the importance placed on non-judgmental care that acknowledges peoples' past experiences of stigma in health care settings, as well as socioeconomic and structural disadvantages and how these can affect health care experiences and outcomes. They offer numerous potential opportunities for accommodating and reducing the anxiety that people can feel in going to the doctor, through interpersonal exchanges, environmental features of the clinic, and others. Future work is required to develop ways to implement these findings into clinic practices and processes and test their effectiveness in promoting equity-oriented primary care for people who use substances.
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
HCV:
Hepatitis C virus
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van Boekel LC, Brouwers EP, van Weeghel J, Garretsen HF. Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug Alcohol Depend. 2013;131(1–2):23–35.
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This research was supported by a Canadian Institutes of Health Research (CIHR) Strategy for Patient-Oriented Research (SPOR) – Patient-Oriented Research Collaboration Grant, with partner funding from Victoria Division of Family Practice, Island Health, and the University of Victoria. Dr. Urbanoski is supported through a Canada Research Chair in Substance Use, Addiction, and Health Services Research from the Canadian Institutes of Health Research. Funders have had no role in study design, collection, analysis and interpretation of data, or writing up study findings.
Grant Schlotter is deceased.
Technology Enterprise Facility, Canadian Institute for Substance Use Research, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada
Karen Urbanoski, Bernadette Pauly, Dakota Inglis & Bruce Wallace
School of Public Health and Social Policy, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada
Karen Urbanoski
School of Nursing, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada
Bernadette Pauly
SOLID Outreach Society, 1056 N Park St, Victoria, BC, V8T 1C6, Canada
Fred Cameron, Troy Haddad, Jack Phillips, Paige Phillips & Grant Schlotter
Umbrella Society for Addictions and Mental Health, 415 Dunedin St #8, Victoria, BC, V8T 5G8, Canada
Conor Rosen
Centre for Health Leadership and Research, Royal Roads University, 2005 Sooke Road, Victoria, BC, V9B 5Y2, Canada
Elizabeth Hartney
School of Social Work, University of Victoria, PO Box 1700 STN CSC, Victoria, BC, V8W 2Y2, Canada
Bruce Wallace
Dakota Inglis
Fred Cameron
Troy Haddad
Grant Schlotter
All authors were involved in conceptualizing the study and methodology. KU, BP, BW, and EH were involved in funding acquisition. KU, BP, and DI led project administration. KU, BP, DI, FC, TH, JP, PP, CR, and GS (deceased) collected and analysed the data. KU wrote the first manuscript draft and all authors contributed to manuscript review and editing. The authors have read and approved the manuscript.
Correspondence to Karen Urbanoski.
This study was approved by the institutional Research Ethics Boards at the University of Victoria and the Vancouver Island Health Authority (J2017–067). All participants provided written informed consent for participation.
Urbanoski, K., Pauly, B., Inglis, D. et al. Defining culturally safe primary care for people who use substances: a participatory concept mapping study. BMC Health Serv Res 20, 1060 (2020). https://doi.org/10.1186/s12913-020-05915-x
DOI: https://doi.org/10.1186/s12913-020-05915-x
Community based participatory research
Quality, performance, safety and outcomes


Cliff Arnebeck: "King Lincoln Election Fraud Case Alive and Well in Columbus, Ohio"
You recently published on your web site a press release from Paddy Shaffer containing various assertions against counsel for the plaintiffs in the King Lincoln case. Paddy's group apparently felt this might be helpful to their effort to persuade the US District Court to change its decision denying their motion to intervene in our case. We responded to those assertions in court.
However, for the information of your readers, our effort continues to be to fully expose the ongoing fraudulent manipulation of our nation's elections. To succeed in this we need the help, not only of our election reform community, but also our nation's investigative press corps and law enforcement agencies--particularly at the national level. The fraud and cover up of the 2004 election was national in scope, and directed by Karl Rove out of the offices of the White House.
Citizens' group Ohio Election Justice Campaign (OEJC) calls on media to investigate collapse of Ohio's landmark 2004 election fraud lawsuit; deadline for prosecution for destruction of evidence expires soon.
Columbus, OH (PRWEB) June 15, 2009 -- As the deadline for prosecution of election officials looms, Brunner's office has taken no action to investigate the 2004 election or the destruction of key evidence in the landmark 2004 Ohio election fraud lawsuit, King-Lincoln v. Blackwell, 2:06-cv-00745 (S.D. Ohio), according to the Ohio Election Justice Campaign (OEJC).
In a May 2009 blog, Ohio Secretary of State Jennifer Brunner admitted, "Numerous election activists have reviewed the centrally stored ballots in great detail, some with conclusions that allege wrongdoing." Brunner live blog on May 16, 2009 (Link).
The deadline for prosecution for the destruction of key evidence in the election fraud case will expire in the next few weeks.
As alleged in court documents, a private corporation, The Ohio Association of Election Officials, encouraged the destruction of evidence in violation of federal court order. Motion for Special Grand Jury (pdf). This group will be holding its summer conference June 15-17th, 2009 in Columbus at the Columbus Renaissance Hotel.
SOS Brunner is hosting this conference, entitled "Election Officials Summer Conference and Trade Show." In Ohio's current tight budget, the SOS office will not give costs for conference hosting.
The OEJC, a citizens' group, believes the problematic history of activities among Brunner, local officials, and the attorneys for the plaintiffs indicate a concerted effort to a) avoid a speedy trial against the State, b) destroy evidence, and c) protect the officials that committed the wrongdoing.
Members of OEJC say for over two years, the press, including the progressive media, has virtually avoided this aspect of the story. Curiously, media outlets that broke the story of the stolen 2004 election have been silent on the collapse of the election fraud lawsuit. One of these outlets, the Columbus Free Press, is controlled by an attorney in this case.
OEJC also believes the attorneys, including lawyer/lobbyist Clifford O. Arnebeck, Jr., who for years claimed to be protecting the records, are failing to take steps to prevent ongoing destruction of evidence.
OEJC member Mark Brown said, "At best, Arnebeck and his associates are providing useful distractions to cover up the wide net of perpetrators. If the Ohio election were investigated, it could pull down the legitimacy of the United States for those four years of the stolen presidential term. Just as with our banking crisis, the media will not pay attention until it is too late."
For more information, visit "Resolve It or Relive It: A Summary of Ohio's Unresolved 2004 Election Fraud Lawsuit".
Brunner promised a fair and open elections program if elected. She was tested early. When a federal judge ordered the collection of 2004 presidential ballots from Ohio County election boards, 58 of 88 failed to return some to all of their ballots.
This was a prime time opportunity for Brunner to open up an investigation into the sorry state of Ohio elections. What did she do? She offered this statement shortly after hearing of the lost ballots.
"If I had evidence of a cover-up, I would investigate," Brunner said. "For me, the bigger question in 2004 was, 'How many people were prevented from voting,' (something) you can't quantify."
Brunner was never asked to explain how she could have any "evidence" without an investigation.


