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Is 'Opt-Out HIV Testing' a real option among pregnant women in rural districts in Kenya?
Opondo Awiti Ujiji1,
Birgitta Rubenson1,
Festus Ilako2,
Gaetano Marrone1,
David Wamalwa3,
Gilbert Wangalwa3 &
Anna Mia Ekström1,4
An 'opt-out' policy of routine HIV counseling and testing (HCT) is being implemented across sub-Saharan Africa to expand prevention of mother-to-child transmission (PMTCT). Although the underlying assumption is that pregnant women in rural Africa are able to voluntarily consent to HIV testing, little is known about the reality and whether 'opt-out' HCT leads to higher completion rates of PMTCT. Factors associated with consent to HIV testing under the 'opt-out' approach were investigated through a large cross-sectional study in Kenya.
Observations during HIV pre-test information sessions were followed by a cross-sectional survey of 900 pregnant women in three public district hospitals carrying out PMTCT in the Busia district. Women on their first antenatal care (ANC) visit during the current pregnancy were interviewed after giving blood for HIV testing but before learning their test results. Descriptive statistics and multivariate regression analysis were performed.
Of the 900 women participating, 97% tested for HIV. Lack of testing kits was the only reason for women not being tested, i.e. nobody declined HIV testing. Despite the fact that 96% had more than four earlier pregnancies and 37% had been tested for HIV at ANC previously, only 17% of the women surveyed knew that testing was optional. Only 20% of those surveyed felt they could make an informed decision to decline HIV testing. Making an informed decision to decline HIV testing was associated with knowing that testing was optional (OR = 5.44, 95%CI 3.44-8.59), not having a stable relationship with the child's father (OR = 1.76, 95%CI 1.02-3.03), and not having discussed HIV testing with a partner before the ANC visit (OR = 2.64 95%CI 1.79-3.86).
High coverage of HIV testing appears to be achieved at the cost of pregnant women not understanding that testing is optional. Good quality HIV pre-test information is central to ensure that pregnant women understand and accept the reasons for testing and will thus come back to collect their test results, an important prerequisite for completing PMTCT for those who test HIV-positive.
The World Health Organization (WHO) and the joint United Nations program on HIV/AIDS (UNAIDS) revised the guidelines for HIV testing in 2007 [1]. The current guidelines were designed to increase coverage of testing and identify patients in need of antiretroviral therapy (ART). In the former 'opt in' HIV strategy, the initiative to be tested was with the individual, not with the health care services, and individual pre-test counseling followed by informed consent was required before testing. In some areas, people were even required to sign a separate informed consent form, which detailed the risks and benefits of being tested [2]. With the new 'opt-out' strategy, individuals have to actively opt out or decline the HIV test after a pre-test information session, often carried out in a group, while post-test counseling is still carried out on an individual basis for all clients.
The implications of provider-initiated HIV testing greatly affect women in sub-Saharan Africa (SSA) where they account for nearly 60% of those infected with HIV and where 75% of those living with HIV are between 15-24 years [3]. Women have more contact with the health services e.g. during pregnancy [4] and are thus more likely to undergo HIV screening [5], but it has been observed that consent may be compromised in SSA, which negatively affects women's autonomy and possibly also completion of PMTCT [6, 7].
The shift from 'opt in'/client-initiated to 'opt out'/provider-initiated HIV testing has generated a debate on how to best increase the uptake of HIV testing while, at the same time, protect individual rights to voluntary consent for HIV testing [1]. Proponents of "opt out" assert that the provider-initiated consent process is crucial to achieve high coverage of HIV testing and prevention of mother-to-child transmissions (PMTCT) while it still protects autonomy [8]. It also helps the 'streamlining' of HIV into 'normal care' thereby decreasing the stigma [8, 9].
Those who question the 'streamlined' consent process express doubt about whether informed consent can be ensured in the context of routinely offered HIV testing under conditions of scarce human resources [10, 11]. Power differences in the provider-client relationship is also identified as a problem, since it is uncertain whether clients who normally have a lower social status will feel able to opt out of testing against the recommendation of their providers [6]. Others are concerned about the client's ability to provide voluntary consent and to what extent any choice will be presented given that providers are encouraged to motivate clients to test and could be coercive [6]. Women in particular are often also unable to make decisions independently due to gender inequality and lack of knowledge [3, 12]. Finally, and most important from a public health perspective, there is concern that pregnant women who fail to make an informed choice about HIV testing are less likely to come back for their test results, an obvious prerequisite for identifying and enrolling HIV-infected women in the PMTCT program, thus undermining the quality and effectiveness of this important intervention [5, 13]. A study from Botswana showed that pregnant women felt compelled to test when it was routinely offered and some instead exerted their decision-making power by not returning to collect their test results [13].
Kenya introduced routine rapid 'opt out' HIV testing at antenatal care (ANC) in 2007 [14]. Approximately 76 000 pregnant women are living with HIV in Kenya, thus ranking it sixth among the ten African countries that contribute 67% of the global burden of MTCT [15]. Up to 40% of all pregnant women enrolled in ANC programs in Busia district in western Kenya are estimated to not come back for their test results and will thus never be enrolled into PMTCT (personal communication). Pregnant women and their infants in these two rural districts are considered to be highly vulnerable to MTCT due to the high HIV prevalence (9%) and high fertility rate (7.1) compared to the national average of 7% and 5.1 respectively [14]. This study aims to identify factors associated with consent to HIV testing under the 'opt out' strategy in this area in rural Kenya.
This study was performed in Busia district located in western Kenya. This rural district has five administrative divisions with a population estimated at 415 000. The study catchment area has a population of 202 348 living in 312 villages, with 50 000 women of reproductive age and 38 000 children less than five years of age. Surveillance studies at ANC show HIV infection rates close to 10% [14]. Agriculture, fishing and small-scale commercial undertakings are the main economic activities in the district where the average household generates approximately $84 per month. The majority ethnic group is Luhya with a few Luo speakers. There are 22 health facilities in the study area that are private, mission-run or government-owned. About 90% of these facilities offer free rapid HIV testing services except for a few dispensaries that refer patients to health centers or district hospitals for testing.
The study was carried out at three public district hospitals collaborating with non-governmental organizations (NGOs) on PMTCT and ART. In all three hospitals, PMTCT and ART have been provided free-of-charge since 2005 to all women in need in line with the WHO treatment guidelines from 2007. According to the new 'opt out' guidelines implemented in 2007, all pregnant women should participate in a HIV pre-test information group session, followed by rapid 'opt out' HIV testing and individual post-test counseling at their first ANC visit. For pregnant women who test positive for HIV, a CD4 cell count is done to determine whether ART should be initiated or if a single dose of nevirapine during labor is enough (short course combination treatment during pregnancy and breastfeeding has not yet been implemented in Busia district as of end 2010). HIV-infected women should be individually counseled regarding hospital delivery, safe infant feeding and contraceptive use.
Study design, sampling and participants
The study included twelve sit-in observations of counseling sessions for pregnant women and a large cross-sectional survey among pregnant women. The observations were performed by the first author, who is of Kenyan origin and fluent in the local languages spoken in the area, during two randomly selected weekdays and with four visits at each facility.
For the cross-sectional assessment, 900 women who were on their first visit to ANC for the current pregnancy were recruited consecutively between August and December 2008. All women in the three hospitals received the same information during the routine pre-test information sessions that followed the Kenyan guidelines on PMTCT. A midwife informed them about the study in the ANC reception area during a session on general hygiene. Those willing to participate met the midwife, gave informed consent and were enrolled into the study. No woman among those approached declined to participate and no participant had been informed of her HIV test results before the interview. The sample included all pregnant women who were tested in the three hospitals within the timeframe.
Notes were taken during the observations about the setting for the pre-test counseling session, the content of the session and of how the information about HIV testing was given. The interviewer-administered structured questionnaire contained both closed and open-ended questions in Kiswahili or Luhyia. Data was collected on socio-demographic characteristics, relationship factors, awareness and knowledge about MTCT and PMTCT and experiences of the group counseling session and the HIV testing. The Kenya Medical Research Institute (KEMRI) and the regional ethics board of Karolinska Institute approved this study.
The observations were compared and evaluated against the Kenya pre-test guidelines of the 'opt out' approach after each observed session.
For the cross-sectional data analysis, data were analyzed using SPSS-PASW, version 18 (SPSS, Inc., Chicago, IL). Descriptive statistics were used to summarize all variables of interest in the study population.
The outcome variable "making an informed decision to decline HIV testing" was derived from the question 'If you could choose to HIV test or not, would you decline? (Yes/No)'. Independent variables that were used to model the outcome variable included; type of union - 'What is your marital status? (Married/Unmarried)', duration of current sexual relationship - 'How long have you been in the current relationship? (Not in a relationship, ≤4 years and >4)', stable relationship with the child's father - 'Do you live together with the child's father? (Yes/No)', knowing HIV testing is optional - 'Do you know that you can choose to HIV test or not? (Yes/No)', tested for HIV - 'Have you tested for HIV at this visit? (Yes/No)', discussing HIV testing with the partner before the ANC visit - 'Have you discussed HIV testing with your partner before this ANC visit? (Yes/No) and knowing testing is performed at ANC before the visit - 'Did you know that HIV testing is done at ANC before coming today? (Yes/No)'
