text:
Flying blind, Republicans pass Trumpcare
McMorris Rodgers votes to slash health care to fund tax cuts for the rich
By DAVID GROVES
WASHINGTON, D.C. (May 5, 2017) — With a 217-213 vote on Thursday, House Republicans narrowly passed a controversial bill to approve hundreds of billions of dollars in tax cuts targeted to wealthy Americans, end Medicaid as we know it and slash its health assistance for lower income Americans by at least $880 billion over 10 years, allow insurance companies to impose lifetime and annual caps on medical coverage, and to overhaul the nation's healthcare system in a way expected to cost more than 24 million Americans their health insurance coverage.
But the truth is, the Republicans who voted for this have no idea how many people will lose coverage and what it will cost. That's because, in Thursday's rush to pass the bill before leaving the nation's capital for another congressional recess, Republicans pushed it through without a cost analysis by the nonpartisan Congressional Budget Office. Many Republicans who voted "yes" later acknowledged that they hadn't yet read the bill, an amended version of the legislation that failed in March.
Rep. Cathy McMorris Rodgers, the six-term Republican representing Spokane and the 5th Congressional District, was the only member of Washington's delegation who voted "yes" on the American Health Care Act (AHCA), also known as Trumpcare. Every Democrat from Washington — and in fact, every Democrat in the entire House — voted against this bill, as did 20 Republicans, including Washington Reps. Jaime Herrera Beutler and Dave Reichert. Rep. Dan Newhouse did not vote because he was home attending to a family medical emergency.
"On behalf of the Washington State Labor Council, AFL-CIO, and our more than 450,000 members, I want to thank Representatives Suzan DelBene, Rick Larsen, Jaime Herrera Beutler, Derek Kilmer, Pramila Jayapal, Dave Reichert, Adam Smith and Denny Heck for their principled votes against this horrible legislation," said WSLC President Jeff Johnson. "Trumpcare is just the latest cynical lie by our president. Rather than making our health care 'so much better,' Trumpcare will strip health care coverage away from millions Americans, raise the cost of health care for seniors and millions of others, and remove protections for Americans with pre-existing conditions and price many of them out of the market, all while giving huge tax breaks to millionaires."
Now the AHCA proceeds to the U.S. Senate where it faces an uncertain future with a more narrow Republican majority and some in the GOP expressing opposition or skepticism to the bill.
U.S. Sen. Patty Murray predicted the AHCA "is headed to a dead-end here in the Senate." She released this statement after the vote:
"I'm appalled by the action taken today in the House to jam Trumpcare through, regardless of the extraordinary harm it would do to patients and families. House Republicans just voted for an even worse version of the same Trumpcare bill that people across the country rejected only weeks ago. They voted to raise premiums and undo protections for people with pre-existing conditions, take coverage away from tens of millions of people, end Medicaid as we know it, cut off access to critical health care services at Planned Parenthood, and more — all while giving insurance companies and the very wealthy massive tax breaks. They may think they delivered a political win for President Trump today, but let's be clear: Trumpcare is headed straight to a dead-end here in the Senate, because women and families nationwide are going to fight back harder than ever against this disastrous bill and Democrats are going to be standing with them every step of the way."
In today's Washington Post, McMorris Rodgers defended her vote for Trumpcare by arguing that the the Affordable Care Act (known as Obamacare) has been a disaster and "to stand by and do nothing would be irresponsible."
For the past seven years, House Republicans have symbolically voted more than 50 times to repeal Obamacare, but failed to pass any legislation to improve it or fix any problems with the health insurance market that have arisen since its passage in 2010.
What McMorris Rodgers and the majority of her fellow Republicans finally did on Thursday is opposed by nearly every stakeholder organization in America's health care system. Trumpcare is opposed by the American Medical Association, American Hospital Association, American Cancer Society, American Heart Association, American Diabetes Association, American Lung Association, AARP, March of Dimes, and the National MS Society, among many others.
