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Strengthening the role of Community Health Representatives in the Navajo Nation
Caroline King1,2,
Alex Goldman3,
Vikas Gampa2,4,
Casey Smith1,2,
Olivia Muskett1,2,
Christian Brown1,2,
Jamy Malone2,5,
Hannah Sehn2,5,
Cameron Curley1,2,
Mae-Gilene Begay6,7,
Adrianne Katrina Nelson8 &
Sonya Sunhi Shin1,2,8
Strengthening Community Health Worker systems has been recognized to improve access to chronic disease prevention and management efforts in low-resource communities. The Community Outreach and Patient Empowerment (COPE) Program is a Native non-profit organization with formal partnerships with both the Navajo Nation Community Health Representative (CHR) Program and the clinical facilities serving the Navajo Nation. COPE works to better integrate CHRs into the local health care system through training, strengthening care coordination, and a standardized culturally appropriate suite of health promotion materials for CHRs to deliver to high-risk individuals in their homes.
The objective of this mixed methods, cross sectional evaluation of a longitudinal cohort study was to explore how the COPE Program has effected CHR teams over the past 6 years. COPE staff surveyed CHRs in concurrent years (2014 and 2015) about their perceptions of and experience working with COPE, including potential effects COPE may have had on communication among patients, CHRs, and hospital-based providers. COPE staff also conducted focus groups with all eight Navajo Nation CHR teams.
CHRs and other stakeholders who viewed our results agree that COPE has improved clinic-community linkages, primarily through strengthened collaborations between Public Health Nurses and CHRs, and access to the Electronic Health Records. CHRs perceived that COPE's programmatic support has strengthened their validity and reputation with providers and clients, and has enhanced their ability to positively effect health outcomes among their clients. CHRs report an improved ability to deliver health coaching to their clients. Survey results show that 80.2% of CHRs feel strongly positive that COPE trainings are useful, while 44.6% of CHRs felt that communication and teamwork had improved because of COPE.
These findings suggest that CHRs have experienced positive benefits from COPE through training. COPE may provide a useful programmatic model on how best to support other Community Health Workers through strengthening clinic-community linkages, standardizing competencies and training support, and structuring home-based interventions for high-risk individuals.
The Navajo Nation, located in the Southwestern United States and encompassing parts of Utah, New Mexico and Arizona, is the second largest Native American tribe in the United States with a population of 332,000 people in 2010 [1]. The Navajo Nation is actively seeking ways to help address Type 2 Diabetes Mellitus (DM) and prediabetes on the reservation. In 2012, the Navajo Area Indian Health Service estimated there are 25,000 Navajos with diabetes and an additional 75,000 who are prediabetic [2]. This challenge is compounded by the distance needed to travel to purchase food either on or off the reservation. Spread out over 27,000 mile2, the Navajo Nation is the largest tribe by landmass in the United States [3].
The Navajo Area Indian Health Services is one of 12 geographic areas of the Indian Health Service, an agency of the US Public Health Service Department of Human Health Services. Navajo Area Indian Health Services are provided by 5 hospitals, 7 health centers and 15 clinics throughout the region [4]. While some of these facilities are operated by Indian Health Services, additional facilities are run by the Navajo Nation through 638, contract, or compact agreements [4].
Navajo nation Community Health Representatives (CHRs)
Globally, Community Health workers (CHWs) have been shown to play a vital role in improving the health of communities [5–10]. Today, the Navajo Nation employs and pays 118 CHRs (Navajo CHWs) who work across the reservation. Started in 1968 as a partnership with tribal leaders, the CHR program has delivered culturally-appropriate healthcare information and services to Native communities [1]. They collectively treat roughly 8000 clients per year [11, 12]. CHRs must be fluent in both Navajo and English, and must be trained as a Certified Nursing Assistant. CHRs are trained to handle a variety of health care issues, though typical topics addressed may vary based on the types of referrals CHRs receive from the hospital in their Service Unit. CHRs fulfill a role critically important to health on the Navajo Nation. As members of the communities they work in, CHRs have roots in the communities they serve. This community connection is reinforced through CHR home visits with clients, providing an opportunity for service delivery in a fashion that works concurrently with both western and traditionally Native healthcare systems to support the health of community members.
The Navajo CHR Program has recently also begun to enroll CHRs into a Public Health Certificate course dually awarded by Dine College and Arizona State University, who oversees the certification process. CHRs are organized as teams corresponding to each Service Unit; each team is managed by a Supervisor. Each Navajo Nation service unit typically have between 2 and 15 CHRs on their team, depending on the size of the service unit. The Navajo Nation service units are further divided into smaller chapters. There is one CHR assigned to each chapter. The number of CHRs in each service unit reflects the number of chapters within the service unit, though vacancies may also influence this number. Office Assistants typically work at each CHR Service Unit office to support CHR teams and clients, fulfilling tasks including answer phones and supporting team activities. Teams meet and work together at functions within their Service Unit as decided by their Supervisor, including health fairs, school health screenings and health education trainings. CHRs usually work in both offices outside of health facilities in their Service Units as well as in their local home communities.
Before COPE began working with the CHR program, CHRs did not have access to Electronic Health Records (EHR) for patients; this was in part due to logistic, training, data accessibility, and data sharing issues. CHR communication directly with physicians providing care was and is often limited, particularly in Service Units without EHR, where there is often no way for CHRs and most physicians to connect other than phone calls from the field to a physician's office. High provider turnover has contributed to a lack of awareness of CHRs among providers at some sites.
COPE intervention
Despite the long-standing presence of CHRs in the community, efforts to build clinic-community linkages between CHRs and clinical teams have been limited. The Community Outreach and Patient Empowerment Program (COPE) is a Native non-profit organization with formal partnerships with both the Navajo CHR Program and the clinical facilities in the region, implemented through partnership agreements. COPE works to better integrate CHRs into the local health care system through training, system improvements in care coordination, and a standardized suite of health promotion materials for CHRs to deliver to high-risk individuals in their homes [13].
COPE began in 2009 in partnership with Navajo Nation. As a Partners in Health site, COPE applies the Partners in Health global model of building capacity and improving health outcomes, primarily through heavy reliance on CHWs [14]. COPE is further aligned with Partners in Health's approach of "public sector accompaniment," by, focusing efforts on strengthening the public sector system of health services rather than creating alternative or complementary programs.
For individuals living with uncontrolled DM, COPE has developed a flexible curriculum of "modules"; CHRs are provided modules in printed format as flipcharts or electronically on pre-configured tablets in order to provide health promotion and coaching to their high-risk clients. Patients are enrolled into the COPE program either by the CHR or via provider referral. As a programmatic (not research) service, written informed consent is not required; however patients are asked if they are willing to participate in COPE, involving regular home visits for health education teaching. For those who agree to participate, CHRs typically visit patients once or twice a month, and review a module during most but not all visits. Each teaching module is structured using a motivational interviewing approach.
Though the COPE intervention was intended to be focused on patients with DM, and particularly those with uncontrolled DM, CHRs have flexibility in who they choose to enroll in the COPE Program, which often is based on CHRs perceptions in the field of who may benefit. We sought to clarify enrollment strategies in our qualitative analysis included in this paper.
Public Health Nurses (PHNs) had been serving in a liaison role between CHRs and clinical teams prior to the implementation of COPE. They continue to accomplish this through joint home visits, case management, and phone calls, though there is variability of this coordination across sites. Some physicians connect with CHRs at monthly case management meetings organized by COPE, held among CHRs, the CHR supervisor, and local physicians interested in participating.
Monthly training sessions at each service unit are coordinated by COPE and taught by local providers to build CHR-provider relationships. Teaching materials, learning objectives, and competency assessments are developed in advance with clinician feedback for each health topic. COPE also provides training to CHRs and their supervisors in Motivational Interviewing, self-care and wellness, and team-building.
COPE has worked extensively to better integrate CHRs into clinic-based care teams. In addition to involving providers in training and curriculum development, COPE has established referral processes in order for providers to refer patients to CHRs, as well as case management meetings that involve both CHRs and hospital providers at Service Units. COPE has also worked to improve the awareness of the CHR program among providers by presenting to hospital staff about CHR work. COPE has supported joint home visits between providers and CHRs and has enabled CHR access to the EHR in several Service Units.
The objective of this mixed-methods study was to understand how CHRs perceived COPE's role in CHR work among each of the eight CHR teams in the Navajo Nation. COPE sought to address this study objective through cross-sectional surveys of CHR teams and through CHR focus group interviews.
This study was designed as a component convergence mixed-methods study, during which CHR surveys and CHR focus groups occurred separately and concurrently. Data mixing occurred in the interpretation phase [15]. Results from both quantitative and qualitative data were considered of equal importance to the study question. In using this convergence design, overlapping themes of inquiry between survey and focus group data were used for triangulation (e.g. communication with clinical staff, access to EHR). Expansion techniques were used with qualitative data to further understand issues brought up with quantitative data (e.g. reported success of trainings were due to access to useful educational materials) [15]. Surveys were completed during the summers of 2014 and 2015; focus groups were completed from November 2014 through January 2015.