The estimated prevalence of "making an informed decision to decline HIV testing" was reported as a percentage. It is important to note that the outcome variable "making an informed decision to decline HIV testing" implies making a decision about whether to consent to HIV testing or not after awareness i.e. the actual decision of women who knew that HIV testing is optional as well as the perceived decision among those who did not know that testing is optional, had they known that this was the case.
The association between "making an informed decision to decline HIV testing" and each categorical independent variable was first assessed using Chi-square or, when the number in the contingency tables was too small, Fisher's exact test. Independent variables with a p-value of <0.20 associated with the outcome at the bivariate level were entered into multiple logistic regression models with the exception of age, education and occupation level that were included regardless of p-value in order to adjust for potential residual confounding linked to the main independent variables. Both backwards and forward logistic regression (Wald test) was performed and gave almost similar result. P-values <0.05 (2-sided test) were considered significant in the final model. Odds ratios (ORs) and their 95% confidence intervals (CI) were computed. The final multivariate model was tested for goodness of fit with the Hosmer-Lemeshow test.
Observations during pre-test information session at group level
The setting of the pre-test counseling session
Pre-test counseling sessions were provided to groups of 10-15 pregnant women in a separate space. There were between three and four information sessions per day at each facility. The sessions normally took 45-50 minutes and were mainly performed in the national language Kiswahili and translated simultaneously into the local dialect of Luhyia. Female midwives greeted the audience and introduced themselves when starting the session. The pregnant women were told that they could ask questions during the session in case they wanted to know more, but no woman asked any question or sought clarification at any of the sessions observed. The pregnant women nodded unanimously when the midwife sought to stress the benefits of HIV testing as shown below.
Midwife : Do you mothers agree that it is important to test for HIV and protect the unborn child?
Women : (nodding) yes (in a group).
The content of the pre-test counseling session
The information included a description of HIV and AIDS, modes of HIV transmission from a pregnant woman to their child during and after pregnancy, the importance of HIV testing for a diagnosis, secondary prevention of HIV transmission to uninfected male partners and the PMTCT program (single dose nevirapine tablets for the mother and syrup for the infant during a six week period after delivery; skilled hospital delivery; and options of exclusive breastfeeding or formula feeding).
Information provided about HIV testing
The women were given information about the importance of HIV testing and of learning about their HIV status, and also the status of their partner. Women were not required, but encouraged, to bring their partners in to be HIV tested as well. The importance of having an uninfected baby was emphasized as well as the fact that testing was important in the first trimester of pregnancy. In all the sessions the midwives' undertone was motivational and the message was that testing and knowing one's HIV status was the best decision a mother could make for her unborn child. No information was provided stating that it was an individual and voluntary choice of the woman to decline or accept HIV testing. The midwives referred to the women as 'mothers' and emphasized that it was their responsibility to take the HIV test to protect the baby and have a healthy and virus-free child. When asked by the main author about reasons for not requiring women to bring their partners for HIV testing, the midwives said that men who really loved their women normally accompanied them to ANC to test of their own free will and did not need to be asked to come.
Cross-sectional survey of 900 pregnant women
Table 1 shows socio-demographic characteristics and HIV testing information of the 900 women enrolled in the study.
Table 1 Socio-demographic characteristics and HIV related data of 900 pregnant women
The median age was 20 years (inter-quartile range 5). The majority of the women (96%) had already had more than four pregnancies including the current one, although 73% were in a relationship of less than four years. About 90% had a stable relationship with the child's father. Eighty percent were in a formal union. About 85% had eight or less years of formal education and 18% were employed. Slightly over one-third (37%), had previously been tested for HIV at ANC using the 'opt-out' approach.
Lack of testing kits was the only reason for women not to be tested i.e., no woman declined HIV testing and nearly all were tested for HIV (97%). About 73% knew that HIV testing was done at ANC before coming there and 69% had discussed the test with their partner before the visit. Following the pre-test counseling session, 90% (N = 810) claimed they had understood the information, but only 17% had grasped that HIV testing was optional, 95% were aware of MTCT and 91% had understood that preventing transmission was possible. The reasons given by the 10% (N = 90) women who reported not understanding most of the pre-test information included: the counselor speaking too fast (N = 45), using complicated terms (N = 27) and difficult language (N = 18).
Only 20% (N = 180) of the women said they would make an informed decision to decline HIV testing. After adjusting for all potential confounding factors listed in Table 1, only three factors remained independently associated with an increased likelihood of making an informed decision to decline HIV testing in the final multivariate model: knowing that testing was optional, not having a stable relationship with the child's father and not having discussed HIV testing with a partner before the ANC visit. Knowing that testing was optional was the strongest predictor for women saying that they would make an informed decision to decline HIV testing (OR = 5.44, 95% CI 3.44-8.59). Women not in a stable relationship with the child's father were more likely to perceive that they would make an informed decision to decline HIV testing (OR = 1.76, 95% CI 1.02-3.03). Not having discussed HIV testing with a partner before the ANC visit also doubled the likelihood for women saying that they would make an informed decision to decline HIV testing (OR = 2.63, 95% CI 1.79-3.86).
Age, occupation and education level were not statistically significant factors but kept in the final model to adjust for residual confounding often associated with these fundamental variables (Table 2). The number of pregnancies both as a categorical and a continuous variable was not significantly associated with the outcome, probably because only one third had been HIV tested before (OR = 1.96, 95% CI 0.63-6.09).
Table 2 Factors included in the final multivariate model analyzing the association with 'making an informed decision to decline HIV testing' among 900 pregnant women
None of the 900 pregnant women included in this study declined HIV testing under the routine 'opt-out' approach. A majority (83%) had not understood that HIV testing was optional and only one in five stated that they would have been able to make an informed decision to decline HIV testing. This is a fundamental shortcoming of unclear pre-test information, which undermines the assumption of voluntary consent. Thus with the current approach, high coverage of HIV testing at ANC may be achieved at the cost of women not understanding that testing is optional and at the risk of low uptake and completion of PMTCT which is a major problem not only in this area, where between 30%-40% of all pregnant women enrolled in ANC programs are estimated to not come back for their test results (personal communication by David Wamalwa project manager for Busia Child Survival Project), but also documented in other parts of SSA [16, 17].
The midwives did provide correct information regarding the importance of HIV testing in the first trimester of pregnancy, but the great majority of women (83%) never understood that it was optional. By saying that testing was 'the best decision a mother could make for her unborn child' the midwives clearly revealed their expectations and left little room for the women to act otherwise. This finding is consistent with another study performed in Kenya showing that women accept HIV testing so as to avoid being perceived as not accepting the message of the midwives [7]. Our findings showed that it was difficult for the providers to remain neutral when informing about routine HIV testing. During the observed counseling sessions the midwives referred to the women as 'mothers' thereby highlighting the importance of the baby. The reason given during the sessions for having the test was the need to protect the child, while nothing was said about HIV testing being optional. From a public health perspective it is important that the women understand and accept the reasons for testing, since this increases enrolment in and adherence to PMTCT.
The high number of women counseled simultaneously under the opt-out approach made meaningful interaction difficult and for the midwives it was consequently easiest to provide information using a top-down approach. This approach could be justified as it reduced waiting time for the many women visiting ANC, in a situation where pre-test counseling is the first step before receiving other services of ANC. However, the current set-up makes most women believe that HIV testing is a prerequisite for obtaining other ANC services. To avoid this, the information needs to not only discuss the benefits of the testing, but also its implications and the importance of the post-test counseling. Our findings showed that 83% of the women perceived testing as a mandatory part of ANC services, not as a service independent of antenatal care. This finding could be attributed to unclear delivery of pre-test information and is consistent with observations that poor counseling prevents pregnant women from making informed decisions about HIV testing.
