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Health and Quality of Life Outcomes
Validation of two generic patient-reported outcome measures in patients with type 2 diabetes
Louis S Matza1,
Kristina S Boye2 &
Nicole Yurgin2
Health and Quality of Life Outcomes volume 5, Article number: 47 (2007) Cite this article
Prior to using a generic patient-reported outcome measure (PRO), the measure should be validated within the target population. The purpose of the current study was to validate two generic measures in patients with type 2 diabetes.
Patients with type 2 diabetes in Scotland and England completed two generic measures: EQ-5D and Psychological General Well-Being Index (PGWB). Two diabetes-specific measures were administered: ADS and DSC-R. Analyses assessed reliability and validity.
There were 130 participants (53 Scotland; 77 England; 64% male; mean age = 55.7 years). Responses on the EQ-5D and PGWB reflected moderate impairment consistent with previous diabetes samples: mean EQ-5D Index score, 0.75; EQ-5D VAS, 68.8; PGWB global score, 67.9. All scales of the PGWB demonstrated good internal consistency reliability (Cronbach's alpha = 0.77 to 0.97). The EQ-5D and PGWB demonstrated convergent validity through significant correlations with the ADS (r = 0.48 to 0.61), DSC-R scales (r = 0.33 to 0.81 except ophthalmology subscale), and Body Mass Index (r = 0.15 to 0.38). The EQ-5D and PGWB discriminated between groups of patients known to differ in diabetes-related characteristics (e.g., history of hypoglycemia).
Results support the use of the EQ-5D and PGWB among patients with type 2 diabetes, possibly in combination with condition-specific measures.
Patient-reported outcome measures (PROs) that assess health-related quality of life (HRQL) and related constructs are often categorized as either generic or condition-specific [1–3]. Generic measures are designed for use among diverse populations with a broad range of medical conditions. These instruments can also be used to characterize healthy samples without a particular medical condition. In contrast, condition-specific measures are relevant to a particular group of patients, and they have been developed to assess specific populations, quantify aspects of functioning, and examine the impact of particular medical conditions or treatments.
A substantial body of literature has focused on comparing generic and condition-specific measures, while identifying advantages of each. Compared with generic measures, the primary advantage of condition-specific measures is that they are usually found to be more responsive to treatment-related change [4–6]. Because of their greater responsiveness to change, condition-specific instruments may be more likely to detect differences between treatment groups in clinical trials [7]. An advantage of generic PROs is that they can be used to compare among various populations, make comparisons to the general population, and estimate the relative impact of various medical conditions or treatments [1, 2, 8, 9]. Generic measures also tend to correlate well with condition-specific measures [10, 11], and in some studies, they have demonstrated responsiveness or convergent validity that was comparable to condition-specific measures [12–16]. Most importantly, generic measures are distinct from condition-specific measures in that they usually assess impact of disease and treatment on overall functioning or a broader range of health domains [8, 17].
Because generic and condition-specific measures have different strengths and are conceptually distinct, it is often recommended to administer both types of instruments as part of a complete outcomes assessment in clinical trials [5, 17–19]. Prior to using a generic measure, however, it is important that the instrument is shown to be reliable and valid in the specific population under investigation [9]. Instruments validated in one population will not necessarily perform well among patients with a different medical condition. Therefore, it is often necessary to validate generic PROs in multiple populations. The purpose of the current study was to examine the performance of two commonly used generic PROs in a sample of patients with type 2 diabetes, an increasingly prevalent disease associated with serious health risks and HRQL impairment [20–27].
One of the two measures evaluated in this study is the EuroQol EQ-5D, a brief health status instrument frequently used for clinical and economic appraisal [28, 29]. The EQ-5D has been used in several large studies involving patients with type 2 diabetes to provide an estimate of HRQL and derive utilities, which used to compute quality-adjusted life years (QALYs) in models evaluating treatment cost-effectiveness [30–35]. However, no studies were located focusing on validation of the EQ-5D among patients with type 2 diabetes. The other generic PRO examined in this study is the Psychological General Well-Being Index (PGWB), which was developed to measure self-perception of affective states and to assess a sense of subjective well-being or distress [36]. The PGWB has been used in several studies that included patients with type 2 diabetes [37, 38], including one study that found adequate internal consistency reliability and convergent validity among a sample of 88 Native American patients with type 2 diabetes [39]. However, no studies were located validating the PGWB in a more general sample of patients with type 2 diabetes. The current analysis builds on these findings by evaluating these properties among a larger sample in the United Kingdom, while also assessing known-groups validity.
Participants were required to be (1) diagnosed with type 2 diabetes by a recognized medical professional (as indicated by patient self-report); (2) between 30 and 75 years old; (3) able to identify the age at which they were first diagnosed with diabetes; (4) able to read and understand English; and (5) willing and able to give informed consent prior to study entry. Patients were not eligible if they had cognitive impairment, hearing difficulty, or severe psychopathology that could interfere with the ability to complete the study measures. Participants were recruited through ten advertisements placed in four newspapers in Scotland and England from June to August of 2005. Interested patients responded by telephone, and 200 potential participants were screened to assess whether they met the study inclusion/exclusion criteria. Of the 200 screened patients, 132 were available, eligible, and willing to participate. Two participants who attended the interview were unable to complete the questionnaires relevant to the current analysis. Thus, the current study includes a sample of 130 individuals with type 2 diabetes.
EuroQol EQ-5D
This questionnaire assesses functioning in five dimensions: mobility, self-care, usual activities, pain/discomfort, and anxiety/depression. Each dimension is assessed by one item with three response options: no problems, some problems, and severe problems. Higher scores on these items indicate greater impairment. Responses to these five items are used to derive the weighted EQ-5D index score, which represents overall health with a possible range from -0.594 to 1.0 [40, 41]. After completing the five dimension items, patients completed the single item EQ-5D visual analogue scale (VAS), on which they rated their current health on a scale ranging from 0 (worst imaginable health state) to 100 (best imaginable health state). Higher scores on the index score and VAS indicate better health status.
Psychological General Well-Being Index (PGWB)
The PGWB is comprised of 22 items in the following 6 dimensions: anxiety (5 items); depressed mood (3 items); positive well-being (4 items); self-control (3 items); general health (3 items); and vitality (4 items). Responses are rated on a six-point Likert scale ranging from 0 (reflecting the most distress) to 5 (reflecting the highest level of well-being) [42]. Scoring approaches for the PGWB have varied in previously published studies, with the global score often ranging from 0 to 100 (when items range from 0 to 5) or 22 to 132 (when items range from 1 to 6). For the current study, this instrument was scored following the approach proposed by Chassany et al. [42] in the recently published user's manual. The six PGWB raw subscale scores were computed by summing the item responses, and the raw global score is the sum of the six subscale scores. Then, these raw scores were transformed to a 0–100 scale by dividing each raw score by the maximum possible score, multiplying by 100, and rounding to one decimal place. Higher scores reflect better well-being.
Appraisal of Diabetes Scale (ADS)
The ADS is a brief 7-item patient-reported scale that assesses the impact of diabetes on a patient's life. This condition-specific instrument was used to assess criterion validity of the EQ-5D and PGWB. The items, which were developed based on theory and previous research, include "How upsetting is having diabetes for you?" and "To what degree does your diabetes get in the way of your developing life goals?". The instrument has been shown to have acceptable internal consistency reliability, test-retest reliability, and construct validity [43]. Higher scores indicate greater negative impact of diabetes.
Diabetes Symptom Checklist – Revised (DSC-R)
The DSC-R is a revised version of the DSC-2, which was developed to measure both the frequency and perceived discomfort of physical and psychological symptoms associated with type 2 diabetes and its potential complications [44]. Like the ADS, the DSC-R was used to assess validity of the two generic instruments that were the focus of the current analysis. For each of the 34 DSC-R items, respondents first indicate whether they have experienced each symptom in the past month by circling "yes" or "no." If the patient answers "no," then the item is scored as a 0. If "yes" is selected, the participant proceeds to rate the perceived discomfort of the symptom on a 5-point scale ranging from 1 (not at all) to 5 (extremely). The instrument yields a total score and scores on the following subscales: psychology-fatigue, psychology-cognitive, neurology-pain, neurology-sensory, cardiology, ophthalmology, hypoglycemia, and hyperglycemia. The total score and all subscale scores range from 0 to 5, with higher scores indicating greater symptom burden.
Demographic and clinical information form
Patients completed a brief questionnaire that included questions on age, sex, ethnicity, living situation, employment, education, diabetes-related health, and general health. Participants' weight and height were measured at the beginning of each interview and recorded on the demographic and clinical information form so that patients' Body Mass Index (BMI) could be computed [45]. Items assessing diabetes-related health included questions asking whether participants had ever experienced hyperglycemia, daytime hypoglycemia, or nighttime hypoglycemia.
Data collection and statistical analysis procedures
Data were collected in Edinburgh and London during August 2005. All procedures and instruments were approved by an independent Institutional Review Board, and all participants provided written informed consent prior to completing any study measures. After signing the consent form, participants independently completed the questionnaires analyzed in the current study.
Statistical analyses were completed using SAS version 8.12 (SAS Institute, Cary, NC). Descriptive statistics were used to summarize demographic/clinical characteristics and scores on health status measures. Categorical variables are summarized in terms of frequencies and percentages, and for each continuous variable, the mean, standard deviation, median, range, percent at floor, and percent and ceiling are presented. In the current study, there were no missing data on any of the measures, and therefore, procedures for handling missing data were not followed. Internal consistency reliability is the extent to which individual items within a scale are related to one another. Internal consistency was examined for the PGWB subscales and global score using Cronbach's formula for coefficient alpha. Cronbach's alphas greater than 0.70 are generally considered acceptable [9].
Construct validity refers to the extent to which the instrument measures what it is intended to measure. To assess the construct validity of the EQ-5D and PGWB, both convergent and known-groups validity were examined. Convergent validity is the degree to which scores from the instrument undergoing evaluation are related to scores from an instrument measuring a similar construct. To examine convergent validity, Spearman correlations were performed to examine the relationship of the two generic measures with diabetes-specific patient-reported measures and patients' BMI. BMI was used as a criterion because body weight is an important health indicator for patients with type 2 diabetes. Roughly 40% to 50% of patients with diabetes meet criteria for obesity [26, 46], and obesity is likely to exacerbate symptoms and metabolic abnormalities of type 2 diabetes, increase the risk of complications, and complicate the goal of achieving glycemic control [47–50]. Correlation coefficients were interpreted based on guidelines proposed by Cohen [51] suggesting that a correlation of 0.10 is small, 0.30 is moderate, and 0.50 is large. It was hypothesized that the generic measures under investigation would be significantly correlated with the condition-specific measures and patients' BMI, with correlation coefficients in the moderate to large range.
Known-groups validity is a scale's ability to discriminate among groups of patients who are known to differ by a key indicator. Using t-tests, EQ-5D and PGWB scores were compared among groups of patients who differed in the following characteristics: symptom burden as reported on condition-specific measures; type of pharmacological treatment (injectable insulin vs. oral medication only); preference for weight change (patients who would like to lose weight vs. patients who would like to stay the same weight); and experience with daytime hypoglycemia, nighttime hypoglycemia, and hyperglycemia (patients who had each of these experiences vs. patients who did not). It was hypothesized that the EQ-5D and PGWB would discriminate between groups of patients in each of these comparisons.
A total of 130 eligible participants completed the study, 53 in Edinburgh and 77 in London (Table 1). The sample in London was more ethnically diverse than the sample in Edinburgh, which was 100% White. There were no other statistically significant differences between the two geographic groups with respect to demographics (e.g., gender, age, marital status, employment) or clinical characteristics (e.g., BMI, age when first diagnosed with diabetes, current treatment). Therefore, data from the two cities were pooled for all analyses.
Table 1 Demographic and clinical characteristics
The majority of participants were male (n = 84; 64.6%), and the mean age of the total sample was 55.7 years old. Most of the patients were currently married (n = 79; 60.8%), over a third worked full-time (n = 46; 35.4%), and over a third were retired (n = 47; 36.2%). The mean Body Mass Index (BMI) of the total sample was 31.5, which is considered to be in the obese range [45]. The mean age when first diagnosed with diabetes was 49.1 years old. Most participants received oral, but not injectable medications for treatment of their diabetes (n = 85; 65.4%). A total of 31 participants (23.8%) were treated with injectable medications, either alone or in combination with oral medications.
Descriptive statistics and internal consistency reliability
There were no missing data on the EQ-5D (Table 2). The great majority of the 130 participants reported no problems on the EQ-5D self-care item (n = 120; 92.3%), while the other four dimension items reflected greater rates of difficulty. Roughly one third of participants reported having at least some problems in the dimensions of mobility (n = 42; 32.3%) and usual activities (n = 41; 31.5%). Approximately a third of patients reported having either some problems (n = 35; 26.9%) or extreme problems (n = 8; 6.2%) in the anxiety/depression dimension. The greatest rates of difficulty were found in the pain/discomfort dimension, with half of the sample reporting either some problems (n = 52; 40.0%) or extreme problems (n = 13; 10.0%). The pattern of responses was similar in the London and Edinburgh samples, although the participants in Edinburgh reported slightly greater rates of problems in mobility, self-care, and usual activities. The mean EQ-5D index score of 0.75 and VAS score of 68.8 both indicate a moderate level of overall impairment in this sample (Table 3). The mean index score was somewhat lower for the Edinburgh sample (0.70) than for the London sample (0.79). Analysis of floor and ceiling effects revealed that 40% of the sample had the maximum EQ-5D index score of 1. The VAS did not have a similar ceiling effect.
Table 2 Frequencies and percentages of participants' responses to the five categorical items of the EQ-5D
Table 3 Distributional Characteristics of EQ-5D Continuous Scales
On the PGWB, there were no missing data, and mean subscale scores were similar in the two samples (Table 4). The greatest impairment was reflected in the vitality subscale, which had a mean score of 59.5 in the total sample of 130 participants. The positive well-being and general health subscales also reflected some impairment (mean scores of 61.1 and 63.4, respectively). Higher scores were found on the anxiety, depressed mood, and self-control subscales (69.9, 78.9, and 78.0, respectively). On the depressed mood subscale, 23.8% of the sample had the maximum score of 100, indicating that almost a quarter of this sample reported no problems with depression. The PGWB demonstrated good internal consistency reliability, with Cronbach's alphas for the six subscales ranging from 0.77 to 0.92 (Table 5). The alpha for the global score was 0.97.
Table 4 Distributional Characteristics of the PGWB Scales
Table 5 Internal consistency reliability of the PGWB
Convergent validity
Convergent validity of the EQ-5D index score and VAS were demonstrated through significant correlations with the ADS, DSC-R, and patients' BMI (Table 6). These correlations were generally in the moderate to large range. Spearman correlations of the index score and VAS with the ADS had coefficients of -0.52 and -0.49, respectively (both p < 0.001). Correlations with the DSC-R total score were -0.64 and -0.53 (both p < 0.001). Correlations between the EQ-5D and the DSC-R subscales ranged from -0.33 to -0.61 (all p < 0.001), except for the correlations with the ophthalmology subscale which were somewhat smaller (r = -0.22 and -0.19; both p < 0.05). Correlations of the EQ-5D index score and VAS with patients' BMI were -0.27 (p < 0.01) and -0.38 (p < 0.001).