Homeowners and business insurance companies will in most cases cover the rehabilitation costs. We can assist you with the filing of insurance claims and provide expert documentation for insurance companies. Every job we perform is photographed and video taped before we start and when we are finished.
We request that you open your claim and have your insurance agent call us for appropriate information and documentation.
For your convenience, we accept Cash, Bank Cheques, Money Orders, Direct Bank Credit and Personal Cheques with verification.


Katie Eder joins 414Wisconsin to talk about her program Kids Tales, which empowers teens to teach younger kids creative writing. Her organization has reached over 1200 children across the US and 7 other countries.
She was awarded $1000 from USCellular as part of their program The Future of Good.


An affordable and confidential process, child support mediation is an ideal way to decide the allocation of child support during a separation and a divorce without involving a court. Mediation is private, polite, and allows each party to take an active role in the process of determining the right amount of child support payments. The mediator's job is to listen to the needs of each party and then help parties talk about how to reach the best financial arrangements for everyone involved.
Graham Law Firm offers experienced, credentialed child support mediation services in Northern Virginia. Call us at 703-687-6817 or fill out our contact form to schedule a consultation. We are located in Leesburg and serve the surrounding areas, including Herndon, Ashburn, Sterling, and beyond.
Why Choose Child Support Mediation?
In child support mediation, the mediator does not take sides in the process. It is the mediators' job to remain impartial, in which Graham Law is experienced. We prioritize the needs of the family during the child support mediation process, which is not the case if the courts decide the amount of child support awarded.
The process of mediation is to help the parties involved talk.
The mediator's job is to help everyone talk about their financial situation and how to fairly decide child support for everyone involved.
The end goal is to leave with an agreement of an amount of child support that will be paid. If this process were undertaken in court, that amount would be decided without either spouse's chance to speak.
These factors will be used by all parties and the mediator to come to an agreement on the right amount of child support for your particular situation.
After the child support mediation is completed, each party will sign an agreement that includes child support guideline calculations and the decision reached by the parties involved.
Have more questions about mediation? Check out our Frequently Asked Questions resource regarding mediation or learn about child visitation.
Our firm has received recognition for our acumen in mediation and arbitration, as respected lawyers in our area, and as one of U.S. News & World Report's Best Law Firms each year since 2011. We also offer stepparent adoption counsel. When you are in search of mediation for the child support process, seek out Graham Law Firm, Northern Virginia's preferred mediation specialists.
Call Graham Law Firm at 703-687-6817 or fill out our contact form to schedule a consultation to discuss child custody support mediation in Northern Virginia.


THIS is what racism looks like. Yes, it's still real. White woman goes off on black man for scaring her children. What did he do? He started his car in a parking lot.
Man on the street, Jesse Watters asks people, what does #MemorialDay commemorate? This is NOT an AP question folks! How do they not know this?
If you think America was NEVER great, your ignorance is showing! Like Krystal, the Home Depot employee who's hat just went viral. And she's shocked she's getting hate mail? There's a price to pay for exercising free speech.


A. After 675 days, 19 lawyers, 40 FBI agents, 500 search warrants, 2800 subpoenas and 13 requests to foreign governments for evidence, Robert Mueller delivered his report to Attorney General William Barr, putting the investigation to rest.
A. Nope. Just the 34 already filed, with 8eight guilty pleas – including the president's former lawyer, first national security advisor, former campaign manager and a slew of top aides.
Q. And what was the overall impression of the final report?
A. Oooh. Sad. Don't look. They've wilted like freshly cut lilies placed in the back window of an 1982 Mustang at the Wisconsin State Fair the second week of August.
A. America has become accustomed to historical incidents where the buildup far exceeds the actual event, like the Comet Kohoutek, George McGovern, Michael Jordan's baseball career, Spiderman: Turn Off the Dark, the jetpack, Star Wars: Episode 1, Theranos, season 2 of True Detective, the Galaxy 7, Ryan Leaf, Google Glass, Y2K and the Edsel.
A. The pPresident is near delirious, hopping around like a leprechaun, chanting "no collusion, total vindication" over and over in the manner of a parrot with Turrets Syndrome.
Q. Has he changed his tune on Mueller?
A. I wouldn't be surprised if he invites Mueller down to Mar-A-Lago for a few rounds of golf.