Only 20% of the women felt they would have been able to make an informed decision to decline HIV testing. This is a remarkably low proportion, given that more than a third also had been tested for HIV at ANC before. Although none among the 900 women declined the test, a majority seemed to have accepted it because they felt obliged to. An explanation for the misconception could be the power difference between the midwives and the pregnant women. Midwives are trusted and have high social status among pregnant women. In a recent qualitative study exploring reasons for adherence to PMTCT in the same setting we found that HIV-infected pregnant women trusted the midwives to keep their HIV diagnosis secret from the mother-in-law at least during pregnancy appointments (data not yet published).
Our findings showed that a great majority of the women had started childbearing at an early age and that 85% of the women had eight years or less of schooling. Possibly many women accepted to have the HIV test because they perceived the midwife to be more knowledgeable and to know best. They seemed not to understand the importance of their own active involvement in accepting or declining the HIV testing and the consequences of having the test. This is consistent with observations that patients in SSA accept to follow recommendations from health providers without fully understanding the consequences of their action as was observed in, for example, Botswana [13]. The implications for HIV testing could be that pregnant women accept to be HIV tested but fail to return for the test results as they realize that they are unprepared for the consequences. Failure to return for results or drop out from PMTCT has been documented from SSA [16, 17]. Unfortunately, we were not able to follow the women through the PMTCT process to assess the completion rate, but as mentioned above, a high proportion of pregnant women in this area are reported to never pick up their test results. The rapid test results are available within a quarter of an hour, and so failure to come for them strongly indicates that many women were not ready to face the consequences of a positive test result. They exerted their decision-making power in a more socially acceptable way by dropping out directly after testing. For improved access to and completion of PMTCT pregnant women need to understand the process of testing and voluntarily and consciously consent to HIV testing [18].
In a qualitative study in the Kibera slum in Nairobi exploring the reasons for becoming pregnant among women on ART, we found that women planned to become pregnant to strengthen their sexual relationships and possibly formalize them [19]. In this study the women who did not discuss with their partners felt more able to decline testing, as did those in unstable relationships. These women live in a more insecure situation and lack support to handle the test results, while those in stable relationships and those who have discussed the testing know that they will have support irrespective of the test-results. Couple testing is often promoted as a means to increase male partner support. However, the state of the relationship between a woman and her partner influences the decision-making of the woman in relation to testing. Perceived negative consequences of an HIV diagnosis, such as partner abandonment, isolation and loss of financial support, may be an important reason for women to test alone, to decline picking-up their test results or to avoid HIV testing altogether. This study shows the importance of having a secure relationship and a supportive environment before the testing. A recent study in rural Uganda showed that pregnant women often feel heavily burdened by partner disclosure and couple testing recommendations in relationships where they feel disempowered and dependant on their male partner [20]. It becomes necessary to understand individual women's sexual relationships and dependencies on men in order to improve acceptance of HIV testing and also enrolment and completion of PMTCT.
The likelihood of selection bias was low since ANC attendance is high in Kenya, about 90% visit ANC at least once, and one can assume that our participants represent of a majority of pregnant women in this area. The hospitals included in this study are NGO-affiliated and one can assume that the quality of care is similar across the PMTCT programs.
High coverage of HIV testing appears to be achieved at the cost of pregnant women's lack of knowledge that testing is optional. Good quality HIV pre-test counseling is central for making pregnant women understand and accept the reasons for testing and encourage consent to HIV testing, an important prerequisite for the consequent completion of the PMTCT program by those who are HIV infected. While provider-initiated HIV testing is necessary to increase the number of women who access PMTCT and ART, caution must be taken to actively involve the woman during the consent process, to respect their autonomy and improve the enrollment and completion of PMTCT. Intensive community campaigns are warranted to raise awareness of the HIV testing being performed at ANC and the reasons why it is being carried out, to sensitize the community and make them better prepared to make informed decisions. Health authorities could collaborate with NGOs to disseminate information, improve education and increase communication at household level in rural areas to supplement human and material resources shortages. More work is needed to understand how best to develop testing policies that both protect the voluntary consent process and expand testing to increase the implementation of functioning PMTCT-programs in areas with high HIV prevalence in SSA.
WHO &UNAIDS: Guidance on provider-initiated HIV testing and counselling in health facilities. Edited by: W. UNAIDS. 2007, Geneva
Branson BM, et al: Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. MMWR Recomm Rep. 2006, 55 (RR-14): 1-17. quiz CE1-4
Quin TC, Overbaugh J: HIV/AIDS in women: An expanding disease. Science. 2005, 308 (5728): 1582-3. 10.1126/science.1112489.
Gruskin S, Ahmed S, Ferguson L: Provider-initiated HIV testing and counseling in health facilities--what does this mean for the health and human rights of pregnant women?. Dev World Bioeth. 2008, 8 (1): 23-32. 10.1111/j.1471-8847.2007.00222.x.
Msellati P: Improving mothers' access to PMTCT programs in West Africa: a public health perspective. Soc Sci Med. 2009, 69 (6): 807-12. 10.1016/j.socscimed.2009.05.034.
Maman S, King E: Changes in HIV testing policies and the implications for women. J Midwifery Womens Health. 2008, 53 (3): 195-201. 10.1016/j.jmwh.2007.11.001.
Kiarie JN: HIV-1 testing in pregnancy: acceptability and correlates of return for test results. AIDS. 2000, 14 (10): 1468-70. 10.1097/00002030-200007070-00030.
De Cock KM, Mbori-Ngacha DA, Marum E: Shadow on the continent: public health and HIV/AIDS in Africa in the 21st century. Lancet. 2002, 360 (9326): 67-72. 10.1016/S0140-6736(02)09337-6.
Bayer R, Fairchild AL: Changing the paradigm for HIV testing--the end of exceptionalism. N Engl J Med. 2006, 355 (7): 647-9. 10.1056/NEJMp068153.
Bennett R: Routine antenatal HIV testing and informed consent: an unworkable marriage?. J Med Ethics. 2007, 33 (8): 446-8. 10.1136/jme.2006.018861.
Csete J, Schleifer R, Cohen J: "Opt-out" testing for HIV in Africa: a caution. Lancet. 2004, 363 (9407): 493-4. 10.1016/S0140-6736(04)15509-8.
Maman S, et al: Women's barriers to HIV-1 testing and disclosure: challenges for HIV-1 voluntary counselling and testing. AIDS Care. 2001, 13 (5): 595-603. 10.1080/09540120120063223.
Weiser SD, et al: Routine HIV testing in Botswana: a population-based study on attitudes, practices, and human rights concerns. PLoS Med. 2006, 3 (7): e261-10.1371/journal.pmed.0030261.
NASCOP: Kenya AIDS Indicator Survey 2007. 2008, Ministry of Health, Kenya.: Nairobi
Global Fund: Switching from Monotherapy and Scaling Up Combination Treatment for PMTCT. Presentation to Regional and Technical Teams. 2010, cited 2010 February 14th, [http://www.theglobalfund.org/en/regionalmeetings/sa/malawi2009]
Manzi M, et al: High acceptability of voluntary counselling and HIV-testing but unacceptable loss to follow up in a prevention of mother-to-child HIV transmission programme in rural Malawi: scaling-up requires a different way of acting. Trop Med Int Health. 2005, 10 (12): 1242-50. 10.1111/j.1365-3156.2005.01526.x.
Perez F, et al: Acceptability of routine HIV testing ("opt-out") in antenatal services in two rural districts of Zimbabwe. J Acquir Immune Defic Syndr. 2006, 41 (4): 514-20. 10.1097/01.qai.0000191285.70331.a0.
Sarker M, et al: Determinants of HIV counselling and testing participation in a prevention of mother-to-child transmission programme in rural Burkina Faso. Trop Med Int Health. 2007, 12 (12): 1475-83. 10.1111/j.1365-3156.2007.01956.x.
Awiti Ujiji O, et al: "I will not let my HIV status stand in the way." Decisions on motherhood among women on ART in a slum in Kenya - a qualitative study. BMC Womens Health. 2010, 10: 13-10.1186/1472-6874-10-13. 2010
Larsson EC, et al: Mistrust in marriage-Reasons why men do not accept couple HIV testing during antenatal care - a qualitative study in eastern Uganda. BMC Public Health. 2010, 10: 769-10.1186/1471-2458-10-769. p. 2010
We would like to thank all the women who took part in this study. Many special thanks to the Busia Child Survival Project (BCSP) staff and the health care providers at the involved facilities. This study was performed within the KI-AMREF collaborative research and financed by the Swedish International Development Agency/SAREC.
Department of Public Health Sciences, Division of Global Health, Karolinska Institutet, Stockholm, Sweden
Opondo Awiti Ujiji, Birgitta Rubenson, Gaetano Marrone & Anna Mia Ekström
African Medical Research Foundation (AMREF) in Kenya, P.O. Box 30125-00100, Nairobi, Kenya
Festus Ilako
AMREF Busia Child Survival Project (BCSP), P.O. Box 30125-00100, Nairobi, Kenya
David Wamalwa & Gilbert Wangalwa
Department of Infectious Diseases, Karolinska University Hospital, Stockholm, Sweden
Anna Mia Ekström
Opondo Awiti Ujiji
Birgitta Rubenson
Gaetano Marrone
David Wamalwa
Gilbert Wangalwa
Correspondence to Opondo Awiti Ujiji.
OAU is the main author of the manuscript and involved in all aspects of the study. AME and BR provided scientific expertise and feedback throughout the development of the study and manuscript. FI was involved in the conceptualization of the idea, tool development and reading and editing of the manuscripts. GM provided statistical support, supervised the analysis and edited the paper. GW and DW were involved during preparations and pre-test of the survey, data collection and reading and editing of the manuscript. All co-authors have seen and approved the final version of the paper and have agreed to its submission for publication.
Ujiji, O.A., Rubenson, B., Ilako, F. et al. Is 'Opt-Out HIV Testing' a real option among pregnant women in rural districts in Kenya?. BMC Public Health 11, 151 (2011). https://doi.org/10.1186/1471-2458-11-151
Informed Decision
PMTCT Program
Voluntary Consent
Busia District
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Neuengamme var en nazistisk kz-lejr. Den ligger i delstaten Hamburg 15 kilometer sydøst for centrum i bydelen Neuengamme og er i dag et museum.