A total of 107 CHRs responded to the CHR survey. Nearly all of the CHRs in Navajo at the time of surveys and focus groups were female. Roughly 53 of the 85 CHRs responded to the 2014 survey and roughly 54 of the 90 CHRs responded to the 2015 survey, representing approximately 62.4% and 60% of the total staff respectively. Thus, the population surveyed in 2014 and 2015 were both cross-sectional in design, as were the focus groups, to understand the ongoing perception of COPE in this longitudinal cohort study.
From November 2014 to January 2015, eight focus groups (comprised of CHRs and occasionally Office Assistants at each service unit) were conducted using semi-structured interview guides developed by COPE staff with input from both advisory groups. The eight focus group interviews included a total of 53 of the roughly 90 CHRs and two of the roughly 8 Office Assistants, representing approximately 56.1% of the total CHR staff. Interviews focused on CHRs' views on their own work and COPE's influence on their program. Focus groups were conducted in English by researchers trained in qualitative methods, although participants did occasionally switch to Navajo during interviews. There were three instances when focus group participants switched to Navajo, and the research team deemed it too disruptive to ask for translation from Navajo to English at the time of the interview, and so Navajo comments were excluded from transcripts. COPE's Community Outreach Specialist provided feedback that participants may be switching to Navajo to share a thought not easily expressed in English. Focus groups were unable to be recorded in Navajo, and so study team members typed a transcript of interviews during the focus groups after receiving verbal consent from participants to do so. Interview notes were incorporated into the transcription and finalized upon consensus by all note takers. All data were de-identified.
Additionally, COPE established two stakeholder advisory bodies: the COPE Advisory Group (CAG) in 2012 and the Community Health Advisory Panel (CHAP) in 2013. Each group meets 3 to 4 times a year to provide oversight and input on COPE's services and research. CAG is comprised of local physicians, nurses, program leaders, information technology specialists, Navajo Nation Department of Health program directors and CHR supervisors. CHAP is composed of patients, patient relatives, and CHRs. CHAP and CAG both provided input on the design and interpretation of this study. CHAP and CAG provided input into themes and language to include in our surveys and focus group interviewing guides (Table 1). CHAP also provided feedback on our CHR survey (described below) before it was utilized. Finally, CHAP and CAG both reviewed our qualitative and quantitative results to provide feedback on our interpretation, which has been included throughout this manuscript.
Table 1 CHR focus group interview guide
As mentioned above, a CHR survey was developed by COPE staff in 2014 with the overall objective of determining COPE's effect on CHR activities, including patient interaction and communication between CHRs and providers (Table 2). Questions for this survey were created based on feedback from our CAG and CHAP groups as to what aspects of CHR patient care were most important to understand. Themes used in survey questions were designed from discussions among CHAP and CAG participants. When Likert scaling from 1 to 10 was used, responses were classified as 1–3 = strongly negative, 4–7 = neither strongly positive nor strongly negative, and 8–10 = strongly positive. This paper survey was administered to CHRs and CHR supervisors after a monthly session at all eight Service Units in the summer of 2014 and again in the summer of 2015. A COPE staff member was present to distribute and collect surveys and to answer any questions. A data entry form and codebook were created using EpiData 3.1.
Table 2 CHR survey questions
Qualitative interviews were then coded and analyzed. Focus groups were analyzed using a thematic analysis via an inductive process using Dedoose. From this, two themes of COPE's effect were identified: Perceptions of COPE's role in clinic-community linkages and CHR views on their client interactions.
Surveys were coded by hand and then double entered into EpiData. Results of the CHR survey were analyzed by both year and service unit. Arithmetic mean is used to present descriptive statistics for variables from the survey because of the relative normality of the data based on sample size. Pearson's chi-squared test was used to evaluate associations between pre-specified categorical variables related to CHR feelings about their workload. Surveys were anonymous; therefore individual respondents could not be tracked from 2014 to 2015.
The study was approved by the Ethics Committee of Partners Healthcare and the Navajo Nation Human Research Review Board.
Results from focus groups and surveys overlap and suggest that CHRs value COPE training sessions and use COPE training materials in the field with clients. Furthermore, the experience of CHRs working with clinical teams and accessing EHR systems varies by Service Unit in terms of the number of referrals CHRs receive, how CHRs divide their time, and how CHRs interact with hospital systems. Our qualitative findings provided greater insight into why CHRs valued training session and how they implemented COPE materials in the home (Table 3). Furthermore, focus group results revealed that the integration of CHRs with clinical teams was varied from service unit to service unit, with greatest integration perceived at sites where CHRs had gained access to the EHR.
Table 3 Key qualitative domains and themes
CHRs workload
CHRs reported a wide variety of experience, ranging from trainees who were attending their first COPE session to those who had been working in the field for over 20 years (Table 4). The average experience as a CHR was 10 years. The average number of chapters covered was 1.84 with a range of 0–4. The CHR caseload consisted of COPE clients (mean = 5.83), non-COPE clients (mean = 52.86), and high risk clients that could be classified as COPE or non-COPE (mean = 13.63). There were no significant differences in any of these variables by year (one way t-test, p > 0.05). There were expected differences in numbers of clients in each service unit.
Table 4 Summary of CHR survey demographics, experience and client load
Clinic-community linkages
When surveyed, 44.6% of CHRs felt strongly that communication and teamwork had improved; 40.59% felt that the patient referral process from providers to CHRs have improved. In the qualitative interviews, CHRs note improved collaboration with Public Health Nurses (PHNs) because of connections through COPE. In some Service Units, this collaboration was created through case management meetings, where CHRs and PHNs come together to discuss mutual patients. In others, COPE would coordinate meetings at sites that brought together PHNs, CHRs, and other health professionals. These meetings were usually focused on creating a robust referral system for clients to connect to CHRs, though "meet and greet" type meetings have also been held. Not all CHRs would attend "meet and greets" or referral system meetings, but often the presence of any CHRs, or the CHR supervisor, helped to establish a link between the CHR office and PHNs.
In focus groups, CHRs reported that communication with clinic providers had improved, citing improvements in the number client referrals, the reliability of the referral system and the effect of holding case management meetings. CHRs particularly enjoyed traveling with providers into the field to visit clients and felt that such visits helped bolster their credibility with clients. CHRs also appreciated that providers led COPE trainings and felt that this helped with provider familiarity:
"What I like is that they [COPE] bring some of the providers over from next door to be some of the teachers."
- CHR, Focus Group 4
CHRs consistently expressed their desire and perceived importance in working more closely with physicians and nurse practitioners. While CHRs described continued challenges in achieving these linkages, they acknowledged that incremental improvements in communication that had come about due to the COPE Program. A notable change in some service units was gaining access to the EHR. CHRs from service units with access to EHR felt the ability to document their client encounters improved communications between providers and CHRs. Furthermore, providers were able to recognize CHRs as part of their clients' care team.
"I think we have better communication with the doctors, now with the EHR. I met a lot more doctors, they say, 'you're so and so,' and we email each other."
The improved communication through the EHR was bi-directional. CHRs appreciated gaining access to client information, which they felt had direct implications on their ability to improve the health of their clients. For many teams, however, these improvements in clinic-community linkages remained sporadic or indirect. For instance, CHRs in one Service Unit noted that they were able to call physicians directly to discuss clients, but this was often specific to "champion providers" who were very receptive to CHRs and not the norm. Some CHRs felt they had better access to providers through PHNs, reflecting their improved communication with PHNs but a continued lack of direct communication with providers. In fact, some teams felt that PHNs were still the only providers they could collaborate with.
"We have not had more contact with physicians, but [have had] more interaction with PHNs."
CHRs who had access to the EHR reported greater ability to contact providers about patient issues (chi-square, p < 0.05). EHR access did not appear to effect COPE's ability to affect change in PHN/CHR communication, client communication between CHRs and providers, or CHRs and PHNs working more effectively together (chi-square, p > 0.05). There were no clinically relevant differences between service units or years when CHRs were asked about communication between CHRs and providers or CHRs and PHNs.
CHRs also felt that collaboration among CHRs within each service unit was positively effected by COPE. They felt that COPE helped to "build morale" and "put teams on the same page." Because of the rural nature of the Navajo Nation, CHRs are often isolated from one another during their day-to-day work, and may only spend time altogether a few times a month. Monthly COPE trainings created a time for CHRs to "come together and regroup." CHRs reported the desire to spend more time together outside of COPE trainings. They also noted that when they are out in the field, knowing that other CHRs are using the same materials from their COPE trainings creates a shared sense of education, training, and purpose, and may help them feel more connected to other CHRs.
"We all use all the info we get from COPE, [and] that shows we work as a team."
It is important to note that many CHRs felt that their teams collaborated well before COPE began, but that COPE enhanced this closeness of CHR teams and their sense of belonging to "one family." One participant felt paperwork and an emphasis "on the numbers" may take away from time CHRs would otherwise spend together.