1. 徐达传, 钟世镇, 刘牧之, 等. 股前外侧部皮瓣的解剖学一个新的游离皮瓣供区. 临床应用解剖学杂志, 1984, 2(3): 158-160.
2. Koshima I, Fukuda H, Yamamoto H, et al. Free anterolateral thigh flaps for reconstruction of head and neck defects. Plast Reconstr Surg, 1993, 92(3): 421-428.
3. Tsuchiya S, Nakatsuka T, Sakuraba M. One-sided soft palatal reconstruction with an anterolateral thigh fasciocutaneous flap: report of two cases. Microsurgery, 2011, 31(2): 150-154.
4. Hallock GG. Evaluation of fasciocutaneous perforators using color duplex imaging. Plast Reconstr Surg, 1994, 94(5): 644-651.
5. Tsukino A, Kurachi K, Inamiya T, et al. Preoperative color Doppler assessment in planning of anterolateral thigh flaps. Plast Reconstr Surg, 2004, 113(1): 241-246.
6. Isken T, Alagoz MS, Onyedi M, et al. Preoperative color Doppler assessment in planning of gluteal perforator flaps. Ann Plast Surg, 2009, 62(2): 158-163.
7. 肖海涛, 时莹瑜, 王怀胜, 等. 高频彩色多普勒超声检测穿支血管在股前外侧皮瓣手术中的应用. 中国修复重建外科杂志, 2013, 27(2): 178-181.
8. 芮永军, 张雁, 杨红, 等. 术前不同定位方法在股前外侧穿支皮瓣应用的对比分析. 中华显微外科杂志, 2015, 38(1): 33-37.
9. Weng L, Tirumalai AP, Lowery CM, et al. US extended-field-of-view imaging technology. Radiology, 1997, 203(3): 877-880.
10. 常树森, 金文虎, 魏在荣, 等. 股前外侧皮瓣术前设计优化及临床应用. 中华显微外科杂志, 2017, 40(2): 118-122.
11. 朱跃良, 殷作明, 王家祥, 等. 股前外侧穿支皮瓣切取技巧分析. 中国修复重建外科杂志, 2017, 31(1): 57-61.
12. Lee YC, Chen WC, Chou TM, et al. Anatomical variability of the anterolateral thigh flap perforators: vascular anatomy and its clinical implications. Plast Reconstr Surg, 2015, 135(4): 1097-1107.
13. Yildirim S, Gideroğlu K, Aköz T. Anterolateral thigh flap: ideal free flap choice for lower extremity soft-tissue reconstruction. J Reconstr Microsurg, 2003, 19(4): 225-233.
14. Yu P. Characteristics of the anterolateral thigh flap in a Western population and its application in head and neck reconstruction. Head Neck, 2004, 26(9): 759-769.
15. Wolff KD, Hölzle F, Kolk A, et al. Suitability of the anterolateral thigh perforator flap and the soleus perforator flap for intraoral reconstruction: a retrospective study. J Reconstr Microsurg, 2011, 27(4): 225-232.
16. Choi SW, Park JY, Hur MS, et al. An anatomic assessment on perforators of the lateral circumflex femoral artery for anterolateral thigh flap. J Craniofac Surg, 2007, 18(4): 866-871.
17. Wong CH, Wei FC, Fu B, et al. Alternative vascular pedicle of the anterolateral thigh flap: the oblique branch of the lateral circumflex femoral artery. Plast Reconstr Surg, 2009, 123(2): 571-577.
18. Kim EK, Kang BS, Hong JP. The distribution of the perforators in the anterolateral thigh and the utility of multidetector row computed tomography angiography in preoperative planning. Ann Plast Surg, 2010, 65(2): 155-160.
19. Cheng HT, Lin FY, Chang SC. Evaluation of diagnostic accuracy using preoperative handheld Doppler in identifying the cutaneous perforators in the anterolateral thigh flap: A systematic review. Plast Reconstr Surg, 2012, 129(4): 769e-770e.
20. Rozen WM, Stella DL, Bowden J, et al. Advances in the pre-operative planning of deep inferior epigastric artery perforator flaps: magnetic resonance angiography. Microsurgery, 2009, 29(2): 119-123.
21. 朱艳珊, 许亮, 来蕾, 等. 超声宽景成像对浅表器官病变诊断的价值. 浙江中西医结合杂志, 2006, 16(5): 316-317.
22. 宋达疆, 李赞, 周晓, 等. 游离分叶股前外侧穿支皮瓣修复口腔颌面部恶性肿瘤术后颊部洞穿缺损. 中国修复重建外科杂志, 2018, 32(5): 607-611.
高频彩色多普勒超声联合宽景成像在股前外侧穿支皮瓣术前导航中的应用. Diss. 遵义医学院附属医院烧伤整形外科(贵州遵义 563000), 2019.
(2019). 高频彩色多普勒超声联合宽景成像在股前外侧穿支皮瓣术前导航中的应用. (Doctoral dissertation, 遵义医学院附属医院烧伤整形外科(贵州遵义 563000)).


How much do you miss every second you take your eyes off the road? That's the question asked by a new video from road safety campaign THINK!
If you've watched the clip, you'll know two things: firstly, that's a bangin' choice of Aphex Twin tuneage. Second, you missed a LOT more pink kittens than you might have first thought.
The final kitten appears on the phone screen of a driver who's too busy looking at it that he's unaware of a mother and young child crossing the road at the traffic lights just ahead of him.
It makes for a sickening thought, but the truth is that drivers travelling at 30mph will cover roughly the length of a passenger plane every time they glance down at their phones.