Lejrens historie

Lejren blev oprettet i 1938 ved et teglværk som en underlejr af kz-lejren Sachsenhausen. I 1940 fik den status som selvstændig kz-lejr og fik med tiden 96 mindre arbejdslejre og "udekommandoer" under sig som underlejren Banterweg, hvor danskeren Gustav Alfred Jepsen var stedfortrædende lejrkommandant. Gustav Alfred Jepsen blev efter krigen dømt til døden af en britisk domstol for krigsforbrydelser begået i Banterweg.

Arbejdet i hovedlejren Neuengamme bestod hovedsageligt i produktion af mursten og bygningen af en kanal til at transportere murstenene fra lejren. Fangerne måtte grave den tunge jord ud med primitive redskaber uden hensyn til helbred og vejret.

Fra 13.december 1938 til 4. maj 1945 havde lejren 106.000 fanger fra 28 lande: russere (34.350), polakker (16.900), franskmænd (11.500), tyskere (9.200), nederlændere (hollændere), 6.950), belgiere (4.800) og danskere (4.800). Der var også tyske jøder, kommunister, homoseksuelle, prostituerede, sigøjnere, Jehovas Vidner og andre. Ca 55.000 døde pga. de umenneskelige forhold: mishandling, hårdt arbejde med meget lidt mad og uhygiejniske forhold.

Tre af underlejrene er bevaret som mindesteder: Bullenhuser Damm, Kritenbarg 8 og Suhrenkamp 98. Den første er viet mindet om 20 børn fra Auschwitz, der blev udsat for medicinske eksperimenter af SS-lægen Kurt Heissmeyer, der injicerede levende tuberkelbakterier i blod og lunger efter at have fjernet deres lymfekirtler. Heissmeyer besluttede at få dem dræbt 20. april 1945 for at skjule spor efter forsøgene. Efter indsprøjtninger med morfin blev børnene hængt i kroge i væggen, "som malerier på væggen", erindrede den ene SS-mand, der var med til drabene. Den anden underlejr var fyldt med kvindelige fanger fra Łódź i Polen. Den tredje underlejr lå ved Fuhlsbüttels fængsel. Dele af den lejr gav plads til kommunister, modstandere af regimet og andre grupper. Ca. 450 fanger blev myrdet dér.

3. maj 1945 blev fartøjerne Cap Arcona, Thielbek, Athen og Deutschland IV lastet med fanger fra lejren, slæbt ud fra kaj og forladt drivende i Lübeck-bugten for at fjerne spor efter lejren. Allierede fly bombede og sænkede skibene. Ca. 8.000 fanger druknede eller blev skudt på stranden af SS.

De fleste af de 6.000 danskere, som kom i koncentrationslejr, kom til Neuengamme eller en af dens underlejre.

Underlejre
Neuengamme var delt op i et antal underlejre (eller udelejre).

De Hvide Busser

Neuengamme blev i marts og april 1945 benyttet til transitlejr for skandinaviske fanger, som blev reddet af De Hvide Busser. Natten til 18. marts 1945 kørte danske og norske fanger fra Sachsenhausen til opsamling i Neuengamme, før turen gik til Frøslevlejren. Himmler havde først tilladt transport ud af Tyskland i april. Da skandinaverne ankom til Neuengamme, blev flere hundrede fanger slæbt ud – døde og døende mellem hinanden. Russerne havde i længere tid gemt de døde i madrasserne for at få deres madrationer. Det tog Røde Kors et kvarter at fjerne dem. Blandt nordmændene vakte det protester, at 2.000 syge og døende fanger måtte give plads til 2.000 skandinaver. Tyskerne havde planlagt at evakuere Sachsenhausen-fangerne til Bergen-Belsen, men de nåede kun at sende et fåtal derhen. De ti nordmænd og den ene dansker, der ankom til Neuengamme fra Bergen-Belsen, var alvorligt syge af tyfus.

I april 1945 skulle grev Folke Bernadotte inspicere fangebarakkerne. Da nogle fanger kom slæbende på en halvtreds liters suppespand, forlangte han at smage den. Kommandanten fik fremskaffet en ske og spurgte, om suppen ikke smagte godt. "Inte ens hunden vill ha den," svarede Bernadotte.
Oversættelse: Ikke engang en hund vil spise det!