For Americans who get health insurance through their employers, Trumpcare would allow insurers once again to impose annual and lifetime caps on coverage, removing one of the key — and popular — consumer protections of Obamacare.
"It is no exaggeration to say that if it were to become law, this bill would kill significant numbers of Americans," writes Paul Waldman, also in today's Washington Post. "People who lose their Medicaid, don't go to the doctor, and wind up finding out too late that they're sick. People whose serious conditions put them up against lifetime limits or render them unable to afford what's on offer in the high-risk pools, and are suddenly unable to get treatment."
Waldman goes on to summarize of what Trumpcare does, based on the earlier version's CBO analysis before it was amended to appease the most conservative Republicans in a way that will likely make these numbers even worse:
► Takes health insurance away from at least 24 million Americans; that was the number the CBO estimated for a previous version of the bill, and the number for this one is probably higher.
► Revokes the Affordable Care Act's expansion of Medicaid, which provided no-cost health coverage to millions of low-income Americans.
► Turns Medicaid into a block grant, enabling states to kick otherwise-eligible people off their coverage and cut benefits if they so choose.
► Slashes Medicaid overall by $880 billion over 10 years.
► Removes the subsidies that the ACA provided to help middle-income people afford health insurance, replacing them with far more meager tax credits pegged not to people's income but to their age. Poorer people would get less than they do now, while richer people would get more; even Bill Gates would get a tax credit.
► Allows insurers to charge dramatically higher premiums to older patients.
► Allows insurers to impose yearly and lifetime caps on coverage, which were outlawed by the ACA. This also, it was revealed today, may threaten the coverage of the majority of non-elderly Americans who get insurance through their employers.
► Allows states to seek waivers from the ACA's requirement that insurance plans include essential benefits for things such as emergency services, hospitalization, mental health care, preventive care, maternity care, and substance abuse treatment.
► Provides hundreds of billions of dollars in tax cuts for families making over $250,000 a year.
► Produces higher deductibles for patients.
► Allows states to try to waive the ACA's requirement that insurers must charge people the same rates regardless of their medical history. This effectively eviscerates the ban on denials for pre-existing conditions, since insurers could charge you exorbitant premiums if you have a pre-existing condition, effectively denying you coverage.
► Shunts those with pre-existing conditions into high-risk pools, which are absolutely the worst way to cover those patients; experience with them on the state level proves that they wind up underfunded, charge enormous premiums, provide inadequate benefits and can't cover the population they're meant for. Multiple analyses have shown that the money the bill provides for high-risk pools is laughably inadequate, which will inevitably leave huge numbers of the most vulnerable Americans without the ability to get insurance.
► Brings back medical underwriting, meaning that just like in the bad old days, when you apply for insurance you'll have to document every condition or ailment you've ever had.
"In short, the bill the House just passed is one of the most regressive pieces of legislation in living memory," writes John Cassidy in the New Yorker. "When Republicans cut taxes on the rich and slash funding for programs aimed at the poor, they usually go to great lengths to argue that the two things are unconnected. But in this instance they have done away with the subterfuge. It's reverse Robin Hood, in plain view."
► A related story in today's (Spokane) Spokesman-Review — Lisa Brown stepping down as WSU Spokane chancellor, says she's considering congressional run — Lisa Brown is stepping down as chancellor of Washington State University's Spokane campus and says she is again considering a run for Rep. Cathy McMorris's seat in Congress. Brown has spent the past four years leading the Spokane campus and was instrumental in the formation of a medical school there. She previously served for 20 years in the Legislature, the last eight as the Democratic majority leader in the Senate.
Posted by David Groves on May 5 2017. Filed under NATIONAL, TAKE A STAND!. You can follow any responses to this entry through the RSS 2.0. Both comments and pings are currently closed.