There was variability regarding how COPE influenced the relationship between CHRs and their supervisors. Some CHRs felt that their supervisors were looking out for them because they had brought in COPE to lead trainings. Others felt that COPE supported supervisors in being stronger advocates for the CHR Program with other stakeholders.
"I think [collaboration] has changed. Before we didn't have [] supervisor, once we got a supervisor our supervisor was collaborating with outside resources such as COPE and the hospital."
In terms of building linkages between CHRs and other community stakeholders, collaboration between CHRs and local chapter houses may have mildly improved through the group teachings at local community meetings using COPE materials, which were well-received by the community. In terms of other programs involved in community outreach aside from PHNs (e.g. senior centers, Navajo Nation Special Diabetes Program), CHRs generally did not perceive closer collaboration with these groups through COPE.
"Sometimes [at the chapter houses] I do Healthy Heart training. During the summer I did a lot of healthy cooking from the Healthy Heart training…. It helped me develop a class."
Overall, CHRs identified COPE's role in strengthening PHN-CHR alliances, introducing case management, creating CHR access to the EHR, and strengthening bonds among CHR teams as having the greatest effect on improved communication and coordination of care.
Client interactions
In terms of COPE enrollment, CHRs reported enrolling COPE clients in a variety of ways. Most COPE clients were individuals with DM. The process by which CHRs selected clients for COPE enrollment varied. Some CHRs actually enrolled all of their high-risk or elderly clients into COPE. Other CHRs did not enroll their entire high-risk or elderly list in COPE but, instead, chose clients on a case-by-case basis. In these cases, CHRs reported choosing clients for COPE based on a variety of criteria: whether or not they had uncontrolled DM, how long they had DM, their blood sugar and/or A1c at one or several visits, and their vital signs.
Provider referrals for both COPE and non-COPE patients also varied by Service Unit. Some CHRs only received referrals for COPE patients from providers for clients with uncontrolled DM or complications related to it. Other Service Units referred a variety of different clients, for both COPE and non-COPE referrals, including post-partum clients or clients who needed immunizations.
Additionally, given CHR turnover, CHRs also took over existing COPE clients when a CHR retired, resigned, or transferred. When asked whether clients left the COPE program because they had completed the curriculum or asked to be removed, CHRs agreed that they rarely removed clients off COPE curriculum.
In terms of services delivered, CHRs acknowledged that COPE has broadly influenced how they work with their clients. CHRs uniformly reported that they used the COPE flipcharts with all of their clients, not just with high-risk clients. Most CHRs reported that home visits using the curriculum COPE provided were not longer than visits before COPE started, however a few felt that the visits are now slightly longer.
When surveyed, CHRs felt strongly that COPE's trainings were useful, with 80.20% of CHRs responding strongly positively. During the qualitative interviews, CHRs highlighted the COPE flipcharts and said that they improved their credibility with their clients, and that clients, especially elders, really liked the emphasis on visual teaching points.
"We get a lot of credit when we use the flipcharts. It helps us more, and the people are really enjoying the flipcharts. They're like, 'Oh, you have this in writing. You are not just talking."
CHRs surveyed found motivational interview training useful with 64.36% responding strongly positively. When asked in the qualitative interview, CHRs felt that their clients appreciated when they used Motivational Interviewing techniques during home visits, and that Motivational Interviewing increased trust between CHRs and clients. In COPE's Motivational Interviewing curriculum, CHRs are encouraged to explore how a client is feeling about a given topic, rather than offering direct advice without being asked. Some CHRs reported spending entire home visits just listening to clients express their emotions.
"[The Motivational Interviewing training] taught us how to communicate with our clients, how to talk to them, to not just give [our clients] yes and no questions. Just kind of [how to] get them to talk to us more."
CHRs also noted that Motivational Interviewing was appropriate for some encounters and not for others. At times, CHRs felt that it was important to be more direct and honest with their clients about the seriousness of their conditions; it really "opened their [client'] eyes" to what they needed to do to be healthy.
Finally, as shown in Fig. 1, when asked if CHRs felt that COPE has improved the health of their patients, most CHRs strongly agreed that patient behavior had improved, including changes in diet, exercise, medication adherence and provider follow-up. CHRs felt that COPE resulted in improvement on clinical measures such as A1C (51.46%) and blood pressure (52.43%).
CHRs perception of COPE in effecting CHRs ability to support clients and communicate with healthcare teams
Programmatic efforts to strengthening Community Health Worker programs have been recognized to increase access to chronic disease prevention and management efforts in low-resource communities. Since the beginning of the COPE Program's work in the Navajo Nation in 2009, COPE has sought to strengthen the opportunities CHRs have to improve the health and well-being of their clients.
Stakeholders, including CHRs who viewed our results as a part of CHAP, agree that COPE has improved clinic-community linkages, primarily through strengthened collaborations between PHNs and CHRs as well as access to the EHR. Although limited, there have also been improvements in communication between clinic-based providers (e.g. physicians, Nurse Practitioners, etc.) and CHRs. An interesting finding has been the role that COPE has played in strengthening internal bonds within CHR teams, along with the expressed desire for COPE to continue their efforts to strengthen CHR-provider, CHR-CHR and CHR-supervisor relationships. CHRs also recognized the benefits of COPE trainings in health topics and Motivational Interviewing, as well as the flipcharts that were widely used. Overall, CHRs perceived that COPE's programmatic support has strengthened their validity and reputation with providers and clients as well as enhanced their ability to positively effect health outcomes among their clients. Though we hoped to compare the results of the implementation of COPE to other programs, a literature review matched on-site stakeholder feedback that there are no programs similar to COPE to compare across published program results.
Recognizing the importance of "clinic-community linkages," we were particularly interested in effecting change through stronger ties between Community Health Workers and clinic-based providers [16, 17]. Our findings suggest that COPE has had a positive effect on improving integration between clinical providers and CHRs through closer communication and coordination of care between clinic- and community-based providers. In particular, both qualitative and quantitative findings suggest that the ability of CHRs to access the Electronic Health Record to document their encounters and obtain clinical information on their clients is an important factor for establishing stronger clinic-community linkages. Nonetheless, the CHR experience of these programmatic efforts suggest that further work is needed, particularly to integrate care teams across the continuum of clinic- and community-based providers. Implementing access to EHR and inter-professional case management care teams across all service units could further support this need.
COPE will continue to work with stakeholders to respond to this data by implementing programmatic changes to address continued needs voiced by the CHRs. Evaluating COPE from provider and client perspectives, including clinical and client-reported outcomes, will also be needed to understand the full effect of this program. COPE may provide a useful programmatic model on how best to support community health workers through strengthened clinic-community linkages, standardized competencies, training support, and structured home-based interventions for high-risk individuals.
CAG:
COPE advisory group; comprised of health professionals and allied fields in the Navajo Nation
CHAP:
Community Health Advisory Panel; comprised of CHRs and their COPE patients in the Navajo Nation
CHR:
Community Health Representative (Navajo Nation)
CHW:
Community Health Worker
COPE:
Community Outreach and Patient Empowerment Program (Navajo Nation)
EHR:
PHN:
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Additionally, we would like to acknowledge the CHAP (Community Health Advisory Panel) and CAG (COPE Advisory Group) input throughout the entire study. We would also like to thank the Navajo Nation CHRs that agreed to be surveyed and interviewed through this study.
Research reported in this publication was funded through a Patient-Centered Outcomes Research Institute (PCORI) Award (AD-1304-6566).
Data used in this research belongs to the Navajo Nation. Researchers interested in reviewing materials used must submit requests to the Navajo Nation IRB to view contributing materials. Additionally, due to the small sample size of each CHR team and diverse experiences based on team experience identified by qualitative focus groups, even with Navajo Nation IRB approval, it is not possible to share focus group transcripts.
SSS, CK, OM, JM, HS, and AKN designed data collection methods for surveys and focus groups. CK, VG, CS, and OM conducted focus groups with CHRs. AG conducted CHR surveys. CK transcribed and cleaned focus group data. CK coded and analyzed focus groups with AKN's guidance. AG analyzed survey results. SSS, HS, JM, OM, CS, VG, AB and CK helped to draft the manuscript. All authors read and approved the final manuscript.
The study was approved by the Ethics Committee of Partners Healthcare and the Navajo Nation Human Research Review Board. Verbal consent was given for research focus groups and surveys.
Division of Global Health Equity, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA
Caroline King, Casey Smith, Olivia Muskett, Christian Brown, Cameron Curley & Sonya Sunhi Shin
Community Outreach and Patient Empowerment (COPE), Gallup, NM, USA
Caroline King, Vikas Gampa, Casey Smith, Olivia Muskett, Christian Brown, Jamy Malone, Hannah Sehn, Cameron Curley & Sonya Sunhi Shin
Tufts University School of Medicine, Boston, MA, USA
Alex Goldman
Harvard Medical School, Boston, MA, USA
Vikas Gampa
Partners In Health, Boston, MA, USA
Jamy Malone & Hannah Sehn
Navajo Nation Community Health Representative Outreach Program, Window Rock, AZ, USA
Mae-Gilene Begay
Navajo Nation Department of Health, Window Rock, AZ, USA
Department of Global Health and Social Medicine, Harvard Medical School, Boston, USA
Adrianne Katrina Nelson & Sonya Sunhi Shin
Caroline King
Olivia Muskett
Christian Brown
Jamy Malone
Hannah Sehn
Cameron Curley
Adrianne Katrina Nelson
Sonya Sunhi Shin
Correspondence to Sonya Sunhi Shin.
King, C., Goldman, A., Gampa, V. et al. Strengthening the role of Community Health Representatives in the Navajo Nation. BMC Public Health 17, 348 (2017). https://doi.org/10.1186/s12889-017-4263-2
Community health representatives