Referencer

Litteratur
 Wolfgang Benz, Barbara Distel (Hrsg.): Der Ort des Terrors. Geschichte der nationalsozialistischen Konzentrationslager. Bd. 5, Hinzert, Auschwitz, Neuengamme. Beck-Verlag, München 2007, S. 313ff. .
 Marc Buggeln: Das Außenlagersystem des Konzentrationslagers Neuengamme, in: Sabine Moller, Miriam Rürup, Christel Trouvé (Hrsg.): Abgeschlossene Kapitel? Zur Geschichte der Konzentrationslager und der NS-Prozesse, Tübingen 2002, 224 Seiten.
 Hermann Kaienburg: Das Konzentrationslager Neuengamme 1938-1945. Dietz, Bonn 1997,
 Peter Langwithz Smith: Neuengamme Koncentrationslejren 1938-1945. Informations forlag 2012,

Eksterne henvisninger

 Gedänkstätte Neuengamme

Koncentrationslejre i Tyskland
Etableret i 1938
Bygninger, konstruktioner og anlæg i Hamborg

redpajama_set_name: RedPajamaWikipedia


Hideo Kojima? Crazy guy. When the Metal Gear Solid creator was working on his cyber-punk title Snatcher, he wanted to bring realism to player's computers with more than graphics or storytelling. He wanted the odor of blood.
Snatcher was released in 1988 for the NEC PC-8801. In a recent tweet, Kojima reveals that he had an idea for the "smell project". The game's floppy would be coated with paint that carried the odor of blood. The heat from the computer would then cause the paint to melt, releasing what Kojima calls "the stench of a murder scene".
The original version of Snatcher were released on floppies and were entirely text-based. Later versions were released on CD-Rom and featured voice acting. Sadly, the "blood plan" stayed in the brainstorming phase as everyone at Konami was against the idea.


AMES, Iowa —A new effort to boost federal investment in agricultural research launched today in Washington, D.C., bringing together Iowa State University with 15 other public and private universities.
Schulte Moore participated in FedByScience briefings this week for Senate and House of Representatives staff. The effort tells stories in which scientific discoveries and innovations have improved the way food is produced and distributed.
FedByScience highlights the work of Schulte Moore and others. Schulte Moore and her colleagues, supported by USDA grants and other funding sources, examined a set of problems confronting corn and soybean farmers—soil and nutrient retention, especially during rainstorms—and engineered an improbable solution: interspersing strips of native prairie vegetation throughout the crop rows. Her team estimated that the prairie strips solution could be used on 9.6 million acres of cropland in Iowa and a large portion of the 170 million acres under similar management in the United States.
"Access to safe, nutritious food and a healthy environment is a fundamental human right. The need for healthy food will only grow as we look to the future. There is no issue of greater importance for our experts in the agricultural and food sciences and few more deserving of federal support" said Kathryn Boor, PhD, FedByScience co-chair and The Ronald P. Lynch Dean of Cornell University's College of Agriculture and Life Sciences.
FedByScience is a collaborative initiative among universities to raise the visibility of the value of federal investment in food and agricultural research. FedByScience's online collection of success stories highlights cutting-edge science that connect to the concerns of everyday Americans.
Iowa State University's agricultural programs are ranked in the top 4 percent worldwide. The Agriculture Experiment Station, administered by the College of Agriculture and Life Sciences, is Iowa's only public agricultural research program and has served the state for 130 years. Over the last 5 years, scientists supported by the Agriculture Experiment Station successfully brought in more than $270 million in external funding. Agricultural scientists at Iowa State generate innovations, technologies, and solutions to immediate needs in food security, human health, economic development and environmental stewardship. Science-based information reaches every county in Iowa through ISU Extension and Outreach and research and research and demonstration farms guided by local stakeholders. The college's 27 undergraduate majors prepare students for careers spanning the study of food, environment, energy, climate, nutrition and science and technology. The college's current placement rate for recent graduates is 99.2 percent.
The SoAR Foundation leads a non-partisan coalition representing more than 6 million farming families, 100,000 scientists, hundreds of colleges and universities as well as consumers, veterinarians, and others. For more information, please visit www.supportagresearch.org.


text:
Мемориальный музей Г. С. Сковороды — музей в городе Переяславе Киевской области, посвящённый жизни и творческой деятельности Григория Саввича Сковороды. Расположен в здании бывшего Переяславского коллегиума по улице Сковороды, 52, которое обладает статусом памятника архитектуры.

История
Григорий Сковорода был преподавателем в Переяславском коллегиуме. В период этой работы он написал значимую часть своих произведений, в том числе «Сад божественных песен». В конце XVIII века помещение бывшего коллегиума стало духовной семинарией. Бывший коллегиум, который был построен в середине XVIII века, признан памятником архитектуры национального значения, был построен в стиле украинского барокко.

В 1972 году в этом здании по указу правительства Украины был открыт музей Григория Сковороды.

Экспозиция
Музейная экспозиция рассказывает о жизни Григория Сковороды и его творческой деятельности. Есть экспонаты, которые относятся к истории Переяславского коллегиума.

Одна из экспозиций посвящена жизни Г. С. Сковороды в Переяславе, представлен портрет поэта, выполненный в конце XVIII века. Среди экспонатов музея есть и музыкальные инструменты, на которых играл художник — скрипка, бандура, цимбалы, лира.
В экспозиции музея представлена мебель XVIII века, которая когда-то была расположена в имении Томар. Это имение посещал Г. С. Сковорода, так как когда-то работал домашним учителем в доме помещика Степана Томары в селе Каврае. Среди мебели — кресла, диван, стол, лампа-торшер, картина XVIII века «Ярмарка», которая была выполнена художником Гагеном.

В мемориальном музее воссоздали ту обстановку, которая была в классе поэтики несколько столетий назад. Здесь стоят столы и скамьи, есть классная доска. На стенах размещены иконы: «Бог Саваоф», «Матерь Божия», «Коронование Девы Марии». На столах разложены книги, а у дверей вешалка с одеждой студентов. В этом же помещении расположена скульптура Г. С. Сковороды, выполненная Иваном Кавалеридзе.

В музее есть помещение, в котором была воссоздана обстановка комнаты учителя. Кровать расположена в углу, на ней лежит кожаная подушка и домотканое покрывало. Секретер и стул расположены напротив двери. На секретере стоит глобус, есть подсвечник и рукописи произведений поэта. Среди рукописей можно увидеть текст сатирической песни «Всякому городу нрав и права». На скамье стоит посуда: миски, медная кружка.

В музее воссоздан интерьер библиотеки бывшего коллегиума. Здесь есть старинные шкафы с книгами, которые датируются XVI—XIX веками. Здесь есть издание «Атласа Российской империи» 1745 года, книги на французском языке «Басни Ла-Фонтена» 1675 года, «Письма малоизвестных особ», которые датируются 1598 годом, «Основ философии и логики» 1557 года на латыни. Есть книги, которые читал Григорий Сковорода: произведения Ломоносова, Горация, Плутарха, Марка Аврелия, Руссо, Прокоповича.

В экспозиции хранится факсимильное издание Пересопницкого Евангелия, которое подарил музею Блаженный Митрополит Киевский и всея Украины Владимир.

Вход в музей платный. Стоимость взрослого билета составляет 20 гривен, детского билета — 10 гривен. Музей открыт с 09:00 до 17:00, понедельник и вторник — выходные дни.