Somewhere along the line in my geography education I learned how to blur the map. The idea is that by blurring the details of the graphic, patterns will emerge. Somehow we humans can do this on demand when the map is close, like on a computer screen. In other cases we can just take a few steps back to blur the details.
I don't think about this skill too often any more; I think it's become automatic. That said, I returned to the concept this past weekend while running in the woods in Georgia. I'd traveled there to tackle a 50 km (31 mile) run. Most of my running is done on the roads in and around Boston; I'm still rather inexperienced when it comes to trail run navigation and simply staying upright on the changing surfaces.
The course was marked with tiny flags on the ground, white chalk arrows and most helpful in the woods, pink survey tape tied to branches, poles, and fences at about shoulder height. I considered one section of the course "bushwacking" because it was quite difficult to see any trail. I ran with a small group on my first loop through this area. We carefully sought out each new piece of pink tape and stopped frequently when it did not appear. The vegetation was thick with brambles and the ground cover included a mix of leaves, rocks and roots. I enjoyed the "hide and seek" aspect of that section on that first loop, but didn't feel I ran it as well as I might have.
When I returned to the "bushwacking" area the second time, I was alone. I realized if I tried to find the big picture, that is, the general trend of the trail ahead, I could find each new marker more quickly. Further, focusing on finding the "line" of the trail distracted me from looking down at my feet and worrying about falling. I ran lighter and more confidently. My mantra was "see the trail, be the trail." It was a lot like "blurring the map" to see that big picture. I felt I ran that section far better using this method.
On the second loop, I also began to get inside the race director's head about how he laid out the course. If there's a choice between up, down or flat, the course goes up or down, never flat. If there's an edge, you run along it. We ran along edges of forests that abutted meadows and property lines marked with rebar. A corollary of the edge principle relates to linear features: If there's a linear feature, you run along it. We traveled along barbed wire fences, creeks and climbed up a gravel road for probably a mile and a half to the local water tower.
I developed a decent amount of intuition, which pleased me. I tested it regularly when the next pink ribbon was no where to be found. I'd head in what I thought would be the right direction and more often than not found the missing ribbon on the ground or well hidden by spring leaves. Only a few markers were actually missing, testament to our out of the way course shared by private land owners in the area.
While I'm sure I could have learned about these spatial tactics of trail running from books and other runners, it was sure fun learning it on the trail.


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Livingston moved out of the bottom two in the Championship with a comfortable home win against Raith.
The goals came from a Jordan White brace and Declan Gallagher as the visitors lost ground on the Championship's leading trio of clubs.
White headed in from close range from a cross by Jackson Longridge.
Gary Glen's corner was headed in by Gallagher and White scored his second following a Kieran Gibbons pass to put the result beyond Raith.
Match ends, Livingston 3, Raith Rovers 0.
Second Half ends, Livingston 3, Raith Rovers 0.
Corner, Raith Rovers. Conceded by Jordan White.
Myles Hippolyte (Livingston) wins a free kick in the defensive half.
Corner, Livingston. Conceded by Kyle Benedictus.
Corner, Livingston. Conceded by Grant Anderson.
Substitution, Livingston. Ryan Currie replaces Kieran Gibbons.
Substitution, Livingston. Jordyn Sheerin replaces Gary Glen.
Corner, Raith Rovers. Conceded by Morgyn Neill.
Corner, Livingston. Conceded by Mitchel Megginson.
Substitution, Livingston. Myles Hippolyte replaces Liam Buchanan.
Corner, Raith Rovers. Conceded by Ben Gordon.
Mitchel Megginson (Raith Rovers) wins a free kick in the attacking half.
Goal! Livingston 3, Raith Rovers 0. Jordan White (Livingston) left footed shot from the centre of the box to the bottom right corner. Assisted by Kieran Gibbons.
Goal! Livingston 2, Raith Rovers 0. Declan Gallagher (Livingston) header from very close range to the high centre of the goal. Assisted by Gary Glen with a cross.


A naturally wind sheltered, seaside site, with uninterrupted views to the sea, to the town centre of Mykonos and to the sunset, is being transformed into a house complex of 3 private luxurious residences. The house complex respects and reflects its' traditional surroundings and is fully adopted by the strict, traditional landscape of Mykonos. The volumes and spaces the structure creates make it possible to play with landscaped private open spaces and create very spacious and integrated ambiances. All is not at once apparent, the landscaped environment reveals its' self slowly, surprising the visitor.
The design and planting strategy stems from the idea of establishing the absolute privacy and uniqueness of each villa. The main addition was rich Mediterranean planting and design elements that hide the undesirable views while capturing all the desirable ones: the endless blue of the Aegean sea, the sun sinking into it, the magical colors of the sky. The pool areas kept very simple in order to focus to these views, yet each pool area has its' unique singular theme. Feature planting accentuates the identity of each space by providing a strong visual impact as a focal point. The beautiful sculptured structure and strong character of olive tree, with its historical value, is placed as a singular planting in selected locations. Clustered canopy trees, climbing vines with flowers and fragrant flowering trees act as the edge treatment along the villas reducing noise and glare, enhancing the privacy, screening the long traditional stoned walls by the pedestrian's walkways , giving a seamless continuity into the landscape areas. Sculptured trees and green rooms mark the independent entrance of each villa, creating a harmonised balance between built environment and nature. Location of plants are also influenced by the need to provide shade by the astonishing sunlight of Mykonos.
Design elements also include landscaped roofs with pocket gardens, open spa areas, pergolas, landscape paving and landscape lighting.