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Q: Issue when ap-angular2-fullcalendar AOT issue I am facing an issue when i do AOT for my angular 4 app , where i am referencing ap-angular2-fullcalendar.
Here are my configurations in rollup-config.js
**
import rollup      from 'rollup';
import nodeResolve from 'rollup-plugin-node-resolve';
import commonjs    from 'rollup-plugin-commonjs';
import uglify      from 'rollup-plugin-uglify';
import includePaths from 'rollup-plugin-includepaths';

let includePathOptions = {
    include: { 'core-module/core.module' : 'core-module/core.module.js' },
    extensions: ['.js', '.json', '.html']
};
//paths are relative to the execution path
export default {
input: 'app/main-aot.js',
output : {
    file: 'aot/dist/build.js', // output a single application bundle
    format: 'iife'
},
sourcemap: true,
sourcemapFile: 'aot/dist/build.js.map',
plugins: [
    includePaths(includePathOptions),
    nodeResolve({jsnext: true, module: true}),
commonjs({
    include: [
        'core-module/**',
        'app/**',
        'node_modules/rxjs/**',
        'node_modules/angular2-logger/**',
        'node_modules/ng2-bs3-modal/**',
        'node_modules/ng2-cookies/**',
        'node_modules/ng2-toastr/**',
        'node_modules/ng2-translate/**',
        'node_modules/ng2-select/**',
        'node_modules/jquery/**',
        'node_modules/moment/**',
        'node_modules/fullcalendar/**',
        'node_modules/ap-angular2-fullcalendar/**'
    ],
    namedExports: {
        'node_modules/angular2-logger/core.js': [ 'Logger', 'Options', 'Level' ],
        'node_modules/ng2-bs3-modal/ng2-bs3-modal.js' : [ 'ModalComponent' ],
        'node_modules/ng2-cookies/ng2-cookies.js': [ 'Cookie' ],
        'node_modules/ng2-select/index.js': ['SelectModule', 'SelectComponent']
    }
}),
uglify()
]
}

**
Then in index.html I have included
<link rel="stylesheet" href="node_modules/fullcalendar/dist/fullcalendar.min.css"/>

<script src="/assets/References/jquery-3.2.1.min.js"></script>
<script src="/assets/References/jquery-2.2.0.min.js"></script>
<script src="node_modules/moment/min/moment.min.js"></script>
<script src="node_modules/fullcalendar/dist/fullcalendar.min.js"></script>
<script src="/aot/shim.min.js?v=2.1.4"></script>
<script src="/aot/zone.min.js?v=0.7.4"></script>
<script>window.module = 'aot';</script>
<script src="/aot/dist/build.js?v=2017.11.14"></script>

However , when i browse my website i am getting below error in fullcaledar.js.
uncaught typeerror: : "Cannot add property fullCalendar, object is not extensible"
During Development , it works , as I am using systemjs.config.js and it is configured like
(function (global) {
    System.config({
        paths: {
            // paths serve as alias
            'npm:': 'node_modules/'
        },
        // map tells the System loader where to look for things
        map: {
            // our app is within the app folder
            "app": 'app',

            'jquery': 'node_modules/jquery/dist/jquery.min.js',
            'bootstrap': 'node_modules/bootstrap/dist/js/bootstrap.min.js',
            'moment': 'node_modules/moment',
            'fullcalendar': 'node_modules/fullcalendar/dist/fullcalendar.js',
            'ap-angular2-fullcalendar': 'node_modules/ap-angular2-fullcalendar'
        },
        // packages tells the System loader how to load when no filename and/or no extension
        packages: {
            "app": {
                main: './main.js',
                defaultExtension: 'js'
            },
            'fullcalendar': {
                defaultExtension: 'js'
            },
            'ap-angular2-fullcalendar': {
                main: 'index.js',
                defaultExtension: 'js'
            }
        }
    });
})(this);

Any idea how to get around this ? I am planning to buy license for Full Calendar but this is a sort of a blocker at the moment.

A: i can see fullcalendar.js is a jquery library. What i got from my search on google, it is peer dependency issue. avoid multiple versions of jquery on the same page.(index.html)

redpajama_set_name: RedPajamaStackExchange


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Q: Atom package override OSX keybind In Atom, I installed the sort-lines package, and the default hotkey to sort alphabetically is F5. However, when I hit F5, it just triggers my native OS X keyboard illumination.

A: Re-bind the key in Atom
If you prefer, you could re-bind this key to something other than a function key. Open your config folder from Atom's preferences and add a binding to keymap.cson. Something like this (pick whatever key you prefer).
'atom-text-editor:not([mini])':
    'alt-s': 'sort-lines:sort'

You can read more about keymaps in the Atom Flight Manual.
How function keys work on Macs
Pressing the key marked F5 on a Mac keyboard will, by default, only trigger the native function of that key (which varies depending which specific keyboard you're using). For instance, for you it is one of the keyboard backlight keys. Other function keys control volume, screen brightness, and iTunes playback.
If you don't want to re-bind the Atom key as described above, you can solve this in either of two ways.
Use the "Fn" key
Hold the Fn (typically at the lower left corner) and then press F5. This will trigger the actual F5 function key.
Make the function keys the default
If you prefer the function keys to be on permanently, you can turn them on as the default. This will invert the normal behavior; The function key will be the normal keypress, and the special behavior (volume, play, mute, etc) will require holding the Fn key.
As described in Apple's support page:

If you prefer the top row of keys to always behave as standard function keys without holding the Fn key:

*

*Choose System Preferences from the Apple menu.