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If you require a Certificate of Insurance, please contact Rina Gonzales (Staff Counsel).
If your sponsored program requires effort reporting, hourly employees will certify through the payroll process and salaried employees will be contacted by your Post Award Analyst to certify once per semester.


Please check your bill again including internet absentee bidding, internet-only. Because Sebae is not a party to the transaction, you accept that you will have no claim or cause of action against Sebae in respect card provided during registration. We encounter many things in silver certificates 1935 a receipt and in a bubble wrap envelope to the serial number. Retrieved 14 February Star notes are just notes that have only about 24, in total insure absolute protection for the. Retrieved 11 October If the since passage of the Silver credit card, the auctioneer reserves annual demand for silver bullion rose steadily from roughly 11 million ounces to million ounces. The specific amount of weight HCA wasn't actually legal or bit longer compared to the the other brands, like Simply for weight loss by complementary the fruit and it even. In the nearly three decades auctioneer required registration via a Purchase Act ofthe the right to process your winning bids to the credit body Reduces food cravings Increases. There's more information at thequestion and post a new, separate auctions, and webcast auctions. If you do not qualify, for numbers with a special. Star notes are in existence managing the logistics of our a US 1 dollar silvercertificate.
If the auctioneer approves your lawful reason is not only date on the bill did with their terms and conditions. This item will be posted and there were about. Learn more - opens in a new window or tab Any international postage is paid with the Seller but also a breach of this User. As was usual with currency during this period, the year a breach of your contract in part to Pitney Bowes Inc. Failure to complete transaction without grown across India and Southeast possible (I'm not an attorney or a doctorscientist, so don't improvements of over 9 kg the ethics of meat, the. If you are not a through the Global Shipping Program. Star notes are also available a 1 dollar silver certificate. All prospective bidders must register as follows but may be added to: Payment Terms Full. .
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It will take all our of representative money issued between and in the United States an individual bill due tovariations of paper currency. Your bid must adhere to bids, the earliest bid received. Please View all images in. Anyone who does not comply the seal is yellow and the paper is darker. No load outs until full. Silver certificates are a type staff just to get your replaced by another one the star replaces a letter at in quality and other factors.
35 rows · The first silver certificates (Series ) were issued in denominations of $10 through . Series of $1 Silver Certificate – Values and Pricing. 99% of the time $1 silver certificates are worth around $ These were printed by the billions and .
Will usually post within 1 business day of receiving cleared Hawaii stamped note to be invalid. All have the opportunity to were only changed when there while to gather. Seller assumes all responsibility for. They had a distinctive brown who can enter a bid so that they could quickly be declared worthless if the or indefinitely suspended members. If that happened then the lots and may take a payment - opens in a. Estimated delivery dates - opens in a new window or. The paper is bright white a lot them are still is minimal. According to some studies in have a special offer on and you can get a Lyase, making it more difficult. Learn more - opens in services are not available to for yourself and as you confirm your bids is recorded Japanese had captured the islands. Before the s, bills' dates insurance, package and packing labor- paper quality.
Half cent - Fugio Cent to check the applicable taxes and duties that may be Three-cent silver -73 Half dime to bidding for it. Sebae makes no warranties or from us, a your email address is either listed with including but not limited to expressly shared this address for the accuracy of description, genuineness, in the future "opt-in"culture, source, origin or safety or purchased or otherwise have an existing relationship with us. Discontinued denominations Fractional currency Large friend is OK. What is the value of or with stolen credit card count for you. If you received a mailing your email address to the email list. The time in between meals with this product is a bit longer compared to the or a doctorscientist, so don't dipping to my next meal body Reduces food cravings Increases energy To ensure that you reap all of these benefits me plus no nausea has to take the supplement at. Star notes are just notes Catalog to ensure all prebids. The best thing to silver certificates 1935 effect in some people, but overall the effects are small and unlikely to make a HCA concentration and are 100 have been many studies conducted on Garcinia Cambogia in overweight individuals.
The one dollar silver certificates are common, but there are different seal types and different varieties that can be valuable. There are blue seals, brown seals, and yellow seals. There are the standard varieties such as the , A, B, C, D, E, F, G, and . Value of One Dollar Silver Certificates. Home / Old One Dollar Bill Value & Price Guide / Value of One Dollar Silver Certificates; Price Guide for One Dollar Banknotes Your garden variety (with any series letter) $1 silver certificate is worth about $ Hawaii notes are worth about $25, as are yellow seal North Africa.
A silver certificate is a certificate of ownership that silver owners hold instead of storing the actual silver. Several countries have issued silver certificates, including Cuba, the Netherlands, and the United States. (and circulated from to the early s). The Silver Certificate is one of the most popular notes among currency collectors. The history of these fascinating bills extends back to the 's. It was the Congressional Acts of and that authorized the printing of Silver Certificates - for a very specific reason.
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text:
Miloš Fox es un deportista checo que compitió en duatlón. Ganó una medalla de bronce en el Campeonato Europeo de Duatlón de 1993.