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Maxxis Dakar Team / Dakar
A tour of Saudi Arabia
The grandiose and varied landscapes of the 30th country to host the Dakar have all the ingredients for a well-rounded route. The same diversity characterises the three cities that will mark the decisive phases of the rally. Jeddah symbolises the country's deep historical roots, while the capital Riyadh evokes the power of a kingdom resolutely turned towards the future, as exemplified by the Qiddiya project.
A supersized rally
Saudi Arabia stretches over more than two million square kilometres —about four times the surface area of France. The largest country in the Middle East, whose population is concentrated in the towns and cities close to the sea, boasts a mosaic of landscapes that will put Dakar competitors through their paces on all fronts: driving and riding, navigation and endurance. It is a call to adventure.
Best Dakar ever for Tim and Tom Coronel
Beste Dakar ooit voor Tim en Tom Coronel
Schrijf je hieronder in voor onze nieuwsbrief!
Tim Tom Team
Tim Tom

redpajama_set_name: RedPajamaCommonCrawl


Pine cones add natural style to our 100% polyester, easy-fitting tee. This tee is designed with a scoop neckline, high-low hem and three-quarter sleeve. Machine washable. Imported. Available in adult sizes: (S-XL) $36.99 (2X) $39.99.
Product Comments: Nice and light feeling. Not bulky. Goes with shorts, jeans or leggings. Perfect top for just about any occasion .
Product Comments: I did not even try on this top. It was way too thin and the material was flimsy. Will be returning as soon as I call the company.
Product Comments: My wife loves this top!
Product Comments: I love this tunic. It's very flattering. The fit is perfect. The print is gorgeous.


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William Shenstone
Leigh Hunt
British author
William Gifford
British editor and scholar
Home Literature Poetry Poets L-Z
English connoisseur
https://www.britannica.com/biography/William-Shenstone
Fact Monster - People - Biography of William Shenstone
November 18, 1714 England
February 11, 1763 (aged 48) England
William Shenstone, (born Nov. 18, 1714, Leasowes, Halesowen, Shropshire, Eng.—died Feb. 11, 1763, Leasowes), a representative 18th-century English "man of taste." As a poet, amateur landscape gardener, and collector, he influenced the trend away from Neoclassical formality in the direction of greater naturalness and simplicity.
From 1745, in response to the current vogue for the ferme ornée ("ornamental farm"; i.e., one that was as picturesque as it was profitable), he devoted his chief energies to beautifying his estate, the Leasowes, by "landscape gardening," a term he was the first to use. His theories, outlined in "Unconnected Thoughts on Gardening" (1764), involved the creation of winding waterways and walks and a series of picturesque views.
Literary Favorites: Fact or Fiction?
In his poetry Shenstone celebrated rustic virtue and simplicity, foreshadowing the sentiments of the early Romantics. His best-known poem, The School-Mistress (1742), commemorates, in Spenserian stanzas, his first teacher at the village school—Sarah Lloyd. He published miscellaneous odes, elegies, and types of light verse, an index of the poetic fashions of the times. He was influential in reviving the ballad and advised and assisted Bishop Percy in the compilation and editing of Percy's Reliques of Ancient English Poetry (1765), the book that conferred literary status on the ballad.
This article was most recently revised and updated by Kathleen Kuiper.


I'm very curious as to how the guest stars [Meredith Baxter (Family Ties), Jackee Harry (Sister, Sister), Florence Henderson (The Brady Bunch), Marion Ross (Happy Days), Tempestt Bledsoe (The Cosby Show)] were selected for this episode... did the producers see who was available and then have the writers craft the jokes from there? I mean, Jackee Harry is perfect for this, but Meredith Baxter and Marion Ross in particular are very interchangeable with the dozens of other sitcom mothers over the years. Tempestt Bledsoe seemed like a fill-in... like maybe Phylicia Rashad was supposed to be there but then they re-wrote it for whichever Cosby kid they could manage, and Tempestt is the most sitcom-oriented these days? Regardless, I loved the catchphrases ("jump the shark"!!) and jokes (haha, younger, cuter kids), particularly Tempestt's about how perfect Cliff and Clair were as parents... a doctor and a lawyer with unlimited time to teach their children lessons in the most creative ways! This series is gonna be fine... and might even pick up a larger audience now that Trophy Wife has been cancelled!


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Q: A generic error occurred in GDI+ when calling Bitmap.Save() I have a problem with the following code I am trying to run. Basically I have a single source PNG, that I want to copy over all other found PNGs within my current directory, but at the resolution of the original PNG:
# Source image to replace all found images with
$sourcePng = [System.Drawing.Image]::FromFile( 'C:\Path\To\image.png' )

# Get all .png files in the directory
Get-ChildItem *.png -Recurse | Foreach-Object {
Write-Host "Converting $_ to image.png..."
  $png = New-Object System.Drawing.Bitmap( $_.ToString() )

  # Make sure the target size matches the existing image
  $newSize = New-Object System.Drawing.Size( $png.Width, $png.Height )

  # Dispose to ensure file handles are closed
  $png.Dispose()

  # Create new bitmap object from source png with old image resolution and save
  $newPng = New-Object System.Drawing.Bitmap( $sourcePng, $newSize )
  $newPng.Save( $_.ToString(), [System.Drawing.Imaging.ImageFormat]::Png ) # Errors out here
}

However, this yields the following error:

Foreach-Object: Exception calling "Save" with "2" argument(s): "A generic error occurred in GDI+."
At line:1 char:55
+ Get-ChildItem *.png -Recurse | Foreach-Object {
+                                                       ~~~~~~~~~
+ CategoryInfo          : NotSpecified: (:) [ForEach-Object], MethodInvocationException
+ FullyQualifiedErrorId : ExternalException,Microsoft.PowerShell.Commands.ForEachObjectCommand

My initial research tells me this happens because the target file has an open handle, but calling the Dispose function doesn't seem to open it back up again. I've checked and there are no other handles to the file I can see.

A: I figured out the solution after I wrote this up as I tried a couple more things, and figured this might still spare someone else the headache. Turns out, since my initial code never disposed of the $png object, the image was still "locked" as far as GDI+ was concerned. I closed out my PowerShell session, opened a new one, and re-ran my code and the images wrote as expected.


text:
Clarke poised for Stoke move after Arsenal recall
Loan players June 18, 2022 9
Arsenal have recalled Harry Clarke from his loan spell at Hibernian with reports suggesting the 21-year-old defender is on his way to Stoke City. Clarke...
Singapore to host Arsenal in Barclays Asia Trophy
Pre-season March 11, 2015 54
The Premier League have confirmed that Arsenal, Stoke City, Everton and a Singapore Select XI will participate in the Barclays Asia Trophy at Singapore's state-of-the-art National Stadium in July. The...
Stoke 0-0 Arsenal – Final third frustrations
Match reports August 26, 2012 210
Arsenal kept their second clean sheet of the season, but again failed to find the net despite a dominant performance against Stoke City. Having...


We need to add some custom PHP configuration, especially so it does not run as a daemon.
Here we need to add some custom PHP configuration, especially so it does not run as a daemon.
The important part is daemonize = no.
Then we can rebuild the image again!


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All set for the Midland Moto Rally
Leitrim Sport
Sam Moffatt (left), who won the Midland Moto Rally two years ago pictured with the title contenders in this year's series
The Admore Air Conditioning Corp Midland Moto Rally in Longford on Sunday next will feature a strong entry including reigning and several former national rally champions for the nine stage rally that is hosted by the Midland Motor Club with Jeremy O'Connor as clerk of the course.
The acquisition of a new title sponsor is a great boost to the organising Midland Motor Club and has come through long time club supporter Paul Rowley, who heads the New York based company.
Paul is originally from Killoe but has lived in New York for the last thirty three years. He is a regular competitor in Irish rallying and first competed in the Midland Moto Stages Rally back in 1985. On Sunday's nine stage encounter Paul will campaign a PCRS run Ford Fiesta R5. His reason for underpinning the rally is based in recognition of all the volunteers that run the club and the marshals that give of their time to ensure that rallying continues.
The Longford Arms Hotel, headquarters of the event are also supporting the event.
Leitrim is well represented in the entry list with Carrick pair Sean Gallagher and Shane O'Rourke being joined by Drumkeerin's Colin O'Rourke (Toyota Starlet), Keelan Grogan (Skoda Fabia R2), Drumsna's Aine Phelan (Honda Civic) and Ciaran Phelan (Honda Civic) Carrick on Shannon's Gavin Gallagher (Mitsubishi) and Manorhamilton's Stephen Reynolds (Honda Civic).
Two years ago Sam Moffatt won the event and went on to claim the Triton series and the Vard Memorial Trophy. However, the Monaghan driver is not contesting the nine stage rally.
The Moffatt family will still be ably represented as his younger brother Josh, a winner of the opening Triton round in Abbeyleix is on the entry. He will be seeking to follow in the footsteps of his brother and win the Triton series for the very first time. Josh has won the Irish Tarmac Championship and the Irish Forest series but so far, the Triton National series has eluded him.
The entry list has all the major national championship contenders including triple national champion Donegal's Declan Boyle (Ford Fiesta WRC), who was second on the opening round in Abbeyleix and will begin in Longford just a point behind Josh Moffatt.
Another former champion Clonmel's Roy White, also in a Ford Fiesta WRC, recovered to finished third on the opening round, two years ago on this event, he was runner-up to Sam Moffatt. White will need to stay pace with his rivals as he chases that elusive win.
It is hard to believe that is it some 27 years since Warrenpoint's Peadar Hurson won the national series, he remains ultra competitive and has won many events in the intervening years and remains a threat in his Fiesta WRC.
The list of past national champions continues with popular Monaghan driver Niall Maguire (Subaru WRC), the first to win three titles, also on the Midland entry. He remains a great supporter of national rallying and in this year's opening round in Abbeyleix came home seventh overall.
Donegal's Joe McGonigle (Mini WRC) is also contesting the event along with Tyrone's Frank Wray (Subaru WRC), Maynooth's Frank Barrett and Tyrone's Declan McCrory.
In the Motorsport Safety Team Group N category former champion Shane Maguire will have Trevor Bustard and Neil Tohill as opposition along with Tomas O'Rourke and the similar Mitsubishi EvoIX car of Sean Gallagher & Shane O'Rourke who are aiming to claim local honours.
The hotly contested Class 14 should feature great action with the likes of Maynooth's Ian Barrett (Darrian T90 GTR), Derry's Camillus Bradley (Ford Escort), Cavan's Gary McPhillips (Ford Escort) Wexford's James Stafford (Darrian T9), Donegal's Kevin Eves (Toyota Corolla) and Cavan's Chris Armstrong (Ford Escort) all capable of class success and a top ten finish.
Other entries include Armagh's Jason Black (Toyota Starlet), Monaghan's Raymond Conlon (Toyota Corolla), Donegal's Johnny Jordan (Toyota Starlet), Tyrone's Barry Morris (Ford Escort) and Monaghan pair David Moffatt (Toyota Starlet) and Vincent McAree (Ford Escort).
In addition to the Triton series, the rally is also counting rounds of the Sligo Pallets Border Rally Championship and Hugo Loonam Motors Midlands East Rally Championship.
Prior to the event, mechanical scrutiny take place this Saturday from 2pm until 7.30pm at Mastertech Business Park, Athlone Road, Longford. On Sunday, the first car away from Pairc Ferme at the old army barracks at 9.10am with the finish ramp celebrations at Main Street, adjacent to the Longford Arms Hotel at 5 pm.