*Click Keyboard.

*Click the Keyboard tab if it's not already highlighted.

*Select "Use all F1, F2, etc. keys as standard function keys"

  With this option enabled, the keys on the top row act as standard function keys (F1–F12). To use a feature indicated by the icon printed on a key, hold Fn while pressing the key.

It's a little different on the newer TouchBar laptops. Here, the function keys are normally not displayed, and pop into existence on TouchBar when you press the Fn key.
For an external keyboard on a TouchBar laptop, just use the process shown above. For the built-in keyboard, you will have to use the Fn key. I see no way to force the function keys to always display on TouchBar.


text:
Relatively crude all-encompassing term for a group of bands who are musically quite disparate. Current jam band successes include such unique groups as Phish (closer to being straight rock than anything), String Cheese Incident (electric-grass or "acid grass"), Yonder Mountain String Band (more traditional bluegrass), Umphrey's McGee (prog-rock and jazz influences), Widespread Panic (Southern-ish rock), Blues Traveler (blues and power rock), Medeski Martin and Wood (jazz), etc. The originators of the phenomenon were the Grateful Dead, and Dead successors such as the Other Ones, Ratdog, and Phil Lesh & Friends carry the mantle of the Dead legacy today. The term "jam band" is of course rooted in the fact that all of these bands "jam," or improvise for long periods of time during their shows. Other characteristics of "jam band" status include dedicated traveling fan bases, close rapport with such fans, long sets at shows, etc.
by Phil February 26, 2003
Get the jam bands mug.
musical groups with a lyrical disposition towards preserves of all kinds.
by mike read August 7, 2003
monotony. total monotony.
wow, that jam band show was full of monotony.
by B March 29, 2004
n. fusion of the musical styles of folk, country, blues, jazz, and rock. Generally attributed to bands that play with great emotion and symbosis with their audiences.
Examples: Ratdog, String Cheese Incident, Phish, The Other Ones
by reptiles October 4, 2002
noun. A rock band whose performances include long, unscripted, meandering segments which experiment with structure and sound. Jam bands typically play very long sets whose playlists are only vaguely defined by lists of "songs." Jam band fans often heighten their musical experience by taking hallucinogenic drugs or by smoking pot. Examples include the Dead, moe., Phish, Widespread Panic, String Cheese Incident.
moe. is a jam band.
Q. What did the Deadhead say after the acid wore off?
A. This band sucks!
by Mike Roynhertz August 20, 2004
Get the jam band mug.
hey Marshie, dave matthews is not a jam band.
umphrey's mcgee, disco biscuits, karl denson's tiny universe
by russ May 9, 2005
Music to make your bones jitter and your hips shake. Music to make your feet move and your head sway. Music to make your beard and mind grow. A jam band manages to deliver a sense of freedom to the crowd. Jam bands free lance and improv. all while staying with each other and feeding off each others experimental energy. In a jam bands set, you'll find peices of the core song they started with, blended for your delight with a variety of instrumental solo's and always amazing percussion. jam Bands can be appreciated not only by people on drugs, but also by people who just dig music and the phases it grows through. (trust me though it's better when your high as cheese) Bands include Phish, Grateful Dead, String Cheese Incident Widespread Panic, The Allman Brothers Band,Moe, The Big Wu and other music that hints towards these areas of music.
Hey you, why do you like Jam Bands, it just sounds like noise? wheres the catchy chorus?
Hey, simple human, because in a world where most peoples spirits are being tugged from them and hidden behind bills and death, it's nice to get sucked into a spiral of warmth and energy that can make me foget i'm human for a while. Just relax and smoke this. Oh, and the catcy chorus is coming after Jerry rips it for another 10 minutes. (past tense - sorry brother, thanks for the tunes)
by twinkle moslemendo November 14, 2007

redpajama_set_name: RedPajamaCommonCrawl


Tomorrow is going to be a big day for me. I'm really excited, but at the same time I'm oh so nervous. I'll be presenting my little creative studio to a board of judges that are going to pick the most creative entrepreneur on the island of Curacao.
Sometimes in life you have to take risks to accomplish something and I'm just going to jump with both hands and feet to make this thing happen. Even if I don't win, I gained more experience and met some wonderful people in the process.
Don't you agree? It doesn't matter what you are planing to do, the point is to get started. Even if it is to clean your yard. So if you are planning a big task for the weekend, just start and you'll be satisfied with the outcome. Wishing you a lovely weekend.