Table 6 Convergent Validity of the EQ-5D and PGWB: Spearman correlations with condition-specific measures and BMI
Convergent validity of the PGWB global score was also supported (Table 6), with the majority of correlations in the moderate to large range. Correlations of the PGWB global score with the ADS and the DSC-R total score had coefficients of -0.61 and -0.71, respectively (both p < 0.001). Correlations of the PGWB global score with the DSC-R subscales, except the ophthalmology subscale, ranged from -0.45 to -0.76 (all p < 0.001). The correlation with patients' BMI was somewhat smaller, but still statistically significant (r = -0.24; p < 0.01).
The PGWB subscales also demonstrated good convergent validity. Correlations of these six subscales with the ADS ranged from -0.48 to -0.61 (all p < 0.001). Similarly, all PGWB subscales had correlations with the DSC-R total score that were in the large range (r = -0.57 to -0.68; all p < 0.001). Correlations between PGWB subscales and DSC-R subscales were all in the moderate to large range and statistically significant (p < 0.001), except for those involving the DSC-R ophthalmology subscale which were notably smaller. Correlations with BMI were statistically significant for four PGWB subscales: positive well-being (r = -0.19), self-control (r = -0.20), general health (r = 0.28), and vitality (r = 0.28). The anxiety and depressed mood subscales of the PGWB were not significantly correlated with BMI.
Known-groups validity
Known-groups validity of the EQ-5D index score and VAS was supported in several group comparisons (Table 7). Both EQ-5D scores significantly discriminated between groups of patients categorized based on median splits of their ADS score and DSC-R total score (all p < 0.001). Groups with higher scores (indicating greater symptom burden) on these two diabetes-specific instruments had lower EQ-5D scores (indicating lower HRQL). In addition, patients who wanted to lose weight (n = 113) had significantly lower EQ-5D scores than patients who wanted to stay the same weight (n = 16) (both p < 0.001). Patients who had experienced daytime hypoglycemia had significantly lower mean EQ-5D index (p < 0.05) and VAS (p < 0.001) scores than patients who had not experienced daytime hypoglycemia. Results followed a similar pattern for hyperglycemia and nighttime hypoglycemia, although comparisons were not consistently statistically significant.
Table 7 Known-groups validity of the EQ-5D and PGWB Global Score: Comparisons between groups of patients
The PGWB also discriminated between groups of patients who differed in scores on diabetes-specific instruments and clinical characteristics (Table 7). Groups with higher scores (indicating greater symptom burden) on the ADS and DSC-R total score had lower PGWB global scores (indicating lower overall well-being) (both p < 0.001). Patients who wanted to lose weight (n = 113) had a significantly lower mean PGWB global score than patients who wanted to stay the same weight (n = 16) (p < 0.05). The PGWB global score also discriminated between groups of patients differing with regard to whether they had experienced daytime hypoglycemia, nighttime hypoglycemia, and hyperglycemia (all p < 0.05). Known-groups validity of the PGWB subscales was also supported (Table 8). Statistically significant group differences were found in most comparisons involving the anxiety, positive well-being, self-control, general health, and vitality subscales. The depressed mood subscale discriminated between groups of patients determined by median splits on the ADS and DSC-R, but significant differences on this subscale were not found in the other group comparisons.
Table 8 Known-Groups Validity of the PGWB Subscales: Comparisons between Groups of Patients
No scales of the EQ-5D or PGWB significantly discriminated between patients treated with injectable medication (i.e., insulin with or without concomitant oral medication; n = 31) and patients treated only with oral medications. In general, scores were somewhat higher in the oral treatment group, but these differences between groups were not statistically significant.
Current findings provide support for the use of the EQ-5D and PGWB in patients with type 2 diabetes. The PGWB had good internal consistency reliability, and both instruments demonstrated excellent convergent and known-groups validity. Convergent validity was supported through consistently significant correlations with self-report, diabetes-specific symptom impact measures as well as patients' BMI, an objective health indicator that is particularly relevant to type 2 diabetes [20, 26, 52]. Furthermore, both the EQ-5D and PGWB discriminated between groups of patients who differed in self-reported impact of diabetes symptoms, preference for weight change, and experience with hyperglycemia and hypoglycemia.
The mean EQ-5D index score of 0.75 is consistent with EQ-5D ratings in other studies of patients with type 2 diabetes. For example, the mean index score was 0.74 in a sample of 1348 patients in the Netherlands [34] and 0.76 in a sample of 4189 patients from five European countries [32]. In previous studies, the PGWB has been scored in several ways (as described in the methods section of the current manuscript), thus making it difficult to compare among studies. In the current study, this instrument was scored using a relatively new standardized approach proposed in the recently published PGWB user's manual. Using this approach, all subscale scores and the global score are normalized so that scores have a possible range of 0 to 100 [42]. The current results provide a benchmark for these normalized scores among a general sample of patients with type 2 diabetes in the UK.
Although the two generic measures were found to be valid in this sample, it would not be ideal to use either instrument as the only PRO in a clinical trial. A published analysis comparing generic to condition-specific measures across 43 randomized clinical trials found that the condition-specific measures were more responsive to change, particularly in studies with a nonzero therapeutic effect [6]. Thus, interpretation of trial outcomes based solely on generic instruments such as the PGWB or EQ-5D could fail to detect true treatment-related improvement, even though these two measures do appear to correlate well with condition-specific instruments. Furthermore, generic instruments may not capture the specific impairments within a particular population. For example, although all participants in the current sample had type 2 diabetes, 40% of the participants had the maximum EQ-5D index score of 1 which theoretically represents perfect health status. This ceiling effect suggests that the brief EQ-5D may not reflect the health-related problems of all patients with type 2 diabetes, particularly patients whose symptoms have an impact on functional domains other than the five EQ-5D dimensions. Given the different strengths of generic and condition-specific measures, we recommend using the EQ-5D and PGWB as part of an overall health outcomes battery that also includes condition-specific measures of symptom burden or HRQL. There are several well-validated instruments designed specifically to assess outcomes of treatment for type 2 diabetes [53, 54], and the decision regarding which measures to use will depend on the specific aims of each study. The generic measures examined in the current study can complement previously validated condition-specific measures by providing an estimate of overall HRQL and allowing for comparisons across trials and populations.
Results of the current study are limited by the fact that data are only available at one point in time. Consequently, neither test-retest reliability nor responsiveness to change could be evaluated. Evaluation of responsiveness using longitudinal data is needed to ensure that the EQ-5D and PGWB would be sensitive to change in patients' condition when true change has occurred in either a clinical trial or naturalistic setting. It is hoped that longitudinal studies will build on the current findings by examining these measurement properties of the EQ-5D, PGWB, and other generic instruments in patients with type 2 diabetes.
Psychometric instrument evaluation is an ongoing process, and confidence in a PRO's performance is strengthened as data accumulate from multiple studies and samples [55]. The current study provides initial data suggesting that the EQ-5D and PGWB are appropriate for use in patients with type 2 diabetes, and future research may provide additional support for this conclusion.
Appraisal of Diabetes Scale:
Body Mass Index:
Diabetes Symptom Checklist – Revised:
DSC-R
health-related quality of life:
HRQL
Patient-reported outcome measures:
Psychological General Well-Being Index:
PGWB
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UK Prospective Diabetes Study Group (UKPDS): Quality of life in type 2 diabetic patients is affected by complications but not by intensive policies to improve blood glucose or blood pressure control (UKPDS 37). Diabetes Care 1999, 22: 1125–1136. 10.2337/diacare.22.7.1125
Dupuy HJ: The Psychological General Well-Being (PGWB) Index. In Assessment of Quality of Life in Clinical Trials of Cardiovascular Therapies. Edited by: Wenger, N. K., Mattson, M. E., Furberg, C. D. and et al.. Washington, DC, Le Jacq Publishing; 1984:170–183.
Herlitz J, Caidahl K, Wiklund I, Sjoland H, Karlson BW, Karlsson T, Haglid M, Hartford M: Impact of a history of diabetes on the improvement of symptoms and quality of life during 5 years after coronary artery bypass grafting. J Diabetes Complications 2000, 14: 314–321. 10.1016/S1056-8727(00)00115-X
Shobhana R, Rama Rao P, Lavanya A, Padma C, Vijay V, Ramachandran A: Quality of life and diabetes integration among subjects with type 2 diabetes. J Assoc Physicians India 2003, 51: 363–365.
Leonardson GR, Daniels MC, Ness FK, Kemper E, Mihura JL, Koplin BA, Foreyt JP: Validity and reliability of the general well-being schedule with northern plains American Indians diagnosed with type 2 diabetes mellitus. Psychol Rep 2003, 93: 49–58. 10.2466/PR0.93.5.49-58
Krabbe P, Weijnen T: Guidelines for analysing and reporting EQ-5D outcomes. In The Measurement and Valuation of Health Status using EQ-5D: A European Perspective. Edited by: Brooks R, Rabin R and de Charro F. Dordrecht, Kluwer Academic Publishers; 2003.
McDowell I, Newell C: Measuring Health: A guide to rating scales and questionnaires. 2nd edition. New York, Oxford University Press; 1996.
Chassany O, Dimenas E, Dubois D, Wu A: PGWBI User Manual. Lyon, France, MAPI Research Institute; 2004.
Carey MP, Jorgensen RS, Weinstock RS, Sprafkin RP, Lantinga LJ, Carnrike CL Jr., Baker MT, Meisler AW: Reliability and validity of the appraisal of diabetes scale. J Behav Med 1991, 14: 43–51. 10.1007/BF00844767
Grootenhuis PA, Snoek FJ, Heine RJ, Bouter LM: Development of a type 2 diabetes symptom checklist: a measure of symptom severity. Diabet Med 1994, 11: 253–261.
Garrow JS, Webster J: Quetelet's index (W/H2) as a measure of fatness. Int J Obes 1985, 9: 147–153.
Centers for Disease Control and Prevention (CDC): Prevalence of overweight and obesity among adults with diagnosed diabetes--United States, 1988–1994 and 1999–2002. MMWR Morb Mortal Wkly Rep 2004, 53: 1066–1068.
Albu J, Raja-Khan N: The management of the obese diabetic patient. Prim Care 2003, 30: 465–491.
Bulpitt CJ, Palmer AJ, Battersby C, Fletcher AE: Association of symptoms of type 2 diabetic patients with severity of disease, obesity, and blood pressure. Diabetes Care 1998, 21: 111–115. 10.2337/diacare.21.1.111
Maggio CA, Pi-Sunyer FX: The prevention and treatment of obesity. Application to type 2 diabetes. Diabetes Care 1997, 20: 1744–1766.
Scheen AJ: Treatment of diabetes in patients with severe obesity. Biomed Pharmacother 2000, 54: 74–79. 10.1016/S0753-3322(00)88855-1
Cohen J: Statistical Power Analysis for the Behavioral Sciences. 2nd edition. Hillsdale, NJ, Lawrence Erlbaum Associates; 1988.
Sullivan PW, Morrato EH, Ghushchyan V, Wyatt HR, Hill JO: Obesity, inactivity, and the prevalence of diabetes and diabetes-related cardiovascular comorbidities in the U.S., 2000–2002. Diabetes Care 2005, 28: 1599–1603. 10.2337/diacare.28.7.1599
Garratt AM, Schmidt L, Fitzpatrick R: Patient-assessed health outcome measures for diabetes: a structured review. Diabet Med 2002, 19: 1–11. 10.1046/j.1464-5491.2002.00650.x
Luscombe FA: Health-related quality of life measurement in type 2 diabetes. Value Health 2000, 3 Suppl 1: 15–28. 10.1046/j.1524-4733.2000.36032.x
Revicki DA, Osoba D, Fairclough D, Barofsky I, Berzon R, Leidy NK, Rothman M: Recommendations on health-related quality of life research to support labeling and promotional claims in the United States. Qual Life Res 2000, 9: 887–900. 10.1023/A:1008996223999
The authors thank Karen Malley for expert statistical programming; Jodi Shorr for production, editorial, and data collection assistance; Julie Meilak for production assistance; and Jessica Brewster-Jordan and Sally Mannix for assistance with data collection. This study was funded by Eli Lilly and Company.
Center for Health Outcomes Research at United BioSource Corporation, Bethesda, MD, USA
Louis S Matza
Eli Lilly & Company, Indianapolis, IN, USA
Kristina S Boye & Nicole Yurgin
Kristina S Boye
Nicole Yurgin
Correspondence to Louis S Matza.
LM works for UBC, a company that received funds from Eli Lilly for this research. KB is an employee and stock holder of Eli Lilly and Company. NY is an employee and stock holder of Eli Lilly and Company.
LM wrote the manuscript and guided data collection, analysis, and interpretation. KS assisted with study design, provided input into data analyses/interpretation, and critically reviewed the manuscript. NY assisted with study design, provided input into data analyses/interpretation, and critically reviewed the manuscript. All authors have read and approved the final manuscript.
Matza, L.S., Boye, K.S. & Yurgin, N. Validation of two generic patient-reported outcome measures in patients with type 2 diabetes. Health Qual Life Outcomes 5, 47 (2007). https://doi.org/10.1186/1477-7525-5-47
DOI: https://doi.org/10.1186/1477-7525-5-47
Visual Analogue Scale
Internal Consistency Reliability
Good Internal Consistency Reliability
Great Symptom Burden
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You are here: Parliament home page > Parliamentary business > Publications and Records > Committee Publications > All Select Committee Publications > Commons Select Committees > Foreign Affairs > Foreign Affairs
Select Committee on Foreign Affairs Minutes of Evidence
Examination of Witnesses (Questions 1 - 19)
RT HON JACK STRAW MP, MR WILLIAM EHRMAN AND MR TIM DOWSE
Chairman: Foreign Secretary, welcome to your first visit to the Quadripartite Committee. Welcome also to members of the public. It is good to see some interest in these matters. The purpose obviously is to take evidence on the Annual Report for 2000 but also on developments since then. Thank you for the written response to the questions that we asked earlier in the year. Towards the end, we will be raising some questions on prior Parliamentary scrutiny. First, let us start with some specific issues arising from the report.
Mr O'Neill
1. Secretary of State, Criterion One, which involves respect for the UK's international commitments, either regarding UN sanctions or EU common positions: we understand that there is evidence that other EU States have exported equipment to China, which the UK has refused to license under our interpretation of the arms embargo. On the other hand, have there have been any instances where the UK has agreed to license any equipment when it has been notified that another Member has refused a licence?
(Mr Straw) Mr Chairman, may I say, by way of a preliminary, that I am delighted to be here. I might have said that it is a joy, as ever, but that might be misinterpreted. Secondly, may I introduce the officials with me: William Ehrman, who is Director, International Security, and Tim Dowse, who is Head of the Non-Proliferation Department at the Foreign and Commonwealth Office. To Mr O'Neill, may I say that some of the detail of this I will need to take in the private session, for reasons which will become clear once we go into private session.
2. Secretary of State, I am sorry to interrupt you at this stage. Could you give some general indications?
(Mr Straw) That is exactly what I am going to do. My aim is to be as forthcoming as I possibly can in public session but by definition some of the reasons for going into private session I can only explain privately, otherwise we are going to be in a circular situation. To deal with what I would like to say in public, the criteria which we have are a consolidation of national criteria and also of EU criteria as well. The EU criteria, although they are criteria which are common to all the European Union countries, are obviously dependent upon national application and therefore it must logically follow that there could be cases, whether in respect of China or anywhere else, where one country in good faith and on similar evidence would come to a different judgment from another country applying the same criteria. I would also say that since some of these issues involve extremely fine questions of judgment, if you took a random group of this Committee and said, "Make a decision" and another random group and said to them, "Make a decision" on exactly the same facts and data, you could end up with two different sets of decisions. That is what we are dealing with here.
3. Does that come out of the fact that within the 15 Member nations there really is not a consensus as to a common interpretation? Would you like to say what is the obstacle? Is it on the one hand that the UK is taking, let us say, a high moral stand and is too restrictive or are there some people who think that the UK is not restrictive enough and therefore there is this failure to agree?
(Mr Straw) I do not think it is either. I think that all the European Union countries are committed to the EU Code and they are also committed to their own systems. It happens that, in terms of parliamentary scrutiny, we are much more advanced, I think, than any other European Union country, with the possible exception of Sweden. The Swedish system can be dealt with later. I have suggested, I think, that there are many disadvantages from the point of view of parliamentarians about the Swedish system and many advantages for ministers to be held accountable. That is part of that. I think it just follows from different interpretations of the same rules and of course arms embargoes and export controls run straight into issues of defence and foreign policy, which Member States of the EU guard jealously as within their own national competence and share not as a Community competence but share under what is known as pillar two of the European Union. I also have to say that even if there were a complete harmonisation of Community law, as it were, as long as these were decisions not taken by a single institution but in different States under a Directive, then there would be differences of interpretation. What we try to do is to share information, particularly between ourselves, so that there is, over time, a more consistent application of the criteria.