Opera Australia is Australia's national opera company and largest arts organisation. Each year it hosts over 600 performances in venues across Australia and Asia including Sydney Opera House and The Arts Centre Melbourne. Interbrand Sydney were asked to breathe new life into their brand to attract new audiences.
In the 21st Century opera is still enjoyed by many audiences, and through rethinking and re-imaging the operatic experience, keeps pace with cultural change. Artistic Director, Lyndon Terracini, has given Opera Australia a refreshing new outlook that speaks to the future of opera – that opera should be for everyone. His bold vision includes performing in non-traditional venues as well as introducing more diverse programming to the mainstage, often involving cutting-edge technology.
We devised a logo system that could open up opera. From OA, to OPERA, to OPERA AUSTRALIA, the identity expands to contain the rich and diverse range of activities the organisation represents.
There's so much more to opera than just the performance on the stage, and this new brand seeks to express that opera isn't one-dimensional – it's multi-dimensional. The costumes, the sets, the stories, the music, the emotion, the stars, the venues, etc. We expressed this by introducing vertical bars, based on musical notation, to separate the different dimensions of opera. Bars change thickness, vertical position and pace to represent the music. In motion, they move at different speeds, representing different instruments and voices; overlapping each other to open up and wipe content in and out.
Images were designed to communicate the genre of productions; helping people understand opera's diversity. Comedies feel funny, tragedies feel sad, and romances feel passionate. We engaged the talents of internationally acclaimed Australian fashion photographer, Georges Antoni to bring a contemporary twist to our classic content.
We took the multiple-dimensional concept one step further with the introduction of an entirely new voice. Since we believe that opera is for everybody, we chose to write articles about the most compelling dimension of each opera. That could be the set design, costume design, location, lead performer, director, technical innovation, the music – in fact anything that was fresh news for established audiences and enticing for new ones.
We're incredibly proud to reveal the new Opera Australia brand to the world. This has been one of the most challenging projects we've faced this year, but with the help of Opera Australia we've managed to create a brand for modern Australia. One that will hopefully delight existing audiences and attract new ones. And, with the continued bravery of everyone at Opera Australia, keep this spellbinding art form alive for a very long time.


The Silver Birch Room has a distinctly traditional French feel about it, influenced by the Toiles de Joy wallpaper covering the main wall. Overlooking the silver birches and Koi pond through beautiful sash windows, this cosy upstairs room is ideal either for a single traveler or a couple. It comprises one room with king size bed and an en suite bathroom with shower and baignoire ancienne.
Half a flight of stairs down from here, is a casual TV/reading room overlooking the infinity pool and garden. During the day, this is a bright, sunny spot in which to unwind.
Check availability and make a booking directly online. If you have any special dietary restrictions please visit our Dining page and complete the form. Please let us know if you have any questions. Thank you for your interest in Doveton House.


Last year Trevor Swonger and Canaan Kugler reached the Section 6A tournament for the Underwood boys golf team. They will be the leaders as the Rockets take to the course for the 2019 season with their entire varsity lineup returning.
Logan Johansen, Logan Frigaard and Braden Thorson are the other varsity golfers coming back. Bryce Jorgenson is expected to fill out the varsity lineup.
Ross says Ottertail Central is the Quad County Conference favorite. OTC and Pine River-Backus are the top teams in Section 5A.
Chad Gronner will assist Ross.


I was having a discussion with my friend who is about to leave the country on vacation and while discussing we got into food and then she said "For the life of me I can't seem to get used to white people's food"; yes this is someone who stayed abroad for more than 7 years and travels at least once every year and you would assume that she would have gotten used to their food by now but nope, she isn't having it.
Do I blame my friend of course not, its actually very hard to get used to "White people's food" because we have so many delicious, tasty and spicy delicacies in this country. Inter tribal marriages and mixing up in the big cities has made it easy for us to learn from each other and hence we now prepare different dishes from different tribes in our various homes.
I remember in an interview with Eku Edewor, she was asked "What are the things you love most about nigeria" and one of her answers was the food. We in nigeria are diverse in culture tradition and food, our food gives us life and its really hard to resist. Today we are on a journey to bring you a snack from the Western part of nigeria, this street food brings a lot of memories, I almost never failed to save money so that at the end of the day I would visit the road side seller to purchase 20 naira (back when 20 naira was worth something) of Ojojo (yam fritters) from the bus stop.
Yes Nigerian water Yam fritters aka OJOJO is our soul food snack of the day, lets watch YouTube Vlogger Bukie's Kitchen has she teaches us how to prepare this fun snack.
Would you try this recipe at home? Leave your comments in the comment section below.


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Luis Alberto has meeting with Tare: the details
Apollo Heyes
Luis Alberto, source: Official Lazio Twitter
Simone Inzaghi's men arrived at Formello yesterday to begin their preseason training after medical examinations are Paideia, and among them was Spanish star midfielder Luis Alberto. The Spaniard met Igli Tare yesterday to discuss his future, and so far all signs point to the number 10 remaining with the Biancocelesti for next season. It has been a long summer full of speculation toward his return to Sevilla, with the Spanish club keen to sign him, especially after the arrivals of Monchi and Julen Lopetegui, who both know the player so well. Both Inzaghi and Lazio believe in him and have been keen to keep him in Rome, and now it seems those efforts have paid off. Over the last few days, the player has sent out signals that suggest he's staying at the club, including a text message to the coach in which he expressed his desire to stay at Lazio.