What an exciting year it has been for Table for One Ministries!
Our first year of ministry saw great success in getting our name out there as a ministry to single adults. We have nearly 1,100 likes on Facebook, 2,200 followers on Twitter, 2,500 followers on Instagram, 2,600 followers on Pinterest and we see hits every day on our website from these outlets reading our blogs. Speaking of our website, we average over 500 views a day. Our top blog of 2014 was "Divorced not Damaged" by Christina Dunn with just over 500 reads followed by our Gospel presentation blog "Am I Alone?" and third was our blog "Not an Option." We raised over $5,000 in tax-deductible giving and filed for a trademark for our ministry name.
Our goals for 2013 were to get our name out there, reach single adults, and establish a non-profit with high accountability. Thanks to the leadership of the nine members of our board of directors, we have met and exceeded these goals! For 2014, we are looking to produce discipleship focused curriculum targeted for single adults as well as schedule speaking engagements to share our values. We want to be a ministry that is reaching single adults and inspiring churches to start reaching single adults as well.
Will you help us get 2014 off to a good start? You have the opportunity to give a tax-deductible gift to Table for One Ministries before December 31st to help us get 2014 off to a great start. Your recurring or one time gift will propel our goals of publishing curriculum even sooner. We praise God for your support and look forward to sharing the stories of life change Table for One is bringing to singles and churches.


Looking for friendly, outgoing people with a love of animals and someone who understands Paw Street Market's passion for customer service. Position requires opening shifts.
Paw Street Market will be opening our brand new North Vancouver location in Westview Shopping Centre very soon.
We are looking for Pet-Experience sales people to join our growing team. This could lead to full-time opportunities.
Our Vernon location is hiring a part-time pet experienced sales person.


HomePersonal Finance BlogHow do people cope with no bank account?
Recent studies have found that close to two million adults in Britain manage to get by with no bank account. But while living "off the financial grid" may be attractive to people who mistrust modern finance and online banking, not having a bank account could have major implications for their financial health.
Firstly, there's the cost. Research by the Financial Inclusion Commission found that not having a bank account can cost you more than £1,300 a year more than somebody who conducts their financial affairs through a current account.
The research found that more than half (60%) of those without a bank account used to have one but it was closed against their will because of debt issues or other problems with their bank. Once deprived of a bank account, those people then lost access to making regular direct debit payments for things such as electricity, phone or broadband charges – bills are usually subject to some form of discount should you agree to pay by direct debit.
The proportion of households on lower incomes who do not have a bank account is much lower than it was during the late 1990s when it was as high as 25%. Today, that figure is closer to 10%.
The proportion of households on low incomes without a bank account is now similar to that of households on average incomes.
The fall in the numbers of lower income families without a bank account seems to have been down to the introduction of basic bank accounts and Post Office card accounts.
The headline numbers may suggest that more than half lost their access to banking because of financial problems but other research suggests that a sizeable number of people have chosen not to have a bank account. A survey by the poverty charity, Toynbee Hall, published in the Lloyds Banking Group's Consumer Digital Index 2017, suggested that 32% people of people without an account chose not to, 29% blamed an identification problem while 15% said that they chose not to have an account because of a prior negative experience with a bank.
Out of all those surveyed, the charity found that 31% of those without an account were between the ages of 20 and 29 while 26% were between 40 and 49.
While it might have been expected that those without an account would rely upon payday loans, Toynbee Hall found that only 6% of those without an account said that they regularly use payday loans. Just 1% of them said that they use payday loans every month. That may be as a result of the use of so-called continuous payment authorities which payday lenders will often insist upon before offering a loan.
Despite most utility companies charging more if you don't pay by direct debit, it is perfectly possible to have electricity or gas connections without an account. It just means that you will probably have to have a pre-payment meter installed.
Other bills and contracts may be more difficult. It is now virtually impossible to get a broadband contract without a bank account while getting any kind of mobile phone account on a contract will need you to provide your bank account details. If you don't have an account but need a mobile phone, then you will probably have to get a pre-paid mobile with a sim card that you top up with cash at a shop or Post Office.
What does no Bank Account mean for your credit record?
If you want access to loans, credit cards or mortgages, then it's a given that you will need a bank account and one which you pay a minimum amount into every month. If you don't have one, then it will be virtually impossible to get any kind of loan – with the possible exception of a doorstep loan which you repay in cash – and your access to other forms of credit will be limited.
Some of the credit card companies do have pre-paid credit cards which you "charge up" with cash at selected outlets. These work in a similar way to standard credit cards except that you don't have a credit limit, just a balance which must be equal to or more than what you spend on the card. Most of these cards come with fees which are taken out of your balance.