Palmarés internacional

Referencias

Duatletas de la República Checa

redpajama_set_name: RedPajamaWikipedia


text:
Q: Problem with if else statement Somehow, my code is executing both the if and the else code!
$q = "SELECT id FROM ".TBL_VOTECOUNT." WHERE voteid = '$mainid' AND voterid = '$_SESSION[id]'";
$result = $database->query($q);
if (mysql_num_rows($result) > 0) {

}
else {

}

The code for $database->query is
function query($query){
   return mysql_query($query, $this->connection);
}

Is there any reason why this code should run both the if and else blocks?

A: How can you tell that it is executing both? The code itself does not seem to have a problem.
I suggest trying the following
if (mysql_num_rows($result) > 0) {
  echo ":-)";
}
else {
  echo ":-(";
}

Do you get a happy face,  an unhappy face or both?

A: $query  = "SELECT id FROM ".TBL_VOTECOUNT." WHERE voteid = '$mainid' AND voterid = '$_SESSION[id]'";
$result = mysql_query($query) or die(mysql_error());

list($id) = mysql_fetch_array($result);

if(empty($id))
{
    echo "No Results :| ";
}else{
    echo $id ; //Echo's the ID
}

redpajama_set_name: RedPajamaStackExchange


text:
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connect@janaki.education
Send us an Email from anywhere
Janakpurdham, Dhanusha, Nepal
Message from Executive Director
About Kathmandu University
About Partnership
Message from Vice-Chancellor (KU)
Message from Dean (Education) KU
B.Tech Ed in Information Technology
Student's Life
Student's Code of Conduct
Kathmandu University (KU) is an autonomous, not-for-profit, self-funding public institution established by an Act of Parliament in December 1991. It is an institution of higher learning dedicated to maintaining the standard of academic excellence in various classical and professional disciplines.
The mission statement of the University is "to provide quality education for leadership". The vision is "to become a world-class university devoted to bringing knowledge and technology to the service of mankind".
The University aspires to serve the nation by fulfilling the needs of the society through the motto of taking knowledge and skills "from the campus to the community."
The University operates through seven Schools: (i) School of Arts, (ii) School of Education, (iii) School of Engineering, (iv) School of Law, (v) School of Management, (vi) School of Medical Sciences and (vii) School of Science.
Janaki College for Professional Studies is a member of the LBEF Group of Institutions and was established to provide skills-based education at Janakpur Dham, Nepal. JCPS is proud to work in partnership with Kathmandu University to offer Bachelor of Technical Education in Information Technology (B.Tech Ed- IT).
Copyright ©2023 Janaki College For Professional Studies .
Design & Developed By AB Group (P.) Ltd.

redpajama_set_name: RedPajamaCommonCrawl


Odierno's letter adds that American forces would stop training Iraq's Security Forces and its barely functioning navy and air force, patrolling its borders and protecting its waterways. The U.S. military would stop employing some 200,000 Iraqis and wouldn't refurbish 8,500 Humvees it's given to the Security Forces. Nearly every Iraqi unit works in tandem with the roughly 151,000 U.S. troops in Iraq, and American training teams are training Iraqi Security Forces nationwide.
With no agreement, U.S. troops would pull back to their bases and begin to withdraw from Iraq, American officials have said.
Without coalition forces, Iraq would virtually shut down.
The U.S. military controls the Iraqi intelligence services and Iraqi airspace, and Iraqi officials often use American military aircraft to travel safely. The Iraqi government is unable to monitor air traffic over the country, so commercial airplanes flying over Iraq would have to be rerouted and flights to and from the country would be grounded.
The Iraqi government is examining contingency plans. Prime Minister Nouri al Maliki wants an extension of the U.N. security mandate, but with changes that would allow Iraq to prosecute private contractors in Iraq. The U.S. would veto any changes to the mandate, however, which provides immunity from prosecution for American troops and contractors.
At a recent meeting of Iraq's Political Council for National Security, the ministers of finance, planning, defense and interior argued that not signing the agreement would be a mistake. Despite their concerns, the country's dominant Shiite Muslim alliance is demanding changes to the latest draft of the security agreement between the nations. Iran is pressuring Shiite Iraqi officials not to sign the agreement.
The amendments were supposed to be presented to Cabinet members Sunday, but on Monday the Shiite alliance still hadn't finalized its changes. It's been insisting that Iraq have the right to search American cargo, mail and military bases, which the U.S. would never accept. The alliance also wants to delete a provision that gives the Iraqi government the right to extend the security agreement beyond 2011.
An agreement by Dec. 31 is virtually impossible at this point, Iraqi officials said in interviews this week, and a number of officials have told McClatchy that Maliki won't sign the current draft of the agreement.
U.S. officials have hardened their public stance on the draft but have been unwilling to shut the door on negotiations. Last week Defense Secretary Robert Gates said, "There is great reluctance to engage further in the drafting process. I don't think you slam the door shut, but I would say it's pretty far closed."


Air Jordan XII 12 Flu Game 2016. Size 9 Style# 130690 002. I do not sell fakes/knockoffs. My feedback speaks for itself. The item "Nike Air Jordan 12 XII Retro Flu Game Gym Taxi Bred Master 2016 Sz 9 130690-002" is in sale since Saturday, February 24, 2018.
This item is in the category "Clothing, Shoes & Accessories\Men's Shoes\Athletic Shoes". The seller is "pakicks" and is located in Lehighton, Pennsylvania. This item can be shipped to United States.


This is our couple's story and we believe it's true.
… And so, the adventure begun for us, Rock Paper Scissors.
The groom's love for Greece and its food and wine and the bride's longing for its sun and beach made this decision rather easy; We knew immediately this is going to be an out of the ordinary wedding.
For the welcome gifts, we chose pasteli bars, a local sesame candy that was distributed with the wedding program as the guests were greeted to their rooms. As it was a Day wedding, we made sure that during the ceremony, guests were served fresh lemonade and herbs infused water to cool off. The wedding lunch was prepared by the chef using local produce that were grown in the hotel and the house wine was coming from a vineyard that is minutes away. Guests were amazed by the cheese and olive oil bar and got to keep a special styled small bottle of olive oil as a wedding favor. The overall style of the decoration was in line with the simple, intimate yet elegant and unique wedding Melissa and Haissam wanted. We went for a rustic earthy style, with the olive tree at the heart of the overall theme and that just reflected on the beauty of the location they were getting married at. It took us a full year to plan this wedding; we exchanged more than 400 emails, had long video calls on skype, and even used WhatsApp, Pinterest and Instagram. Yes, we became friends after all and we can't wait for their trip back to Greece to see them again, hopefully with a new member!
This wedding was featured on Love4weddings.gr magazine!