Donald Anderson
4. There are also problems, Secretary of State, of profound and differing national interests with the defence industry. To what extent, in your judgment, is the original purpose of the whole project being undermined by widely differing interpretations by Member States?
(Mr Straw) I do not think it is. I can go into more detail about this when I come to give evidence in private, but I have been struck, in the time that I have been dealing with these applications - and I have to say within the British Government they are dealt with extremely carefully—by the care and seriousness which, from my perspective, I believe is shown by other European Member States. I obviously have no brief from each of those but that is my view. So far as national interests are concerned, yes, as Mr Anderson will be aware, in our criteria as laid out by Peter Hain in his written answer on 26 October, he said, actually quoting Robin Cook from 1997: "The Government are committed to the maintenance of a strong defence industry as part of our industrial base as well as of our defence effort, and recognise that defence exports can contribute to international stability by strengthening collective defence relationships; but believe that arms transfers must be managed responsibly." Then at the end he goes on to mention other factors which are under the operative provision of the EU Code of Conduct, which specifies that Member States, where appropriate, take into account the effect of proposed exports for economic, social, commercial and industrial interests, that these factors will not affect the application of the Code. They list those factors but it also makes clear elsewhere in the criteria that an export licence will not be issued if the arguments for doing so are outweighed by the need to comply with the UK's international obligations and commitments. My concern is that they could be used for internal repression or international questions by risk to regional stability or other considerations. You have the background which is that we have a big defence industry and we have national defence interests but you also have these criteria, some of which are taken into account and some of which override that.
5. Of course there would be subjective elements and there will be different weights given to different criteria but the whole purpose was the aim of consistency.
(Mr Straw) I agree with that.
6. How do we work towards a consistency of approach? Is there beginning to be built up case law in respect of individual cases?
(Mr Straw) At the moment we do not have case law because this does not come within Community competence; in other words, it could not end up at the European Court of Justice. It is a matter which is embedded in Member States' national interests but if you mean by "case law", is there a sharing of experiences, is there a desire certainly by foreign ministers of the European Union, and I think by others, to ensure that, since we have a single code and EU criteria that should be applied consistently, the answer to that is "yes". I would just say this to you, Mr Anderson, as a fellow member of a similar profession, the legal profession, that you can apply criteria, however detailed, consistently and yet two sets of people may arrive at the margin at different judgments, and sometimes these are very fine.
7. In the light of experience so far, there must be a spectrum of those who apply the criteria strictly and those much less strictly. Where do we appear in the spectrum?
(Mr Straw) I think we are pretty good. In a sense, one of the things we need is a greater degree of information about this.
(Mr Dowse) I think from the experience that we have, and you are absolutely right, we have now had the operation of the EU Code of Conduct for several years, it is true we are building up experience. One way you can judge whether the system is working is by the number of consultations that take place. Under the rules of the Code of Conduct, when any Member State issues an export licence for a transaction essentially identical to one that has previously been denied by another Member State, it will first consult the Member State that issued the denial. Although, as a result of that consultation, we are not obliged then to follow the denial, the process of consultation in itself obliges Member States to look that much more carefully at their export procedures, and it is not something that is done lightly to undercut a denial. The fact is that there have been relatively few cases year by year where these consultations have had to take place. It has happened in a relatively small number of cases. So I think that is one piece of evidence that in fact the guidelines, the criteria, are being applied pretty consistently across the EU.
8. We now move on to a different issue. When we have asked in the past about military equipment exported to Israel, the Government's response has been that there has not been any evidence that this has been used against civilians. Clearly Ben Bradshaw made a statement on 11 March, and we have had a letter today from the Foreign Office clarifying the position. It now seems that indeed UK-manufactured equipment has been used by the Israeli Government against civilians in the Occupied Territories. My question, Secretary of State is: how can we be sure that the example that has now come to light is an isolated example?
(Mr Straw) In a mathematical sense of proving a negative, it is almost always impossible to prove a negative. Do we take care to check, so far as we are able, on the end use of this equipment? Yes. It is precisely because we do take care that this example has come to light. It came to light because of very rigorous checking by our defence attaché and his staff in the Occupied Territories. I think it is a testament to their work on behalf of the Government and also, if I may say so, on behalf of Parliament, that they have managed to pin down the connection. What they discovered is that these were Puma armoured personnel carriers which had been deployed in the Occupied Territories in September of last year. There were sightings in November and December of last year and a Nachpadon APC observed first in the Occupied Territories on 29 January 2002. These vehicles have chassis which were essentially cannibalised from Centurion tanks which were exported to Israel between 1958 and 1970. They do not look like Centurion tanks at all. It requires a high degree of skill to appreciate that a chassis from a Centurion tank could form the basis of these Puma and Nachpadon APCs. It is as a result of observation by the defence attaché and his staff going into the Occupied Territories, I may say at some degree of personal risk, that they were able to identify this and set out the other circumstances. As you will see, I decided that Parliament should be informed on the day on which I was informed.
9. Was this the outcome of routine, rigorous, end-use monitoring or was it just a lucky observation?
(Mr Straw) No, it was not just a lucky observation. Part of the job of defence attache"s is to do this. We may come on to the general principles of end-use monitoring. Obviously how far it is possible physically to control the end use if you have a government which is determined to break undertakings depends on the size and nature of the equipment. If it is easily transferable; it is difficult. In this case actually I suggest that it was pretty difficult to identify but it was identified. If it is equivalent to whole tanks as exported or whole aircraft or artillery pieces as exported, it is relatively straightforward. We are not dealing here with a perfect system but we are dealing here with a system which I think the Committee will accept is considerably better than the system which existed three or four years ago.
10. I do not think anyone suggests that the system has not got better in recent years. Your Department's letter to the Committee today points out that the Israeli Government had given an assurance on 29 November 2000 that no UK-originated equipment, nor any UK systems, et cetera, are used as part of the Israeli defence force activities in the Occupied Territories. A clear undertaking has been given there that you are now telling us is false.
(Mr Straw) Certainly not being followed.
11. Not followed, false, wrong, misleading.
(Mr Straw) We have to find out. We have to await the response of the Government of Israel before we make judgments about whether the undertaking was given in bad faith. It could have been given in good faith but we are checking. We want proper recognition that the Centurion tanks had been cannibalised in this way. However, whatever judgment we come on to as to that, the simple fact of the matter is that the undertakings which were given by the Government of Israel on 29 November 2000 that, as you say, none of the UK-originated equipment has been used by the IDF in the Occupied Territories, turns out not to be the case and I take that extremely seriously, which is why we are pursuing it with the Government of Israel, as well as why I laid the letter before Parliament in the form of the answer which Ben Bradshaw gave to George Galloway on the day that I first had this drawn to my attention.
12. There is a number of items of equipment listed in the report: machine guns, et cetera. What actually happens? Do the Israelis, when they are engaged in activities in the Occupied Territories, say, "Well, hang on, we had better put those UK-manufactured machine guns down and pick up someone else's machine guns"? What does the Government really know about the end use of this equipment in a very complex situation such as that in the Middle East? Are concerns about this justified, in your view?
(Mr Straw) I think, as long as you have a system of licensing, which I strongly support, we should all be concerned about circumstances in which, either inadvertently or advertently, the undertakings which governments give about end use could be broken. I think, on the whole, experience shows they are not and that where material is sold under clear undertakings, governments do not break those undertakings because it is not in their interests to do so. Over time, that would put them beyond the pale of the international community. But within the availability of resources, which is a crucial issue, and what is practical, of course we should strive for means by which we improve the overall regime. I do not argue with that.
13. Are you re-examining end-use monitoring?
(Mr Straw) Yes. In the world in which we live you are not going to be able to end up with a situation—perhaps you could do but it would be extremely expensive and I am not sure it would achieve more than we currently achieve or are able to achieve—where you have a system of end-use monitors. Of course we are going to examine very carefully the full details of what happened in this case, certainly. I will also make sure that the Committee is fully informed about that, and it may well be that you will want to return to this at a further session.
Rachel Squire
14. Can I turn to Criterion Four—preservation of regional peace, security and stability—and particularly ask concerning India and Pakistan? The Report for 2000 appears to indicate that India and Pakistan were the most likely zone for the arms race which could undermine regional peace and security at that time, and the Government recognised that. In your judgement, has the threat to regional security improved or worsened since then?
(Mr Straw) Since 2000? It has varied from month to month, day to day. I think it was in the middle of 1999 that Kargil took place, so it was very serious at that time. There were then some negotiations between India and Pakistan in the east and it has been going up and down like that. In the last three months, it became serious after the terrorist attack on the State Assembly in Srinagar on 1 October and a lot of diplomatic and other efforts were put in to try and reduce the tensions, including action which was taken by President Musharraf to ban a number of Pakistani-based terrorist organisations which were almost certainly behind that attack. Then, as we know, on 13 December there was the attack on the National Parliament, the Union Parliament, in Delhi and tensions then rose. Overall, again if you are asking me about averages, given the fact of Kargil and what happened in 1999, it is probably on average about the same, although day by day it changes.
15. It is very much a roller coaster?
(Mr Straw) I would not say that. It is a serious situation and it is one obviously we take account of in determining whether licences should be issued. I am well versed in trying to make judgments in respect of Criterion Four. It is one of the crucial things I know every member of the Committee has on board but sometimes others may not: by definition, arms are materials designed to be used in an aggressive manner because these are instruments of violence, but this is about whether the export would be used aggressively against another country or to assert by force a territorial claim. Then we have to go through a balancing judgment against the other criteria, including, for example, the criteria in respect of international obligations. That then runs into things like obligations under United Nations Security Council Resolution 1373.
16. Do you think that the UK Government's position on the situation between India and Pakistan can be reconciled with what is extremely strong marketing by UK defence manufacturing companies to sell arms and equipment to that area?
(Mr Straw) Yes, I do. Unless we make a decision that we are going to pull out of defence industries, then what we have to do, it seems to me, is to make judgments on a case-by-case basis in the round against these criteria but against the fact that, if the criteria are met in a sense that the export appears to be one that is not caught by the criteria, then it is an export of defence material which ought to be made. I do not believe that the licences whose issue I have been a party to have contributed to a breach of Criterion Four because otherwise I would not have made the judgments there. I agree there have been some licences which I have refused in respect of both Pakistan and India where, amongst other criteria I think have been potentially in breach, Criterion Four has been one of them.
Tony Baldry
17. Can I ask a slightly different question about India. As I understand the export controls, they seem to infer that licence applications should be considered with regard to whether a defence export might hamper a country's sustainable development. I am a bit confused by India because you and the Prime Minister and others have been promoting the sale of Hawk jets to India, which are going to cost India just under £1 billion, as I understand, but India is our largest recipient of bilateral development aid. £1 billion is equivalent to 10 years' worth of UK development aid to India. Effectively what is happening is that we as taxpayers are subsidising primary health care and basic education in India to the tune of £1 billion every 10 years to enable the Indian Government to purchase Hawk jets from us. I just do not quite see how that is consistent with any concept of supporting sustainable development. I wonder if you can help me on that.
(Mr Straw) I will do my best to help you, Mr Baldry. First of all, I am not going to comment on the possible sale of Hawk jets because there has been no contract. Yes, it is certainly true that I and other Ministers have made representations to the Indian Government about that particular sale, but that is a separate issue from whether, if we were presented with a particular application for a licence, we would approve it against these criteria. That would depend on the circumstances at the time. Who knows whether or not the contract is entered into or otherwise? So far as India, however, is concerned, India's overall defence spending is as a proportion of their GDP, and when I looked into it—and I have to say I have double checked this—that is surprisingly low, given what is a large number of people involved in their defence services. When you go around Indian cities, you see large garrisons. Notwithstanding that, that is partly because India is a huge country of over one billion people. Their defence spending looks like being somewhere between 2.5 and 3 per cent of their GDP, which is, roughly speaking, the same proportion as for many countries in Europe. On the issue of sustainable development, you will be aware that one of the criteria is that of sustainable development, but it is whether the proposed export would seriously undermine the economy or seriously hamper sustainable development of the recipient country. As with any other criteria, those have to be weighed in the round against aspects of the criteria which were set out two years ago.
18. That is the point I am putting to you, Secretary. Would you not think that 10 years' worth of bilateral UK development aid waved around is rather a substantial sum?
(Mr Straw) I am sorry, I am not going to go down that route. As I say, that is based on a hypothesis, first of all, that the contract would be awarded to a British contractor; and, secondly, having been awarded, that the British Government would then license it. Whether we license it, if it is awarded, depends on the circumstances at the time but of course, may I say that we would look at all these matters very carefully and report to the Committee.
19. I think that affects the integrity of this Committee and how we pursue policy in this area. Sometimes we are approaching these things in a rather artificial way because I think you very fairly acknowledge that you and the Prime Minister, and indeed it is a matter of public record, have lobbied the Government of India on this particular contract. If you are then saying that, because no contract has been awarded, you are not prepared to answer questions on it, fine. Can I just push you on this, that if a contract should be awarded, I and I am sure others would wish to pursue in detail this whole question of sustainable development, otherwise I think it becomes a pretty artificial exercise.
(Mr Straw) Thank you very much for the notice. Funnily enough, I thought that might be the case. Indeed, I do not think you would be doing your job if it were not.
© Parliamentary copyright 2002
Prepared 19 July 2002