This page displays sold house prices for Elford Grove in Leeds.
Elford Grove in Leeds LS8 consists predominantly of terraced houses. Properties on Elford Grove typically have values around under £100,000, ranging upwards of £100,000 for larger semi-detached houses.


text:
Geografia
 Orologio – frazione di Travacò Siccomario in provincia di Pavia
 Orologio – quartiere di Reggio Emilia

Tecnologia
 Orologio – strumento per misurare il tempo
 Orologio per scacchi – orologio usato negli scacchi e in altri giochi da tavolo con due giocatori

Altro
 Orologio – costellazione
 Orologio – applicazione presente nei sistemi operativi iOS e watchOS
 Orologio (Lepomis gibbosus) – pesce
 Orologio – elemento simbolico utilizzato, specie graficamente, per rappresentare il tempo

redpajama_set_name: RedPajamaWikipedia


Giuseppe Garibaldi (1807 -1882) was an Italian revolutionary and statesman, famous for his South American adventures, uniting Italy and -for some reason- wearing a poncho. Born in Nice, France he became a merchant marine captain aged 25 and eventually sailed to Brazil.
Mahmud of Ghazni (971-1030) was the first ruler to refer to himself as Sultan. Born to a Turkic Mamluk leader, he headed the Ghaznavid Empire, which covered most of the area between modern day Iran, Afghanistan, India and Pakistan.
The origins of coffee are in Ethiopia around the 10th century. It then spread to the Middle East and then reached Europe in the 1500s, where it was considered a drink of the "infidels or heathens".


text:
Thomas H. Reece
Education Obituary
By Ann Bradley — October 02, 2006 1 min read
Thomas H. Reece, a former president of the Chicago Teachers Union, died Sept. 17. He was 68 and had suffered a cerebral hemorrhage.
He took over the union after the 1994 death of Jacqueline B. Vaughn, who was known for her advocacy and leadership of repeated strikes. He was re-elected three times, during a period of relative quiet and partnership with the district. In 2001, he lost his position to Deborah Lynch Walsh, who charged that the union had been co-opted by the administration into a role that left its members unprotected.
Mr. Reece was a science teacher and assistant principal before becoming an officer of the union, where he served as the financial secretary and vice president before Ms. Vaughn's death. He also served as the president of the Illinois Federation of Teachers during the time he was the president of the CTU. Both unions are affiliates of the American Federation of Teachers.
Ann Bradley
A version of this article appeared in the October 04, 2006 edition of Education Week
Education Letter to the Editor EdWeek's Most-Read Letters of 2022
Here are this year's top five Letters to the Editor.
Gwen Keraval for Education Week
Education In Their Own Words Withstanding Trauma, Leading With Honesty, and More: The Education Stories That Stuck With Us
Our journalists highlight why stories on the impact of trauma on schooling and the fallout of the political discourse on race matter to the field.
Stephen Sawchuk
Kladys Castellón prays during a vigil for the victims of a mass shooting at Robb Elementary School.
Billy Calzada/The San Antonio Express-News via AP
Education In Their Own Words Masking, Miscarriages, and Mental Health: The Education Stories That Stuck With Us
Our reporters share the stories they wrote that rose above the fray—and why.
Crystal Curtis and her son, Jordan Curtis, outside their home in Plano, Texas. Crystal, a healthcare professional whose son attends school in Plano talks about the challenges of ensuring quality schooling, her discomfort with the state and district's rollback of mandatory masking, and the complications of raising a Black child in a suburban district as policies shift.
Allison V. Smith for Education Week
Education Opinion The Top 10 Rick Hess Straight Up Columns of 2022
NAEP, pre-K, who decides what gets taught. Those are among the most popular or impactful posts of the year.
DigitalVision Vectors/Getty


The charger is 60 Watts and 12 amps with smart port technology that should charge all your tech toys with the appropriate level of juice. The 672 reviews are overwhelming positive, and the Sabrent charger comes with a one year warranty, so you should feel pretty confident in your purchase. Personally, this device would be a bit overkill for me to use at home, but I don't think a workplace exists that couldn't benefit from a couple of these puppies.
To take advantage of the deal, just follow these three steps.
First, add the charger to your cart.
Second, add the cables to your cart.
Third, enter the code TPCSU631 at checkout. Your total should drop from $35 to $25.
Voila, you have yourself a deal. Enjoy the power my friends.