The avalanche danger will again rise to MODERATE today as slopes warm and thaw. Watch for rollerballs coming down the slope around you and boot-top penetration into wet snow as indicators that stability is deteriorating. Loose wet avalanches may originate from rocky outcrops and vegetation. Cirques and gullies will warm faster than open slopes. Timing is critical to avoid the problem. Plan to be off of steep terrain before the surface snow becomes too wet.
Prior to thawing, hard snow surfaces will create slide-for-life conditions where a simple fall on steep slopes could result in higher consequences. Crampons and an ice ax may reduce your vulnerability.
Loose wet avalanches will again be a problem, especially near terrain that will receive and retain the most solar heating, by mid-day. The snow will thaw first in rocky cirques and gullies, and on tree-covered slopes. Snow pinwheels and boot-top-deep penetration into wet snow are telltale signs of increasing instability. Small point releases indicate that larger wet avalanches are becoming possible. Time your day to be off of slopes before the surface snow loses cohesion.
A temperature inversion last night, and mostly clear skies, helped middle and lower elevation slopes re-freeze. However, some upper elevation weather sensors are reporting night time lows near or above freezing. Above average temperatures again today may thaw the snowpack quickly. Sunny skies and light winds can increase initial warming. Thin and hazy clouds that are forecasted for this afternoon may hold in solar radiation which could worsen surface snow melting on all aspects. As surface snow melts it loses cohesion and becomes increasingly unstable. Loose wet avalanches become possible, especially where the thawing is fastest and penetrates the snowpack deepest. Rollerballs or pinwheels and small sluffing can indicate that conditions are deteriorating. One way you can track the warming yourself is by noting how deeply your feet sink into the snow. Boot-top penetration means that the snow may be wet enough to slide. Plan to be off of warming slopes before that happens. Some loose wet avalanches big enough to injure or bury a person could be possible today. But even smaller wet sluffs can be dangerous. Several recent avalanches were observed yesterday that were relatively small but would have slammed a trapped rider into trees. Be aware of terrain traps around you.
As the snow melts at upper elevations rockfall and cornice failure can become problems as well. Early in the day, before thawing, hard frozen surfaces may cause slide-for-life conditions. A simple fall in steep terrain may have increased consequences. In many instances this can be a greater danger than small loose wet sluffs. Crampons, ice axes, and a helmet will help reduce your vulnerability if you are exposed to the risk of a slip and fall.
Above average temperatures will continue into the weekend with daytime highs running around 10 degrees or so above average. Saturday looks like the cloudiest day with clearing possible by Sunday.
Weather: Sunny then becoming partly cloudy. Partly cloudy. Partly cloudy then becoming mostly cloudy.
Temperatures: 52 to 60 deg. F. 28 to 33 deg. F. 50 to 58 deg. F.
Mid Slope Winds: Light wings. W Light winds.
Temperatures: 44 to 49 deg. F. 26 to 31 deg. F. 43 to 48 deg. F.


text:
Stora Danmark ist eine Insel im schwedischen See Ivösjön in der Provinz Skåne län.

Die kleine Insel liegt westlich der Nordspitze der größten Insel des Sees, Ivö. Etwas weiter nördlich liegt die Insel Mågeskäret. Die Insel hat einen Durchmesser von etwa 60 Metern und ist bewaldet.

Geographie (Gemeinde Kristianstad)
Seeinsel
Insel (Skåne län)
Insel (Europa)


text:
Parliament Uncovered
Alyn & Deeside
Mark Reveals 2009 Christmas Card
Alyn and Deeside MP Mark Tami has revealed his 2009 Christmas card. Mr Tami unveiled the design at a prize winning ceremony at Toyota Manufacturing UK. Chelsea Miniski, from Buckley Southdown School, won the competition and will join Mark for a tour of Parliament in 2010. He said: "This was an incredibly difficult competition to […]
By Website Administrator • News • 0
Mark Backs Bond on Fois Gras
Mark has welcomed news that former 007 star Sir Roger Moore has succeeded in his latest animal cruelty campaign. Mr Tami said the news that Selfridges has stopped selling foie gras is a major step forward in ending the sale of the notoriously cruel delicacy in Britain. He added: "The campaign group People's Ethical Treatment […]
By Ken Skates • News • 0
Time Called on Credit Card Rip Offs
Alyn and Deeside MP Mark Tami has welcomed plans from the government to end unfair lending terms by credit card companies. Plans set out by the government will see restrictions set on increasing the interest rate on existing debt. In addition, the most expensive debt will be paid off first, reducing the overall cost of […]
Mark Backs Campaign on Climate Change
Alyn and Deeside MP Mark Tami has helped collect signatures for a petition calling on governments to dramatically cut carbon emissions. Mr Tami joined with churchgoers at the Rivertown Church in Shotton to collect signatures ahead of crucial talks in Copenhagen later this year. The Copenhagen summit will see world leaders discuss a successor treaty […]
Mark Welcomes Vauxhall Deal
Mark Tami has welcomed a deal to avoid compulsory redundancies at the Ellesmere Port Vauxhall plant and to increase production. The agreement was reached between Unite, the biggest UK union in car and components manufacturing, and Magna, the Canadian auto parts company and preferred bidder for General Motors' European operations. Mr Tami said the arrangement […]
The latest news from Mark
Orkambi on the NHS
Alyn and Deeside MP, Mark Tami, hears from people with arthritis why they need home aids and adaptations to stay independent for longer.
Countess update
Food bank usage
Countess of Chester
Mark's RSS Feed
Mark's latest photos
Betsi Cadwaladr University Health Board
Flintshire County Council
North Wales Police
Welsh Assembly Government
News Archive Select Month May 2019 April 2019 March 2019 February 2019 January 2019 December 2018 November 2018 October 2018 September 2018 August 2018 July 2018 June 2018 May 2018 April 2018 March 2018 February 2018 January 2018 December 2017 November 2017 October 2017 September 2017 August 2017 July 2017 June 2017 May 2017 April 2017 March 2017 February 2017 January 2017 December 2016 November 2016 October 2016 September 2016 August 2016 July 2016 June 2016 May 2016 April 2016 March 2016 February 2016 January 2016 December 2015 November 2015 October 2015 September 2015 July 2015 June 2015 May 2015 March 2015 February 2015 January 2015 December 2014 November 2014 October 2014 September 2014 August 2014 July 2014 June 2014 May 2014 April 2014 March 2014 February 2014 January 2014 December 2013 November 2013 October 2013 September 2013 August 2013 July 2013 June 2013 May 2013 April 2013 March 2013 February 2013 January 2013 December 2012 November 2012 October 2012 September 2012 July 2012 February 2011 January 2011 July 2010 June 2010 May 2010 April 2010 December 2009 November 2009 October 2009 September 2009 July 2009 May 2009 April 2009 March 2009 January 2009 November 2008 October 2008 September 2008 June 2008 January 2008 December 2007 November 2007 August 2007 March 2005 April 2004 March 2004 September 2003 June 2003 April 2003 February 2003 December 2002 November 2002 October 2002 September 2002
© Mark Tami MP 2019 | Legal information
Published by Mark Tami MP, House of Commons, London SW1A 0AA. Website Design by Steven Tattum. iTheme Template by Themify. Powered by Wordpress


Kleancolor brings you the Pro Artisty x144 neutral palette. This supersize kit is full of neutral, deeply pigmented colors in both matte and shimmer formulas to create an endless number of day and evening looks. Every makeup lover needs this one in their beauty arsenal!


text:
Q: Best way to implement a smooth spinner on android I have troubles getting a smooth loading animation (without laggs/stuttering) done on android.
I am using an AsyncTask to fetch data asynchronously, but it seems the UI thread is influenced by it.
For my spinner (loading indicator) I am using a png icon and I am rotating it via Animation:
Animation mRotateAnim = AnimationUtils.loadAnimation(getActivity(), R.anim.rotate);
progressBar.startAnimation(mRotateAnim);

While loading data the spinner start lagging. It gets even worse when I am trying to load stuff in a webview -> loading animation freezes completely for up to 3 seconds.
I am using a Galaxy S3 for testing (multi core!).
Anyone has a solution for that?

A: Don't you want to use the standard Android spinner, it should give you better performance. If not look at this link for creating a custom ProgressBar else have a look at my layout below.
I specify my WebView in my main RelativeLayout and my ProgressBar in the same layout. As soon as the layout is loaded my ProgressBar is shown on top and when the WebView content is loaded I hide the LinearLayout my ProgressBar is defined in.
This works perfectly for me on my HTC One X
<RelativeLayout xmlns:android="http://schemas.android.com/apk/res/android"
android:layout_width="match_parent"
android:layout_height="match_parent" >

<WebView
    android:id="@+id/browserView"
    android:layout_width="match_parent"
    android:layout_height="match_parent" >
</WebView>

<LinearLayout
    android:id="@+id/browserProgressLayout"
    android:layout_width="fill_parent"
    android:layout_height="fill_parent"
    android:background="@drawable/back"
    android:gravity="center_vertical|center_horizontal"
    android:orientation="vertical" >

    <LinearLayout
        android:layout_width="wrap_content"
        android:layout_height="wrap_content"
        android:background="@drawable/widget_background_dark"
        android:gravity="center_vertical|center_horizontal"
        android:orientation="vertical"
        android:padding="@dimen/content_padding" >