Charlene Pettway moved here after being laid off in Mobile, Ala. She and her son are living at the Salvation Army.
About $17 million in federal stimulus money is being pumped into Houston-area social service agencies to prevent homelessness, and it couldn't have come at a better time. With the spiraling economy, private donations are down and demand for assistance is up.
Local agencies say they've been helping more people who are homeless for the first time and more people who are on the verge of homelessness with fewer dollars. The stimulus will help fill the gap, agencies said.
"It's the only thing that's keeping people from homelessness," said Gerald Eckert, social services manager for The Salvation Army of Greater Houston.
Harris County recently awarded about $4.4 million in stimulus funding to six agencies, and the city of Houston is expected to soon award about $12.3 million to 11 agencies. The money will be used to provide rent, deposit and utility assistance to individuals and families who are homeless or at risk of becoming homeless.
Agencies in Fort Bend, Galveston and Montgomery counties also will receive stimulus funding.
The growing need for assistance has kept the phones ringing nonstop at The Salvation Army since March, Eckert said. The agency, which received about $2 million, normally provides rent and utility assistance for one month, but more people are needing help for three to five months, he said. The agency's discretionary fund is low, and its donations have dropped about 13 percent from this time last year.
Memorial Assistance Ministries saw a 30 percent decline from last year, said executive director Martha Macris. The nonprofit received $1 million in funding from the state and will get $550,000 from the city, she said.The Houston agency has provided emergency financial assistance for 25 years.
SEARCH Homeless Services, which received $1.6 million in funding, provides support services for the homeless. The Houston-based organization has been tracking the number of first-time homeless people who have sought help from the agency. The number jumped from 1,400 people last year to 2,200 people this year, said executive director Thao Costis.
The agency's goal is to get them in housing and on the road to self-sufficiency quickly. Her agency is working with 33 clients and has hired case managers to help them navigate public aid, such as food stamps and medical care. In addition, it is working with Westside Homeless Ministries on a program to find housing for ex-offenders recently released from jail, Costis said.
Single mother Charlene Pettway is homeless for the first time after being laid off.
She worked three jobs in Mobile, Ala. to make ends meet and lost them all within a five-month span this year. She and her 14-year-old son, Jeremey, moved to Houston in July in search of a better life.
While demand for social services has increased, it doesn't necessarily mean the homeless population has gone up, said Anthony Love, executive director of the Coalition for the Homeless of Houston. Many people are trying to hold on to every penny they have, so to supplement their income they're using food pantries and clothing banks.