См. также
 Литературно-мемориальный музей Г. С. Сковороды в селе Сковородиновка Харьковской области

Примечания

Музеи Переяслава


Minors participating in GVC-ADK activities.
Minors are welcome to participate in GVC-ADK activities; however the minor (any person under 18 years of age) must be accompanied by a parent or legal guardian.
If that is not the case, the minor must be accompanied by a responsible adult who must provide both a Release of Liability Minor form and an Emergency Medical Care form signed by a parent or legal guardian.
These forms are available here.


text:
For the love of music (Anna's Anchor and Bob O'Keeffe)
Published: 04 June 2017 | Email | Hits: 456
There are nights when it doesn't matter how many people are in the room, sometimes less means time for more intimate songs and you feel like in someone's living room. This was the case of the Saturday night, June 3rd in Stara pekarna in Brno where the Irish songwriters Bob O'Keeffe, from Wexford but currently based in Prague, and Marty Ryan, also known as Anna's Anchor (from Limerick), were the stars of the night.
With not so many people in the room, the feeling of the night was relaxed but some artists might feel more nervous on nights like this than with a packed house.
Bob O'Keeffe's set was full of energy and the listener got the impression he might not even need a microphone. He knows his trade, learnt on the streets of Ireland and you don't doubt that when you hear him sing.
Anna's Anchor followed and he also immediately caught the attention of the listeners with lyrics that go deep below the surface and as he himself says each song has a meaning and a sense of purpose. You can get an instant idea about the honesty of the songs when you hear a line like "as a father, you had to turn your back on your daughter". It sends chills down your spine. But Marty made the audience laugh when telling stories from his travels, for example about last time in Brno, staying in a hostel with a weird guy from Croatia following him around all night or about playing at the islands of Ireland and the different feel each and every one of them has.
He was nicely surprised about the atmosphere of the night, so quiet that you could hear a pin drop.
An inspirational evening where two great acts shared their love for music.

redpajama_set_name: RedPajamaCommonCrawl


My head is spinning when I think of how a "Buck a Beer" took precedence over safe injection sites. To me it is discounting the massive opioid problem we have in every city. Look at the timeline of your brothers health problems and addictions.
So why not continue his battle in a positive way. Help others who are fighting with this "disease" As I write this in Windsor, every single day tons of needles are found near parks where children play, and the alleys are filled with them. "Buck a Beer" makes a great headline – but is this why the residents of Ontario voted you in. When you think of how drugs destroyed your brothers life, you would think that you would have made it a TOP priority to get drugs off the streets. Drugs kill more people than guns. Read the Globe and mail article, 25 gun deaths!!
Now lets compare the gun deaths to Opioid deaths.
Ontario to REVIEW safe injection/overdose sites??
"We need to take a look at the evidence and understand what the experts are saying, so I want to hear that. The premier wants to hear that. He wants to know that continuing with the sites is going to be of benefit to the people of Ontario," she said.
Please explain why you have to review it. You have to understand what the experts are saying?" You want to benefit the people of Ontario by delaying a solution? What high paid "experts" will say anything different than what you can find on Google. Hospital staff, Doctors and Coroners have been telling the public for over 5 years. How many young kids have to be exposed to the drug paraphernalia in parks, school grounds and on the street. You want to make sure Programs your investing in have value? Your investing and protecting our next generation. The Opioid problem is escalating every year, it is not going away. Why wouldn't you fight for solutions?
Dilkens added the increased staffing compliment will also help deal with people suffering from addiction and mental health issues.
The $1.4 million proposal would create a mobile unit, with an initial focus on the downtown core.
How do more police help deal with people suffering from addiction and mental health issues? Arresting people on the street does not help addiction and mental health issues. If this was given to the Downtown mission who deal with addicts and the homeless every day, we WOULD see a change in this city. If this $1.4 million was given to experienced drug counsellors who would work on the street to address the problem we would see a bigger result. Adding more police just to arrest them and take them off the street for a night is not the answer.
Doug Ford, my sister was killed because of Fentanyl. An accidental overdose from a patch that she was prescribed by her family doctor in Richmond Hill. She should never have been prescribed it, and nothing happened to her doctor. But the street variety is a "loaded gun". There are various groups in Windsor who are getting tired and frustrated with the lack of support they are getting locally and Provincially. Regular citizens volunteer to pick up needles. I volunteered with one of the groups and was shocked with what we found. Your own family was touched by tragedy. The stark reality that drugs had seeped into your family and what it did to your brother. Every SINGLE day, someones Brother, Mother, Father, Sister gets hooked on drugs. Opioids given to them by their doctors, which led them to the streets when the doctors would not give them any more. Drugs that are peddled to the less fortunate on the street, who have lost hope, or have no one to help them with their addiction. What about the devastated families who have to deal with a drug addict, and watching them self destruct. But "Buck a Beer" was a promise that you felt that you needed to deliver on?
In closing – If I was a councillor or a representative of Ontario I would not be promoting Buck a Beer by labour day. The former first lady Betty Ford was instrumental in helping others.
Former First Lady Betty Ford put a courageous new face on recovery when, at age 60, she openly sought treatment for addiction to alcohol and prescription medications. Her candor created a national dialogue and lifted the shame surrounding addiction, unlocking the door to recovery, especially among women.
You could start something right here in Ontario by paving the way for solutions for our Opioid crisis – in memory of your brother. Keep his memory alive and help thousands of people with their addictions in Ontario.


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text:
Back to Hockey | Ben Hilhorst
With under three weeks to go until the puck drops on 2020-21 in the MJHL, the end to last season may seem like a distant memory to most who have endured the ongoing COVID-19 Pandemic, including Ben Hilhorst who hopes to put last season behind him.
After spending his first two years in Neepawa, Hilhorst was traded early in his 19-year-old season to OCN where he capped off his first year in the north as Captain of the Blizzard.
"Towards the end of the year once we were eliminated from the race we were a bit discouraged," Hilhorst said of the Blizzard in 2019-20. "We agreed that coming into next season, things had to change a lot."
"At the start of summer there wasn't a whole lot to do, lately I've just been trying to do as much as I can, trying to get prepared for the season as best as possible."
Getting prepared for the upcoming season included recovering from ventral hernia surgery that was taken care of earlier this summer before the 6-foot-1, 195-pound defender could hit the ice for full contact.
Feeling healthy as he approaches his final season in the league, Hilhorst is ready to help lead the newest members of the OCN Blizzard.
"I'm very excited for this season, with it being my last year, I'm excited to be in the role of showing the ropes to the younger guys coming in. I'm going to try to take it all in and hopefully make a playoff run to finish it all off."
"With the role I was given, I want to do as much as I can to guide the team in the right direction from the start of the season. Building our identity and turning the culture around is important. I'm trying to have a good year for myself as well to try and further my hockey career."
Finishing 16-39-5-0 last season, the Blizzard missed the playoffs for the second consecutive year which triggered a change at the helm of the club. In mid-July, OCN announced the hiring of veteran MJHL coach, Billy Keane which Hilhorst says will be a welcomed addition.
"Coming off last year, a fresh start will be good for the team. Bringing some experience in with Billy behind the bench will be a positive shift for the team for sure. I think it will be great for us having him running the show. He's had success coaching at numerous levels and I think it will be a big part of us molding our team and finding our identity."
"Getting into the grind and being around with the guys is great. Going through it all with the team, I'm looking forward to doing it one more time," Hilhorst concluded.
Previous PostMJHL announces partnership with The Coaches SiteNext PostMJHL continues partnership with Headcheck Health


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text:
Сергій Леонідович Стась (народився 28 квітня 1974 у м. Мінську, СРСР) — білоруський хокеїст, захисник. Заслужений майстер спорту Республіки Білорусь (2002).

Вихованець хокейної школи «Юність» (Мінськ), тренери — Е. Мілушев, В. Астапенко. Виступав за «Хімік» (Новополоцьк), «Динамо» (Мінськ), «Тівалі» (Мінськ), Erie Panthers (), Greensboro Monarchs (ХЛСУ), Fort Wayne Komets (ІХЛ), Phoenix Roadrunners (ІХЛ), Las Vegas Thunder (ІХЛ), San Antonio Dragons (ІХЛ), «Куод Сіті Меллардс» (CoHL), Saginaw Lumber Kings (CoHL), «Нюрнберг Айс-Тайгерс», «Ревірлевен Обергаузен», «Вельфе Фрайбург», «Аугсбург Пантерс», «Крефельд Пінгвін», ХК «Гомель», «Москітос Ессен», «Дресднер Айслевен», «Юність» (Мінськ), «Шахтар» (Солігорськ).

У складі національної збірної Білорусі виступав з 1992 по 2005 роки, провів 97 матчів (11 голів, 20 передач). Учасник зимових Олімпійських ігор 1998 і 2002; учасник чемпіонатів світу 1997 (група B), 1998, 2000, 2001, 2002 (дивізіон I), 2003 і 2004 (дивізіон I).