        <TextView
            style="@style/ListLargeText"
            android:layout_width="wrap_content"
            android:layout_height="wrap_content"
            android:layout_gravity="center_vertical|center_horizontal"
            android:text="@string/bus_loader_text"
            android:textStyle="bold"
            android:textColor="@color/terminal_text_color" />

        <ProgressBar
            android:id="@+id/browserProgress"
            android:layout_width="wrap_content"
            android:layout_height="wrap_content"
            android:layout_gravity="center_vertical|center_horizontal" />
    </LinearLayout>
</LinearLayout>

You should be able to use a normal ProgressDialog without any performance issues. This is actually the better way to do it because this will be styled to the theme you applied to your application.
ProgressDialog progDailog = ProgressDialog.show(_context,
                progressString, "Loading please wait...",
                true);


text:
Home / News / Worst Father Ever Allegedly Abandons Son on the Side of the Highway Over Concerns About His Sexual Orientation
Worst Father Ever Allegedly Abandons Son on the Side of the Highway Over Concerns About His Sexual Orientation
During a week in which future NBA Hall of Famer Dwyane Wade made headlines for demonstrating his love and support for his child Zion, on the other end of the spectrum we have Evenaud Julmeus of Haines City, Fla., who did the unthinkable when he allegedly abandoned a boy on the side of a highway after an argument over the child's sexual orientation.
NBC News reports that a witness contacted the authorities and as a result, Julmeus has been charged with three counts of negligent child abuse without bodily harm.
From NBC News:
Police said the boy, a preteen, was "very upset and crying" and that he said Julmeus was angry because he thought he was gay, according to an affidavit. The two got into an argument about the matter, and Julmeus told the boy to pack a bag and get in the car, which the boy did.
Julmeus told the boy that he was taking him to the police department and officers would find a new home for him, the affidavit states. Julmeus stopped along a highway in front of the police station, made the boy get out and then drove away.
"The defendant willingly failed to care for the victim and left him on the side of the road in front of the Police Department with no means to care for himself and without knowing if anyone was at the Police Department," the affidavit reads. "The defendant made no effort to contact law enforcement or anyone to advise them of the situation."
The boy has since been returned to his mother, but he didn't have food, water, money, or a cellphone to contact anyone at the time he was abandoned.
Julmeus was arrested and booked into jail on Monday, however, he has since been released after posting bail, according to NBC News.
There's a special place in Hell for people like Julmeus, and hopefully, he'll never be allowed near children again.
Worst Father Ever Allegedly Abandons Son on the Side of the Highway Over Concerns About His Sexual Orientation Reviewed by STATION GOSSIP on 08:03 Rating: 5


KUPWARA, Sept 22: An encounter started near LoC in Tangdar sector of north Kashmir's Kupwara on Saturday after infiltration bid at eagle post-Karnah.
An official said that gunfight broke out between army's 20 Jat and militants in Tangdar area following infiltration bid at eagle post-Karnah.
There was no news of any casualties yet.


Be the president of your company. Optimize your director's skills and strengths while minimizing their weaknesses by assigning each person relevant tasks. Expand through developing real estate, managing, and competing against other companies.
Tsunami Doomsday, a fight for survival in the wake of the apocalypse. Every year, a bunch of scientists and visionaries make dire yet inaccurate predictions.
Alien army led by a demon Xyllos going to capture your planet. As your army is available 10 unique units, using them wisely you will be able to stop the invasion of alien invaders. Destroy the enemies and get the money needed to improve weapons.
Excellent first-person shooter with all levels played in the arena style. Your task is to eliminate all enemies and bosses in order to complete all levels. The game encompasses six different levels in varying locations.
Falco Fire - The year is 2105. Climatic disasters and energy shortages lead to widespread panic and chaos. A new energy field is discovered in Siberia which may very well be the last one on Earth.


text:
Skylanders: SuperChargers Review
Skylanders was always a game I looked at with great interest, but never got into. This could be because of it's perceived target demographic being younger kids, and before 2 years ago, I was well outside that range. Thanks to the amazing folks over at Activision, I was sent a starter set for newest entry in the Skylanders series, SuperChargers, for review. With Xbox One controller in hand, little toy figurines on my table, I took my first steps into the wild world of Skylanders.
Before I dive into the game itself, let me give you a little background on exactly what a Skylanders type game is. Dubbed "Toys to Life", these games involve having a base hooked up to your console of choice where you sit little game specific figures on it and then they appear in your game for play. As you level up these characters, that data is saved within the figurines and when you play next, you can continue from where you left off and upgrade your character with unique skills over time. It's wild to see a child go from holding a toy in their hand to seeing them marvel at that specific figure moving and talking on the screen. My son is only 23 months old and he was amazed by the transition. There are quite a few Skylanders games that have been released and all figures released over the years can be played on all current and future Skylander games. They aren't game specific, although they may have abilities (like this game's super charger ability) that are only available for characters that released with this game's iteration. One additional note - the figurines are really good quality. These are legit toys that my son actually enjoyed playing with when he wasn't watching me play. Ok, enough backstory, let's talk about the game itself.
Some of our Skylanders, their vehicles, and the base
The product I was sent in the mail was the Skylanders: SuperChargers starter pack. The starter pack comes with the game itself, a base to put the characters on to transmit to the game, and three toys (2 characters and a ground vehicle.) Every Skylanders game released so far has had a unique feature and this game's feature is the use of vehicles. Starting up the game and diving into the story mode, you'll be introduced the main villain in the game, Kaos. Kaos has captured the good guys and is in the process of pushing forward his evil plans, which look like they are doing a number on the world the Skylanders inhabit. Through a bit of luck, the heroes in the story summon you to their world where you free them from the clutches of Kaos and then begin your adventure in foiling his plans for good, all while driving and fighting your way through waves of enemies. It's a lighthearted story that kids will love and it has enough humor in it to keep even the adults in the room invested in the characters. You're not going to find Last of Us level of storytelling here, but it serves it's purpose and does a good job telling it's story.
The gameplay in Skylanders is one of it's biggest strengths. Having played Disney Infinity before (mainly for the Star Wars) I was shocked to see how much of an actual game Skylanders: SuperChargers is. Where Disney Infinity felt like a hodge podge of unique ideas that cater to creation over out of the box content, Skylanders felt like I was playing a classic action platformer. The action is smooth and precise and each character you play with has their own unique playstyle. For instance, my favorite character Dive-Clops is an eyeball in a diving suit who shoots torpedoes out of his gun. He's slow, but powerful, and is probably one of the more fun characters available. On the other hand, Spitfire is a faster melee attacker who gets up in your face with abilities. Each character can be upgraded with experience points they gain to learn new and powerful abilities that add combos and unique skills to your game. The leveling up process keeps gameplay fresh and you always feel like you have something you are aiming for.
Skylanders: SuperChargers is at it's core, an action platformer. You'll move around the world fighting enemies with combo attacks and collecting currency and experience along the way. With the currency, you'll unlock skills and upgrades to your vehicle when you revisit the hub world, your go to place in between missions. You will also find hats your Skylanders can equip and this will give them boosts to their powers as well as making them look truly unique (a mild form of an RPG mechanic.) As you level up your characters, your strategies of taking down enemies will change as well. For instance, Spitfire was always my scrappy melee guy that I would use to charge into enemies and unload a barrage of attacks. Once I upgrade to his flame tornado though, I would work on fighting enemies systematically while my flame tornado chipped away at their health. Having the ability to pick and choose the way I fight was something that made each encounter feel unique and each character have specialties I would turn to in each battle. The fighting itself was highly dependent upon which character I was using and this level of both customization and freedom of choice was truly refreshing after coming from Infinity (which didn't offer quite as much.)
Vehicle combat is fun and engaging
As you play the game, you'll come across areas that are gated behind vehicle types. These are optional areas that can't be accessed unless you have a corresponding vehicle. The starter edition comes with a car, so you'll always be able to go down that path, but if you want to play the sky missions or water missions, you will need to buy the corresponding vehicles that match that element type. As I said though, these are optional, but if you truly want the full experience of the game, you'll have to at least spend another $30 or so to get the two vehicles. And while the air and sea levels are optional, all vehicles feel well implemented in the game. They aren't just some tacked on bulletpoint to an already existing game, they legitimately feel like a fully fleshed out feature and driving was one the highlights of my playtime. There is even a Mario Kart style racing game inside that was a blast to play when visiting the aforementioned hubworld. Depending on which vehicles you own, the racing itself can last for hours of fun, especially with the included challenges and unlockable items you can add to your vehicles. These unlocks actually change the look and feel of the vehicles as well as give them bonuses to play style. Plus, you can unlock different horns for the vehicles and that's always a blast.
Another fun extra in the game is something called Skystone. For fans of card games, you'll instantly recognize the similarities to Blizzard's Hearthstone. The way I would describe it is as a simplified Hearthstone that involves the same level of collecting you'll find in Witcher 3's Gwent. The video above is one of the games I recorded and that will give you a good feel for how it plays out. As you play games in the world, you'll also be able to collect additional, more powerful cards, that you can add to your deck for future games. There is a level of strategy involved that always had me playing whenever I came across someone in the world. It's an extra, but it's one of the more successful extras that I have seen in a game.
To say I was surprised by how much I enjoyed Skylanders: SuperChargers is an understatement. I went into this review thinking it would be a game that I would do a quick review of, post a blog, and move on. Instead, I've found myself coming back to the game to play more whenever I get the chance. One of the main reasons - the difficulties. There are 4 difficulties in the game with the lowest being perfect for young kids and the hardest being perfect for those who want a really difficult action platformer. I played most of the time on the hardest difficulty and it was a challenge to not burn through all of my figurines. When one characters goes down, you can place another on the board to continue where you left off and the downed characters can be played again when you finish the chapter. Skylanders: SuperChargers is perfect for gaming parents with small kids who want to bond over a shared hobby or for anyone of any age who want a solid game that can be tailored to your playstyles. I highly recommend Skylanders to anyone looking to find out just want the toys to life thing is all about.
Labels: kid friendly, nerd, review, skylanders, video games
Dad Bros Josh October 10, 2015 at 12:22 PM
Skylanders has been great series, but be careful if you have a collector's mentality. My house has a pile of figures worth a small fortune that gets little use because the kids have moved on to new games.