Most Web teams spend a gazillion hours trying to craft Websites that will ring with their B2B buyers.
They pour over visitor satisfaction surveys. Track visitor click streams with the intensity of a big game safari.
Throw out mountains of content and interactive gizmos to entice and educate potential buyers.
Why? Because the real secret to building a B2B powerhouse starts with clearly understanding — and aligning your Website — around the steps your buyers go through when they are making a B2B buying decision.
How they use the Web to put you on the long list.
Use your corporate Website to move you to the short list.
And gather the information they need to choose your product — and collaborate with colleagues who are also part of the final purchase decision.
It's a complex ballet that is defined by 17 activities organized into six steps. Turns out, your Website plays a critical role in all of but one (define the problem).
Here's what your B2B buyers are really doing when they are on your Website. (If you are a Library subscriber you can download the entire report using the link at the bottom of the page).
The first step in any B2B buying process is to assemble a "long list" of suppliers that might offer the products, services, and/or or solutions that will address the company's needs.
Once upon a time, second-tier suppliers were found by scouring industry journals and magazines and by word of mouth. Today, the Web plays this role.
High rankings on popular search engines, including ad-word feature positions, inclusion in "breaking news" results, and links to micro-sites optimized around specific campaigns and promotions. If you can crowd out the competition on the first five pages of search results, you're in the driver's seat.
Consistent presence on popular social networks, such as Twitter, Facebook, and YouTube, plus a growing range of business networks, such as "Meet the Boss", a business network sponsored by various business and technology companies.
Visibility on relevant social bookmarking sites, preferably those that have over a million monthly visitors, and a traffic ranking of 600 or above. Venues currently in this class include Digg, Delicious, and Technorati. Think of this as your 'ode to the technical buyer'.
Visibility on popular news aggregation sites (i.e. ZDNet, TechRepublic, TechWeb); technical venues (i.e. TechTarget and product/company-specific satellite sites), and sites that cater to CXOs, such as Search CIO and CIO.com.
Mentions and reviews on heavily trafficked industry consultant and topic "expert" blogs.
Inclusion in reports published by leading market research firms that validate your company's strategy or products, and identify it as an industry leader (i.e. Gartner Group, Forrester Research).
Presence in powerful print media, including business magazines (i.e. Fortune, Business Week) and industry publications (varies based on product and target market). Typically, this presence is created by purchasing advertising space or, if pockets are deep, sponsoring a multi-page advertising insert. In a perfect world, a supplier will be the subject of a business article or editorial.
Once the "long list" is assembled, a B2B buyer will turn to conducting first-level due diligence on the suppliers that made it onto the list.
But here's the rub. In this phase, buyers will be focused on quickly eliminating companies that don't fit the project's profile or the company's appetite for risk.
Company size and reputation, and a quick assessment of the size and class of customers currently using the company's products.
First-level financial information that reduces risk (a billion dollar company, fast growth company, profitable).
The number of influencers & decision makers. No B2B buyer is an island. He or she is always part of a larger group of people involved in the decision process. Smaller groups prefer to handle a smaller number of "short list" contenders. Larger groups have more resources to vet a larger number of contenders.
Urgency. The faster the timeline, the faster the group needs to "cut to the chase". Fewer candidates makes that happen.
Risk. High-risk and mission-critical decisions are vetted more carefully, and favor companies that can provide more pieces of the solution. Think of it as the "one neck, one noose" factor.
Once a "short list" has been assembled and agreed upon, the focus turns to assembling detailed information about each company on the list.
And this is when your Website really kicks in.
Technical members, who will view the product based on its technical merits, and alignment with the company's existing standards and installed systems.
Technical members range from "evangelists" who are advocates for the latest technologies and features, to conservatives who will place a premium on technologies that will have a more moderate effect on operations.
Project managers, who will be largely tasked with implementing the decision. They tend to balance the technical aspects of a decision against the ability to successfully implement the solution — and its affect on other operations, such as the impact or ripple effect on existing systems and business processes, employee training, and acclimation to the new solution.
Some project managers will also be sensitive to the financial impact on their specific line of business or department; others will leave these details to other individuals involved in the decision process.
Business managers are the cornerstone of the financial business case, and tend to look at the "big picture" impact of a project and its costs. In some cases, business managers will be technically savvy, which allows them to sift through the sometimes polarized opinions of technical evangelists and conservatives. It's not that they understand every wire and widget. They just know enough to be dangerous.
Business managers often manage the project managers involved in the B2B buying process, and tend to pay special attention to these members since their focus on implementation and potential disruption can have a profound effect on cost over-runs and the hidden costs related to any technology purchase. These members are the keepers of the company's pocket book and, arguably, have the most skin the game.
It's interesting to note how many companies believe that the Research phase is the final step in B2B buying decision. It isn't.
Turns out, this is actually the point when the strengths and weaknesses of a company's site will play a pivotal role.
Why? Because once the "short list" of candidates is assembled and vetted, B2B buyers turn their focus to reducing the list to a handful of finalists that merit more detailed investigation.
In this phase, B2B buyers are ruthless for a simple reason: finalists will be subject to detailed, time-consuming evaluations, "try and buy" test drives, and deep dives into customer references.
The shorter the list, the faster this process goes.
This is also the point where B2B buyers begin to engage with the company's sales force in earnest.
They attend sales demonstrations and Webinars; ask detailed questions that determine exactly how a product will fit the company's technical, feature, and business needs; determine final configurations and pricing — and ask the supplier to document its recommendations by responding to formal requests for quotes and detailed bids.
This is the "all in" part of the process where the quality of a supplier's sales force — and fast response to requests entered through the Website — can make or break a deal.
Contact requests and requests for RFQs and RFPs must be answered promptly. Otherwise, it's a perfect reason for a B2B buyer to gladly strike a company from the list (less to do).
Demonstrations must be crafted to address the needs of many constituents — from technical capabilities, to competitive differentiators, to business impact and benefits. "One-size-fits-all" demonstrations essentially ensure that none of the interested parties will get the answers they need.
"Try and buy" downloads and test drives must trigger quick and efficient follow-up activities, and must be carefully monitored to ensure that problems are addressed before they crop up.
B2B buyers and influencers must be guided to the customer references that best fit their industry, business problem, or objective.
In the final phase of the B2B buying process, buyers are all about putting their information together and sharing their recommendations with their boss and in most cases, with other colleagues involved in the decision. This is when your Website will play its final — and pivotal — role in the process.
This is when your buyer will use those comparative matrices to put together a summary that demonstrates your value propositions to best effect.
Will download and consolidate customer case studies, after-purchase services overviews (support, consulting, training) and product data sheets as part of a recommendation package to be shared with colleagues and the final decision maker.
And finally, depending on the type of product and purchase mode, the buyer might even place the final order through your e-commerce system — or re-engage with a salesperson directly from your site.
Library subscribers can download the complete report below, which includes a detailed analysis of the 87 types of content & features that must be provided on a best-in-class B2B Website.