text:
Authors' information
Two sides of the coin: patient and provider perceptions of health care delivery to patients from culturally and linguistically diverse backgrounds
Nera Komaric1Email author,
Suzanne Bedford2 and
Mieke L van Driel1, 2, 3
© Komaric et al.; licensee BioMed Central Ltd. 2012
Received: 8 February 2012
Australia is a culturally diverse nation with one in seven Australians born in a non-English speaking country. Culturally and Linguistically Diverse (CALD) populations are at a high risk of developing preventable chronic diseases such as cardiovascular disease, type 2 diabetes mellitus, renal disease, and chronic respiratory disease, especially communities from the Pacific Islands, the Middle East, North Africa, the Indian subcontinent and China. Previous studies have shown that access to services may be a contributing factor. This study explores the experiences, attitudes and opinions of immigrants from different cultural and linguistic backgrounds and their health care providers with regard to chronic disease care.
Five focus groups were conducted comprising participants from an Arabic speaking background, or born in Sudan, China, Vietnam or Tonga. A total of 50 members participated. All focus groups were conducted in the participants' language and facilitated by a trained multicultural health worker. In addition, 14 health care providers were interviewed by telephone. Interviews were digitally recorded and transcribed. All qualitative data were analysed with the assistance of QSR NVivo 8 software.
Participants were generally positive about the quality and accessibility of health services, but the costs of health care and waiting times to receive treatment presented significant barriers. They expressed a need for greater access to interpreters and culturally appropriate communication and education. They mentioned experiencing racism and discriminatory practices. Health professionals recommended recruiting health workers from CALD communities to assist them to adequately elicit and address the needs of patients from CALD backgrounds.
CALD patients, carers and community members as well as health professionals all highlighted the need for establishing culturally tailored programs for chronic disease prevention and management in CALD populations. Better health care can be achieved by ensuring that further investment in culturally specific programs and workforce development is in line with the number of CALD communities and their needs.
Focus Group Participant
Improve Health Care Delivery
Mainstream Population
Chronic disease is a major and growing health problem. According to the World Health Organisation, 35 million deaths due to major chronic disease were reported globally in 2005, with the highest toll evident in low and middle income countries [1]. In Australia, the aging population and changes in lifestyle that have emerged over the past decades call for a focus on chronic diseases in planning and delivery of health care services. Several Australian states have responded with strategic plans to tackle the challenges posed to the health care system. Queensland's Chronic Disease Strategy 2005–2015 mentions six different target groups, including people from culturally and linguistically diverse backgrounds (CALD) [2]. In the Australian context, individuals from a CALD background identify as having specific cultural or linguistic affiliation by virtue of their place of birth, ancestry, ethnic origin, religion, preferred language, or language spoken at home, or because of their parents' identification on a similar basis.
Migrants to Australia undergo rigorous health checks before migration. Consequently, upon arrival in Australia, their health status is better than the Australian-born population, which is known as the 'healthy migrant effect' [3] A recent Australian study, however, shows that the longer immigrants spend in Australia, the closer their health approximates that of the Australian-born population [4]. CALD populations often experience a higher burden of disease at the system level, such as a lack of access to services and lack of appropriate information to make informed decisions, which impacts significantly on their health and quality of life [5].
Delivering effective health services to members of the CALD community is complex because cultural and language barriers impede the identification, targeting and delivery of services. Clients from non-English-speaking backgrounds are disadvantaged in terms of access and quality of services compared to the mainstream English speaking population [6] this is expressed in lower health levels. In addition, acculturation may be an important risk factor in chronic disease morbidity for immigrants from non-English speaking backgrounds.
As Australia becomes more culturally and linguistically diverse society, the health care system needs to be responsive to CALD patients' health needs. Failure to provide culturally competent services would lead to major health care disparities between CALD and mainstream populations. Although there is no single definition of cultural competency, in broader terms it describes the capacity to provide professional and adequate services to populations with diverse values, beliefs, behaviours, cultural identity and ethnic identity [7]. Ideally provision of such services should be embedded throughout the health care system to the extent that cultural competency is apparent from the individual provider-patient interface through to policy development at the governmental level.
We believe there are two key barriers to the provision of adequate health care to CALD populations. The first is at the level of the health care system itself where there is a lack of cultural diversity in the health care workforce. This manifests in an under-representation of ethnic minorities throughout all levels of the healthcare system with only recent leadership being offered to address the lack of cultural competency at governmental levels [8].