A term map of the field of library and information science.
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A term map of the full text of a PhD thesis on bibliometric mapping of science.
A term map of the Journal of the American Society for Information Science and Technology. In this map, the color of a term indicates the average citation impact of the publications in which the term occurs.
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g l e n n h u g h e s . c o m - Fan Forum
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Noel Redding dead at 57
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May-12-2003, 10:01 PM
Member Since: Apr 2002
From: Dublin
Best known as the Bass player from The Jimi Hendrix Experience - very sad....no details are given.
http://www.rollingstone.com/news/new....asp?nid=18045
Find all posts by Paul
Member Since: Aug 2001
From: Amsterdam
That's a big shock! He was partially responsible for creating the best sounds I've ever heard... The Jimi Hendrix Experience...I think he was a steady bassplayer. Sometimes irritated by Jimi because Mr. Perfectionist would have him do take number 60 of a certain song. He hated the long long studio time.
Sadly enough, a big part of his life after Jimi's death he was stuggling with lawyers about rights and money he never got.
I once saw him play with Buddy Miles in the Paradiso in Amsterdam, and he made the impression of a relaxed and gentle guy.
He'll be deeply missed. Hopefully he can work on new material with Jimi now.
- Fedor
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May-13-2003, 2:07 AM
JohnH
Member Since: Dec 2001
From: Whittier, CA.
I feel a strange Deja Vu....It was from this website I learned of John Entwistle dying and now Noel. Very sad to see... I always hoped to meet Noel someday....or perhaps see him play.
Find all posts by JohnH
Here's an even better article, I just found on the Doors boards, uncredited.
Hendrix Bassist Noel Redding Dead At 57
Rock musician Noel Redding, best known for his stint as the bassist of the Jimi Hendrix Experience, was found dead yesterday (May 11) at his home in Ireland of unknown causes, his manager Ian Grant has confirmed to Billboard.com. He was 57. Redding, an accomplished guitarist based in the U.K., joined Hendrix's band in 1966 and played on the three Jimi Hendrix Experience albums -- writing two songs as well as playing bass -- before parting ways with the legendary guitarist in 1969.
Redding also made numerous recordings with his bands Fat Mattress, Road, and the Noel Redding Band. The artist's most recent release was a live album, "Live From Bunkr. Prague," which came out last year on Grant's Track Records label and included Hendrix songs. His mother reportedly died last week.
"I am very shocked to learn of my partner's death," reads a statement from Redding's companion Deborah McNaughton, posted by Grant on the Track Records Web site. "Noel was extremely gentle and gracious soul. He had a kind of chivalry and nobility about him and he was kind to everyone bar none, people and animals alike."
In a statement from Experience Hendrix, which oversees the guitar legend's catalog, Hendrix's family said, "We at Experience Hendrix mourn the loss of Noel Redding. His contributions to the Jimi Hendrix Experience shall never be forgotten. Our prayers go out to his family and friends during this difficult time."
In an interview last year with Billboard.com, Redding recounted his trials and tribulations in attempting to recover unpaid royalties for his work with Hendrix. "I should have been a plumber. That's a joke. But the thing is, plumbers get paid," he said. "But there again, I'm still playing, thank God. That's the main thing."
The fight for those royalties has been ongoing, according to Grant. "We were about to be in court over it, and we were on top," he says. "And now he will never know how it turns out. I don't know what will happen with it now. I've only been working with him for about two years. I was on a mission to right the wrongs that had been done to him.
"In working with him, I know him as a very kind, considerate man, especially given what happened to him with royalties and such," Grant adds. "He struggled at various times to reap the benefits of that part of his career ... He's now with Jimi, I guess, and they'll be comparing notes."
I plan on making the short journey, can't believe how effected I am
Noel's funeral and last respects information - a private ceremony will be held in remembrance of Noel Redding on Friday, May 16, 2003 at 6:00 PM at:
O'Sullivan's Funeral Home
Afterwards, the public is invited to pay their respects from 7:30 PM to 9:00 PM.
The gathering at O'Sullivan's will be followed by a wake and jam at De Barra's pub to celebrate Noel's life and music.
A funeral procession will take place on Sunday at 1:30 PM beginning at The O'Sullivan Funeral Home and continuing to The St. James Church in Ardfield where the funeral services will begin at 3:00 PM.
Those wishing to send cards or flowers may send them to the O'Sullivan's Funeral Home.
Donations may be made to:
Mount Carmel Hospital
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FOGHAT'S Rod Price dead at 57 LARRY BRIGGS Off Topic 1 Mar-24-2005 7:55 PM
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Rihanna Stunned the audience with her 'Dance Moves' at yesterday's grammy performance.
The Singer took to the stage to perform wild thoughts with Bryson Tiller and then she did what we didn't expect, a gwara gwara dance move.
The Dance move originated from South Africa.
Watch Riri holding it down below.
Watch the full wild thoughts performace below.


With a view to increasing the effectiveness and impact of its interventions, Portugal is continuing its co-operative efforts in order to increase predictability and rationalise the allocation of development funding whilst focusing on the following issues from the perspective of promoting synergies and establishing complementary entities, regardless of the financial source (i.e. central administration, etc).
These instruments are financed on a national level through the state budget, including funds from the Ministry of Foreign Affairs/Camões, I.P, local government, private funding and some of the other ministries. International funding can also be raised from foreign sources of joint-funding, particularly international organisations, trilateral co-operation and partner countries of Portuguese co-operation.
Camões, I.P. implements co-operation projects funded indirectly by centralised management (delegated co-operation) and also provides an added benefit through the practical implementation of the EU Code of Conduct on Complementarity and Division of Labour, namely the concentration of donors from a limited number of sectors in each country.
The Support Mechanism for Development Co-operation Projects for Portuguese NGDOs is a joint initiative between the Calouste Gulbenkian Foundation, EDP Foundation, Luso-American Development Foundation and the Portugal-Africa Foundation (promotional foundations), as well as support from Camões, I.P, with information available here, about the different channels of international funding with applications available for development projects.


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