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Is There a Perfect Murder?
February 7, 2013 by Janice Cantore
There is a line from the TV show Castle that goes something like this: "Two types of people sit around and try to think of ways to kill people, psychopaths and mystery writers, I'm the one that pays better." Since I write suspense and mystery, I too sit around ant try to think of ways to kill people. A question that often comes to mind, Is there a perfect murder? I'm sure people have committed murder and have not yet been caught, but could someone really plan and commit a perfect murder? Here are two real life scenarios of people who tried to do just that.
Scenario one: A man, I'll call Homer, is drowning in debt. His life insurance policy is worth 4 million dollars. Trouble is, he has to die to collect the money. So he devises a scheme to only make it look as if he has died. He lures another man, I'll call him Tim, with a similar build to his garage, kills him and then sets the body on fire, making certain to remove all of Tim's ID and replace it with his own ID, then he flees in Tim's car to another state with Tim's ID and credit cards, planning to become Tim since everyone will think the burned body in his garage is Homer. Homer had help from his wife who probably planned to collect the life insurance money and then join her husband.
Scenario two: A devoutly Hindu man is furious when his son, I'll call him Moe, marries a non Hindu woman, I'll call Grace. Despite the father's fury, the couple seems happy, they have a baby daughter and life seems to be going smoothly for them. They move away from angry daddy to the town where Grace's parents live. And tragedy strikes, Moe tells Grace and her family that his father has died suddenly. He attends the funeral in India by himself. Then one day some time after that, Moe comes home from work to find Grace stabbed and strangled in their apartment. The baby is unhurt but there is no evidence left at the crime scene as to who killed Grace and why. The case goes cold for years.
The first plan seemed to work for a while. Tim's body was burned beyond recognition and initially police believe Homer is the dead man. But this crime really was not well thought out. First of all, Tim had family who knew immediately something was wrong when he didn't come home. They went to the police right away so when Homer used Tim's credit card to rent a hotel room, the jig was up. Tim was in the system as missing/endangered so police were sent to check out the hotel room. Homer, realizing he was found out, killed himself when police knocked.
The second plan almost worked. With no evidence at the crime scene and no suspects since the only person that hated Grace was Moe's dad, police are baffled and the case goes cold. It's about six years before they get a break. A woman is arrested after leading police on a chase in a stolen car. At the station she tells cops she has information about a murder. When she describes the murder, cops realize she's talking about Grace and they call the detective who handled her case. The woman describes the homicide scene exactly and names the killer, I'll call him Ted. Apparently, Ted took two women with him to Grace's apartment. They knocked on the door and asked Grace if they could use her bathroom. When she said yes, Ted forced his way inside, then told the girls to wait in the car while he killed Grace. Neither Ted nor the girls have any relationship with Moe or Grace, they are complete strangers. Police look for Ted and find that he is in prison serving time for armed robbery. Eventually he tells them he was hired to kill Grace by a man I'll call Howard. Again, Howard doesn't seem to have any connection to Grace or Moe, why would he want her dead? Then they find out that Howard was Angry Daddy's business partner in another state. And low and behold, they also find out that Angry Daddy is not dead! Eventually he is convicted of hiring Ted through Howard to kill his daughter in law. (there is more to the story about his faked death, but it's complicated.)
In both scenarios, the killer thought he was devising the perfect murder. But only the second one had any chance of working, and it might have worked if Ted hadn't taken witnesses to the crime with him. I personally believe it's impossible to think of every contingency when planning a murder, which works great for a novel. Something always trips the killer up so the murder or crime can't be perfect, my fictional detective has to solve it. And there really is no such thing as the perfect murder because nothing is secret from God. So even if someone thinks they'll get away with it here on earth, they will be busted sooner or later.
Reality Versus Television
2 thoughts on "Is There a Perfect Murder?"
Wow, that is pretty cool. A little creepy the things people will do. Still sounds like TV and movies to me. But then today's news sounded like a TV show or movie. Hard to believe it's real life, even though it's happening where I live.
Love the last line!
If you are interested in topic: make money money go shopping lyrics
– you should read about Bucksflooder first