According to today's edition of Il Tempo, a three-way meeting between Tare, Luis Alberto and his agent is scheduled for Friday. It will be an important discussion where the three parties talk and decide the future of the Spaniard. Although the player is keen to return to Seville, the city where he grew up, his special relationship with Inzaghi and Lazio may prove more powerful to his decision. Lazio had asked for between €30-40m for the star, and Sevilla's highest offer to date was only €25m (including bonuses), which is considered too low for Claudio Lotito. More will be known in the next 48 hours, in a crucial stage of Lazio's transfer window.
Tags: Igli Tare, Lazio, Luis Alberto, Sevilla
Salernitana insisting for Casasola
Salernitana attempting to convince Lombardi to join club


Fresh Store Builder (FSB) is an e-commerce software that allows you to create a website to sell products from Amazon.com. We use FSB on several websites.
The software functions similar to WordPress and there is a supplemental WordPress plugin available for purchase.
Display: Nice clean display of products. Seriously, everything is lined up nicely from listing products in a row, to descriptions, to shopping buttons. Makes a very nice, smooth, user and visitor experience.
Stand Alone: Does not rely on any other software. Runs outside of WordPress so there is no impact on your WordPress site, no stress on the WP database or WP page load time.
Other Vendors: Create custom URLs to create "Buy Now" links to other products on the Web, outside of Amazon.com. You might use this feature to link to products on Commission Junction, Share-a-Sale, Click-Bank, etc.
Unique Search Results: Search box feature that pulls products from Amazon into the search results if a user looks for something you have not yet listed.
Spin Options: Comes with a feature to spin text (which means creating a sentence with alternative words) to assist you in ranking higher and avoiding duplicate content penalties by Google.
Seasonal Offers: Use the Hide or Disable features for products, sideboxes, and widgets to promote seasonal items.
Community help: TWO community forums to ask questions, search for past discussions, and browse user's sites for ideas to improve your own income. This is actually more important than one initially thinks. It's very nice to run a search for your problem or ask fellow users, than to wait 24 hours for a submitted tech ticket.
Booster Plugin: Optional affordable booster plugin for those who wish to integrate products with WordPress posts and pages.
Cons – What's not to Like?
Amazon only for Add to Cart: The store is only for Amazon products, so if you have your own products, you will need to look into how to list them on Amazon for sale through Amazon seller programs, such as Fullfilled by Amazon (FBA), or use the Buy Now button option with a Custom URL.
Limited Web Design Options: Unless you know coding, your store will have a similar layout to all other FSB stores because there are only so many "templates" to choose from. Also, WordPress users should understand that while you can use the CSS settings to modify the color and layout of your Fresh Store, you most likely will not be able to match it exactly to a WordPress theme.
You cannot purchase this WordPress Plugin as a stand alone software. You must purchase FSB for the plugin to function. The plugin allows you to show your FSB store categories, products and shopping cart contents inside WordPress by using Widgets or embedding into Posts and Pages. This is perfect for integrating a smooth transition from WordPress to your FSB software.
Great – You installed the software. Now what?
Navigation: Set your top and bottom navigation links at Template > Template Options.
Sidebar: At Content > Add Sidebox, you can choose some sideboxes to add such as Search, Shopping cart, custom HTML, etc. Also under Content are options to re-arrange your sidebar boxes.
Widgets: Visit Content > Add Widget to add widgets of BestSellers, Random Products, Sliders, Special Offers, or custom HTML. Note: To edit a custom HTML widget, you go to Template >Template Options and the widgets are toward the middle of the item list.
Social Links: Add links to your social networks: Template > Template Options > Template Options … scroll toward the bottom for Facebook, Twitter, Pinterest, YouTube, and Google Plus options.
Decide on Tag Use: Go to Tools > Change Parameters > Product Tags and choose your Tag settings. You can choose how many tags to set for each product imported, turn the import feature off to add your own tags, etc.
Decide on Add to Cart Options: You can use only Add to Cart, only Buy Now, or a mixture of both buttons. To show only Buy Now buttons, look in two locations. Go to Tools > Change Parameters > Cart & Checkout will let you hide Add to Cart button on all product pages. In the same location, but under Products, you'll find the option to turn on the display for a direct link to Amazon on the Product page.
SEO your Categories and Products: Go back to your Product and Category section of the dashboard and choose View All Products and View All Categories, respectively. For each category and product, click Edit and create unique text descriptions. Check the SEO & Meta to be sure it is acceptable to you. For example, you might shorten the URL, remove words people don't search for, or replace that URL with keywords of your ow.
Go Live: Under Get Started > Store Health you can make your store live.
Test Run: Open another browser where you are not logged in and click around your store. Click all the way through a product until you arrive at Amazon. Make adjustments if needed.
Promote: Begin normal Internet Marketing steps such as scheduling products etc. For the best social media scheduler see our post here.
Hide – Products that are hidden give a 404 error if it receives any visit. Keep them in your store if you don't want the system to add them in again when you use autoposting. Keep in mind, there is no way to retrieve a product once it's hidden.
Queue – This term is used in two ways. Under Parameters, you have a Product Queue where you can set the number of products to add each time the Queue runs. This is used for populating or autoposting products. The second type of Queue is used to edit a group of items and referred to as a Queue Run (Product Edit Queue > Queue Run). It allows you to place items in a "group" or queue and make edits to each one. This is really helpful if you think of outsourcing a task or if you are working on mass edits across your sites as it will keep track of your last item edited so you don't have to do it all in one sitting.
SEO – best practices, keep a good ratio of unique content vs FSB products. Also, add some CSS and unique content – anything to make it look less like a template so Google doesn't think you store is just like all the rest!