Чемпіон Білорусі (1993, 1994). Срібний призер чемпіонату Німеччини (1999).

Посилання
 Профіль  на Eliteprospects
 Профіль  на Мир хоккея Беларуси

Уродженці Мінська
Хокеїсти «Хіміка-СКА»
Хокеїсти «Динамо» (Мінськ)
Хокеїсти «Тівалі»
Хокеїсти «Нюрнберг Айс-Тайгерс»
Хокеїсти «Аугсбург Пантерс»
Хокеїсти «Фрайбурга»
Хокеїсти «Гомеля»
Хокеїсти «Юності» (Мінськ)
Хокеїсти «Шахтаря» (Солігорськ)
Хокеїсти «Обергаузена»
Заслужені майстри спорту Республіки Білорусь
Хокеїсти «Форт-Вейн Кометс»


text:
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">

<title>Impurity</title>
<meta name="date" content="2014-12-16">
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weka.classifiers.trees.m5

Class Impurity

java.lang.Object

weka.classifiers.trees.m5.Impurity

All Implemented Interfaces:

RevisionHandler

public final class Impurity
extends java.lang.Object
implements RevisionHandler

Class for handling the impurity values when spliting the instances

Version:

$Revision: 1.8 $

Author:

Yong Wang (yongwang@cs.waikato.ac.nz)

Constructor Summary

Constructors

Constructor and Description

Impurity(int partition,
        int attribute,
        Instances inst,
        int k)

Constructs an Impurity object containing the impurity values of partitioning the instances using an attribute

Method Summary

Methods

Modifier and Type
Method and Description

java.lang.String
getRevision()

Returns the revision string.

void
incremental(double value,
           int type)

Incrementally computes the impurirty values

java.lang.String
toString()

Converts an Impurity object to a string

Methods inherited from class java.lang.Object

equals, getClass, hashCode, notify, notifyAll, wait, wait, wait

Constructor Detail

Impurity

public Impurity(int partition,
        int attribute,
        Instances inst,
        int k)

Constructs an Impurity object containing the impurity values of partitioning the instances using an attribute

Parameters:

partition - the index of the last instance in the left subset

attribute - the attribute used in partitioning

inst - instances

k - the order of the impurity; =1, the variance; =2, the stardard deviation; =k, the k-th order root of the variance

Method Detail

toString

public final java.lang.String toString()

Converts an Impurity object to a string

Overrides:

toString in class java.lang.Object

Returns:

the converted string

incremental

public final void incremental(double value,
               int type)

Incrementally computes the impurirty values

Parameters:

value - the incremental value

type - if type=1, value will be added to the left subset; type=-1, to the right subset; type=0, initializes

getRevision

public java.lang.String getRevision()

Returns the revision string.

Specified by:

getRevision in interface RevisionHandler

Returns:

the revision

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redpajama_set_name: RedPajamaGithub


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Army Public School has dispersed A job notice regarding APS Dagshai Recruitment to inform the The most eligible and effective Candidates for the Various positions of Teachers. Eligible Candidates can apply for APS Dagshai vacancy by filling offline application form till the last date that is 11th February 2019.
Qualification Details: Aspirants must have Graduation/PG Degree with B.Ed/D.Ed/CTET/TET from well recognized Board/ University/ Institute according to post.
Age of aspirants applying for above Vacancy must be above 40 Years (For Fresh Candidates), 57 Years(For Experienced Candidates).
APS Dagshai and that is http://apsdagshai.org.
Last Date for Receiving Hard Copy of Application Form Is : 11-02-2019.
Click Here For APS Dagshai Official Notification Link.


Principal of Cambridge High School, in St. James, Ms. Mavis Hamilton, who tells JIS News about the re-branding exercise taking place at the school.
The rebranding of Cambridge High School in St. James is already resulting notable improvements.
Principal of four years, Mavis Hamilton, who launched the rebranding initiative,tells JIS News that the school community is pleased with the improvements that are being made.
The Principal says she and her staff wants to graduate world-class students from Cambridge.
The rebranding of Cambridge High School in St. James is already resulting notable improvements in the school's culture and the performance of its students.
Ms. Hamilton says when she took over the reins of the institution in 2010, she saw the need for a drastic turn around. "I quickly identified disciplinary deficiencies and low academic performance as the two major challenges facing the school. The students' general behaviour lacked social and personal development so we really wanted to change all of that," she reveals.
The school's recent National Education Inspectorate (NEI) report also highlighted the need for transformation.
"We saw where we needed to intensify efforts to revolutionise our school community. To polish our act as well as our image," says Ms. Hamilton.
The primary focus was on the areas of social and personal development; andacademic performance, and discipline. So far, the exercise has galvanised the co-operation of the institution's internal and external stakeholders, pulling support from the Ministry of Education, students, staff, Parent Teachers Association, the Board and the police.
Ms. Hamilton and her staff have been impressed by the enthusiastic response fromthe students. " It is the entire school (that is on board), but moreso the clubs such as the Red Cross, music and choir, speech and drama, book club, Girls Guide, 4H and Dance clubs," she says.
Board Chairman, Rev. Leroy Sterling has high praises for the innovative Ms. Hamilton and her team. He commends her determination to build and promote cohesiveness among staff.
Of great significance he states, is the addition of a Dean of Discipline to the team in September 2013. The Dean's military background has augured well for his effectiveness and efficiency, Rev Sterling says.
Guidance Counsellor, Sophia Campbell is optimistic that "the children are getting the message." She concurs with the principal that the students were less boisterous and aggressive, and that fewer were being sent on suspension.
Now that discipline is under control, greater focus is being placed on the school's vocational training departments and attendance. "Most of our students are skills oriented, and so we want to push the vocational training aspect in this direction. We are working with HEART Trust/NTA and this year 103 students have qualified to sit the level one CVQ Examinations," she informs.
Attendance is still a challenge for the institutions, as some parents are experiencing financial difficulties.
"It is difficult to teach effectively without consistency in attendance. Currently ourbest attendance is on Tuesdays. By Thursdays and Fridays (students) don't come to school because the money is just not there. Our investigations have revealed that some parents are spending upwards of $600 daily just for transport to get their children to school. This is of great concern," Ms. Hamilton discloses.
Plans are therefore being put in place to achieve a higher level of co-operation from parents to formulate strategies to address the economic challenges they are facing.She noted also that parent attendance at PTA meetings, is low and that this too, is being addressed.
On April 10, the school staged its first exposition along with its annual Career Day, which sought to bring attention to the top quality performance and ability of students and the school's academic and vocational disciplines.
"We want to create that total person so that when we put them out into the world, we can proudly say that is a Cambridge High School graduate. Our ambition is to be known as the secondary school of choice for the parish of St. James. I know we have capable teachers and I know that if our students use this as a stepping stone, we will get there," she says.