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text:
Department of Political Affairs
Find UNOAU on TwitterFind UNOAU on FacebookUNOAU RSS feed
13:16 - 20 Jan
All UN missions
UNOAU
United Nations Office to the African Union
Menu for articles (menu position rule)
Statements and AU Communiqués
RECOGNISING AFRICAN WOMEN'S CONTRIBUTIONS TO PEACE AND SECURITY
African Governance Architecture
African Peace and Security Architecture
Conflict prevention, including early warning and mediation
Regional Coordination Mechanism
Peacekeeping Planning and Management
Disarmament, Demobilization and Reintegration
Joint Communiqué: United Nations-African Union Joint Task Force on Peace and Security Holds Eighteenth Consultative Meeting in Addis-Ababa on 11 February 2020
The United Nations-African Union Joint Task Force on Peace and Security held its 18th consultative meeting at the African Union Headquarters in Addis-Ababa, Ethiopia on 11 February 2020.
During the meeting the Joint Task Force (JTF) reviewed the status of the partnership between the United Nations (UN) and the African Union (AU) with an update on the implementation of the Joint Framework for Enhanced Partnership in Peace and Security. The JTF also exchanged views on the situations in Central African Republic (CAR), Libya, Somalia, Sudan, South Sudan, Mali and the Sahel region and further discussed cooperation in support to elections in Africa.
The AU Commission and the UN Secretariat were represented respectively by Commissioners Minata Samaté-Cessouma (Political Affairs) and Smaïl Chergui (Peace and Security); and the Under-Secretaries-General Rosemary DiCarlo (Political and Peacebuilding Affairs), Jean-Pierre Lacroix (Peace Operations) and Hanna Tetteh, Special Representative of the Secretary-General to the African Union and Head of UNOAU. Under-Secretary General Atul Khare (Operational Support) attended the meeting via VTC from New York. The meeting was also attended by other senior officials from the two organizations.
communique_post-jtf_final.pdf
 MoU signed between the African Union Observer Mission in the Central African Republic (MOUACA) and the United Nations Multidimensional Integrated Stabilization Mission (MINUSCA) concerning the provision of support to MOUACA in CAR
 SRSG Tetteh outlines five key recommendations for youth engagement at inaugural Denmark-Africa Dialogue
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SRSG and Head of UNOAU, Hanna Tetteh (left) exchanges the signed agreement with the Permanent Representative of Norway to the African Union, Ambassador Morten Aasland (right)
UNOAU and Norway sign a new agreement to support the UN-AU partnership in peace and security
Norway signed an agreement with the United Nations Office to the African Union (UN
Blog: The WPS Agenda | Why Partnerships Matter?
As we approach the 20th Anniversary of the UN Security Council Resolution (UNSCR) 1325 (2000), it is natural to reflect on the history and the journey that culminated into the adoption of this landmark resolution, that was founde
UNOAU ARRANGEMENT FOR NO-COST FLIGHT FOR AU OBSERVERS MISSION IN CAR
At the request of the African Union Commission (AUC), UNOAU coordinated air transportation of critical electronic equipment for the AU Military Observers recently deployed to Bangui city in the Central African Republic (CAR).


What is a belief? How are our beliefs formed and how do our beliefs affect our success?
Your beliefs have the power to create and the power to destroy. Most of us have sent little or no time looking at our beliefs and separating our old worn out useless beliefs from our current story. Our Beliefs live in that space just below our awareness yet affect everything we do and dream.


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Q: Time taken to load a uiscrollview I am trying to find the time taken for a uiscrollview to be displayed on a screen. I have a uibutton which when clicked creates a label with a very long text and adds it to a scrollview. Then the scrollview is added as a subview to self.view. I need to know the time taken for the scrollview to be displayed on the screen.
Please help. Thanks in advance. Code below
- (IBAction)clickeMe:(id)sender {
    self.start=[NSDate date];

    NSString *text="a very long text";

    NSMutableAttributedString *attributedText =
    [[NSMutableAttributedString alloc] initWithString:text];

    NSRange range1 = NSMakeRange(100, 300);
    [attributedText setAttributes:@{NSForegroundColorAttributeName:[UIColor redColor]}
                            range:range1];

    UILabel *label1=[[UILabel alloc]initWithFrame:CGRectMake(10, 10, 700, 1000)];
    [label1 setAttributedText:attributedText];
    [label1 setNumberOfLines:0];
    [label1 sizeToFit];
    scrollviewtest *scrollview=[[scrollviewtest alloc]init];

    scrollview.frame=CGRectMake(10, 50, 700, 1000);
    CGSize maxSize = CGSizeMake(label1.frame.size.width, CGFLOAT_MAX);
    CGSize labelSize = [label1 sizeThatFits:maxSize];

    [scrollview addSubview:label1];
    scrollview.contentSize = CGSizeMake(700, labelSize.height);
    [self.view addSubview:scrollview];
    [self performSelector:@selector(viewLoaded) withObject:nil];

}

-(void)viewLoaded
{
    NSLog(@"[viewloaded]");
    NSTimeInterval timeInterval = [self.start timeIntervalSinceNow];

    NSLog(@"time taken is %f",fabs(timeInterval));

}

The problem with the above code is that viewLoaded is actually getting called before the scrollview appears on the screen.

A: Save the time before loading your stuff, then save the time when finished loading.
Make a substract then you have your loading time.
It's like php or other languages.

redpajama_set_name: RedPajamaStackExchange


make a bequest/donation to the Church in my will.
establishing a new community service activity.
These property issues are not so straightforward. If you need a hand with anything you think could be property related, please call the Property Resources team on 07 3377 9838 or email property@ucaqld.com.au.
There will be more resources to assist day-to-day property matters on this site in the coming months.
Is your congregation interested in getting solar panels?
You might like to read the Synod guide Becoming a Solar Church.


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ASPCA Provides Emergency Supplies for Animals Affected by Tornado in Taney County, Mo.
Disaster response team offers sheltering supplies to help pet owners, animals in local community
NEW YORK—The ASPCA® (The American Society for the Prevention of Cruelty to Animals®), at the request of the Taney County Health Department Animal Control Division in Branson, Mo., has dispatched its disaster response team to provide emergency supplies to aid animals affected by the devastating tornado that struck the city of Branson and Taney County on February 29, destroying commercial, residential and rural areas. ASPCA officials estimate that approximately 250 to 500 animals have been directly impacted by the tornado.
ASPCA responders arrived on the ground Wednesday, February 29, to work with local officials to assess the situation and establish a system that will provide pet owners with much needed supplies such as pet food, bowls and crates, which are being generously donated by PetSmart Charities, Inc. Additionally, the ASPCA is providing an initial grant in the amount of $10,000 to help animals in need of emergency sheltering and veterinary care. For information about qualifications for grant assistance please contact Taney County Animal Center at (417) 332-0172.
"Many people have lost their homes due to the tornado, and our goal is to alleviate some of the stress for pet owners by keeping them together with their animals," said Dr. Dick Green, director of Disaster Response for the ASPCA Field Investigations and Response team. "The ASPCA has worked with the Taney County Animal Control to establish a shelter-in-place plan where pet owners can request sheltering units consisting of kennels, food, bowls, leashes and collars. The sheltering units will be assembled and delivered to pet owners by the Taney County Animal Control. The ASPCA will continue to provide ongoing assistance, personnel and resources in Branson as long as we're needed."
"The Taney County Animal Control is currently going through a remodeling project, which has limited our capacity to take in more animals affected by the storm," added Eric Hansen of the Taney County Animal Control. "We are grateful that the ASPCA is able to provide assistance to the animals in our community."
Taney County residents who need emergency animal shelter units or for any animal control issues should contact the Taney County Animal Control at (417) 332-0172.


PSG were eager to sell Tottenham signing Lucas Moura over claims he was a locker room leaker, it has been claimed.
Le Parisien says the prime reason for Lucas' sale was due to concerns over UEFA's Financial Fair Play laws.
However, other reasons cited were due to discipline related matters. The paper also maintains that the Brazilian player along with Hatem Ben Arfa were the Parque des Prínces insiders filtering information to the media centering on the unrest within the PSG dressing room.
It's also maintained that certain squad members are annoyed in the manner that club sporting director Antero Henrique, tried to push the Brazilian towards the exit door on numerous occasions with Neymar deeming that the way his compatriot left the Ligue 1 was "unjust" adding "I'm not the owner of the club".


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For a chef concierge, the guest is everything
Kimberly Haas
Tourism is a major industry in Philadelphia, and the city is home to several iconic grand hotels. Our guest on Recap is an important fixture at one of those properties. He has "chef" in his title, but don't ask him to cook you breakfast.
"Chef concierge. It's French for chief concierge, the official title for a head concierge," explains James Portner, chef concierge at the Ritz-Carlton Philadelphia. "The members of Les Clefs d'Or, the international association of hotel concierges, agreed upon this title."
He mentions the association casually, before going on to explain the process of being admitted to this exclusive organization, with only about 450 members in the U.S.
"To apply, you have to have a recommendation from a member, referrals from your general manager, you have to be sponsored by two other members … and then there's a big test you have to take," he says.
His two lapel pins with pairs of crossed gold keys signify his membership.
James Portner gave us a glimpse into the work week of a concierge.
About Kimberly Haas
@kimberlyhaas khaas@whyy.org