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text:
News from Lithuania
PLUNGE, LITHUANIA: The evangelistic seminar has begun in Plunge. On Friday, August the meetings opened with about 40 in attendance from the community. The next evening there were 55 in attendance, and it appears that all are very sincere and interested in knowing more about Word.
VILNIUS, LITHUANIA: The last week of July saw the visit of Alexi II, patriarch of Moscow and the Russian Orthodox Church to Vilnius. On July 27, Alexi II together with Roman Catholic Archbishop Bachkis participated in joint services, and finished by standing side by side to bless the people.
The Russian Patriarch said that the relationships between religions are very complicated in Europe, but that he was thankful that in Lithuania the people and the government are sincerely trying to find solutions to these problems.
Archbishop Bachkys responded by saying "In free Lithuania the Catholic and Orthodox churches can easily organise their work together and I would like very much to see the rights of the Catholic Church protected in the Russian Federation."
Lithuanian President, Algirdas Brazauskas, who is personally acquainted with Alexi II, promised to help the patriarch solve his problems with different religious confessions and relations with them.
Bertold Hibner,


text:
Latinos and Rappers perform in Ontario arena
Rappers and Latino performers at Ontario arena
Liset Márquez, Staff Writer 01/23/2009
ONTARIO - Citizens Business Bank Arena will be mixing up its musical lineup in the next couple of months to include rappers and Latino performers.
Rapper Pitbull and hip hop artist Baby Bash on March 24 will perform at the arena.
Tickets go on sale at 10 a.m. this morning.
The concert will provide a couple of firsts for the arena. The show will be the first time that the arena will host performers outside of the country and rock genres as well as multiple acts in one night
The Hollywood Live promoted concert will be called "March Madness" and will also feature performances by E-40, MC Magic and Lala, arena spokeswomen Sue Oxarart said.
"We anticipate it to be a popular show and for it to sell out," Oxarart said.
To date, the arena has had success with several of its concerts. Performances by pop singer Carrie Underwood and heavy metal band Metallica sold out, Oxarart said.
"So far we've received a great response," Oxarart said. "This type of entertainment venue in the Inland Empire is something we've all needed for a long time," Oxarart said.
The city-owned, 225,000-square-foot arena in the 4000 block of Ontario Parkway can hold up to 11,000 seats, depending on how a stage is set up, she said.
Oxarart said the arena will be bringing in more acts to attract different audiences.
Earlier this month, arena officials took notice when San Manuel Indian Bingo and Casino in Highland held a sold-out show featuring Mexican recording artist Jenny Rivera.
Oxarart said the arena is working to host two different shows in the near future with a well-known Latin performer and a variety of Latino acts. Additional details were not provided.
In the next year, arena officials will look to put on more shows to draw in the Latino community such as boxing and rodeos, she said.
"It's not only us. The promoters and agents know its a great site and are contacting us," Oxarart said. "We're on their radar too."
liset.marquez@inlandnewspapers.com (909) 483-8556
Labels: Latino Music
7th Annual Sac Taco Festival
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The Story of a Mexican American Musical Icon
BOOK REVIEW by Adrian Perez W hether you're Latino or not, if you enjoy Tex-Mex music, you've probably he...
Latino art showcase in AZ art walk
Busy art walk showcasing Latino art by Jahna Berry - The Arizona Republic Apr. 3, 2009 Latino artists are increasing their profile on Firs...
Latinos not reflected on Spanish TV
Blonde, Blue-Eyed, Euro-Cute Latinos on Spanish TV Has Spanish language TV violated its trust to maintain American Latino cultural identity?...
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Jenna is currently Digital Editor at the CSIRO, overseeing editorial direction and strategy for the organisation's multiple websites. Prior to that, she worked in corporate communications for Optus and as a journalist for Fairfax in NSW and Queensland. She studied at the University of Sydney and has been working in communications for over a decade.


This book deals exclusively with the subject of moral etiquette in Islam, focusing on the customs and traditions of the early Muslims.
Al Adab Al Mufrad is Imam al-Bukhari's second most well known work, which contains 644 sections with 1322 ahaadith and narrations from the pious predecessors. It comprises benefits from the daily life of the Prophet Muhammad (PBUH), his companions, and the early Muslims.
You may expect a fascinating insight into how one should behave as practiced by the Prophet Muhammad (PBUH), his companions, and the Aimmah of the Tabi'in from the following generation. It tackles a variety of issues; from dealing with specific family members, to how to write letters, as well as how to go shopping, or even on how to walk properly. The unique depth and importance of this book makes it an undeniable classic, covering all areas of life. One would become a model citizen for others by following this true guidance and adapting these great characters.
Al Adab Al Mufrad deserves the most attention after the book Sahih Al Bukhari by the one who seeks to follow the sunnah of beloved Prophet (PBUH).
You need to register an account when purchase ESPECIALLY E-Books from dakwahcornerbookstore.com.my.
This will enable you to keep track your links and Password for Ebook, whenever you log in to your account. We will keep your personal information private and ensure it is safe.
You can either register for an account before or upon checking out your order.


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Yesterday I spent a day with Jack Lynch. This is now the second time I have shot with him. The first time I got an article in Soggybones magazine.
I was up at 3:30 am and begun my drive south to Scotts head to pick jack up so we could be at Crescent head by sunrise. Once there we shot, ate, shot more, jack ate more, surfed and so on. I will let the photos tell the story from now on.
Hands down, Jack can eat the most food out of anyone I have ever met. While we were in crescent head he ate 3 pies, a blueberry turnover, Jam donut, chocolate donut, custard tart, chocolate milk, 2 muesli bars and a bottle of water.
Jack likes to take photos too... you can find a link to his blog in 'my links' section.


text:
L'aéroport Plaine Corail, situé  à Plaine Corail, dans la région sud-ouest de l'île Rodrigues, est la seule structure aéroportuaire de l'île.

Historique
Inaugurée en 1972, la petite piste d'atterrissage ne pouvait accueillir que des petits transporteurs comme l'ATR-42-500 de la compagnie « Air Mauritius ».

Au cours des années, le développement touristique dans l'île prit son essor, et le nombre grandissant d'arrivées a encouragé les autorités à procéder à l'agrandissement de la piste et la construction d'un nouvel ensemble de bâtiments comprenant aérogare, tour de contrôle et pompe à incendie. Le tarmac peut maintenant accueillir deux appareils de type ATR-72-500. La nouvelle piste fait  contre  auparavant.

Les travaux d'agrandissement se déroulèrent en deux phases. La première phase des travaux à Plaine-Corail concernait l'agrandissement de la piste d'atterrissage et l'installation d'équipements d'aide à la navigation aérienne. La compagnie Airport of Rodrigues (l'Aéroport de Rodrigues) contracta des prêts à hauteur de Rs , remboursables sur quinze ans, auprès du Fonds de Pension de Maurice pour financer ces travaux. La seconde phase des travaux, notamment la construction d'un nouveau terminal pour passagers avec des facilités hors taxes et d'autres facilités aéroportuaires fut livrée en 2003.

Le nouvel ensemble entra en service en octobre 2003 et a vu atterrir le premier vol en provenance de La Réunion (aéroport de Pierrefonds) le 26 décembre 2003. Ce vol direct fut possible grâce à la mise en service de l'ATR-72-500, le Port Mathurin. Air Mauritius annonça la fermeture de la ligne Rodrigues-Réunion à partir du 10 avril 2006 vu que les vols étaient à moitié vides. Le trafic aérien se limite à des dessertes quotidiennes entre Rodrigues et l'île Maurice. Deux compagnies aériennes assurent la liaison entre les deux îles, Air Mauritius et Catovair.

Le 4 octobre 2007 le gouvernement central annonça que l'aéroport de Plaine Corail serait dorénavant connu comme l'aéroport Sir Gaëtan Duval, en hommage à ce dernier, qui avait grandement contribué au développement de l'île.

Catovair
La compagnie est une filiale d'Ireland Blyth Ltd. Elle opère avec deux Beechcraft 1900 D pouvant transporter . Un des deux appareils assure la liaison Rodrigues-Maurice alors que le second est basé à Madagascar pour des vols internes sur la grande île. Le vol inaugural sur Rodrigues eut lieu le  septembre 2005.

Air Mauritius

La compagnie nationale de la République de Maurice fut la pionnière de l'aviation à Rodrigues. Les premiers vols furent assurés par des Twin Otter et par la suite par des ATR-42-500. La nouvelle piste d'atterrissage ne pouvant pas accueillir les Airbus A319, la compagnie opta pour la version améliorée de l'ATR, qui peut transporter .

Air Austral

La compagnie aérienne de La Réunion Air Austral, décide de desservir l'aéroport de Rodrigues depuis l'aéroport de Saint-Pierre Pierrefonds en ATR 72-500.

Duty Free
La Rodrigues Duty Free Paradise Ltd est une organisation autonome qui gère la boutique hors-taxe de Plaine Corail. Les passagers peuvent s'y approvisionner en whisky, vin, confiseries, cigarettes et parfums.

Article connexe
 Liste des aéroports à Maurice

Notes et références

Plaine Corail
Infrastructure de Rodrigues