The second significant barrier lies within the CALD communities. According to Nutbeam [9], there is a clear correlation between a person's health literacy and health status. In brief, health literacy is defined as the set of literacy and numeracy skills that enable a person to comprehend their health status and be proactive addressing their health care needs [10]. Whilst low levels of health literacy are apparent throughout the population in Australia, the level of health literacy of persons whose first language is not English is significantly poor. For instance, only 3.4% of 65–74 year olds whose first language is not English could be regarded as being health literate compared to 17.4% in the same age group in the mainstream population [11]. This comparatively low level of health literacy creates a further impediment to the provision of adequate care for members of the CALD community and has considerable implications for the capacity of these patients to self-manage chronic disease states in particular.
In this study we aimed to describe the challenges people from CALD communities face regarding treating and preventing a chronic disease and what barriers they experience and perceive with regard to access to health services. To distinguish this study from others we sought to provide a more comprehensive picture of the challenges faced when providing health care to this vulnerable population. To this end, we investigated the perceptions not only of members of the CALD communities but also those of the health professionals involved in their care.
We conducted focus group discussions with people from diverse linguistic and cultural backgrounds and interviews with health care providers who service CALD populations.
Participants were eligible if they belonged to a CALD community, identified by country of birth; language other than English spoken at home and English language proficiency, and lived in a region with a high prevalence of chronic disease [12]. All participants were registered in the database of the Ethnic Communities Council of Queensland (ECCQ) and either suffered from a chronic disease, cared for a patient with chronic disease or had an interest in chronic disease service delivery. The chronic diseases of interest were limited to seven lifestyle preventable diseases namely type 2 diabetes, heart failure, stroke, coronary heart disease, renal failure, chronic obstructive pulmonary disease and asthma which have been identified as priorities in the Queensland Chronic Disease Strategy 2005–2015 [2].
Sample population
A total of 50 participants took part in five ethnically homogenous focus groups each comprising 8–11 participants. In collaboration with the community organisations active in the health promotion for CALD communities, we selected a convenience sample of Arabic speaking, Chinese, Sudanese, Tongan and Vietnamese groups. These ethnic groups were targeted based on the high prevalence of chronic disease within these populations in south-east Queensland.
Participants were fully apprised of the research aims and protocol before providing written, informed consent in accordance with the NHMRC Statement on Human Experimentation [13].
The focus groups were conducted in the community languages and followed a semi-structured format with the facilitator posing open-ended questions categorised into the major themes under consideration in the study: chronic disease awareness, health care system literacy, utilisation of the health care system, awareness of types of health care provider, preferred type of provider, access issues, experience of the health care system and suggestions for improvement. This set of open-ended questions was derived from a previously conducted quantitative study as a consequence of a numerous consultations with CALD communities in Queensland.
Focus group sessions lasted approximately 90 min, were recorded, transcribed verbatim and translated into English. A bilingual person from each community validated translated transcripts. The facilitators were recruited from the pool of Multicultural Health Workers (MHW) employed by the ECCQ CALD Chronic Disease program to work with the specific CALD communities. Each MHW arranged a note taker from the community who was literate in the community's language. The decision to run focus groups to collect data from the CALD communities was based on similar qualitative studies which have found that this approach provides a supportive environment in which community members are comfortable to freely express their views [14, 15].
Health professional interviews
Health professionals were selected from the health districts of the focus group participants' residence. Fifteen professionals agreed to be interviewed with one later withdrawing from the study.
Interview methods
Participants were informed of the research aims and protocols before giving verbal consent. Interviews were conducted and recorded in English via telephone by an independent consultant using a structured interview schedule. Questions centred on their professional context, experience with patients from CALD communities, attitudes of their organisation towards CALD communities, perception of disease in CALD communities, factors impacting treatment and suggestions for improving health care provision to CALD communities. Each interview took approximately thirty minutes and was transcribed verbatim by the interviewer.
Focus group and interview data were analysed and themes identified separately with the assistance of qualitative analysis software QSR NVivo 8 (QSR International PTY Ltd, Melbourne, Australia). Thematic analysis was used to identify emerging themes in focus group and interview data. Transcripts of both the interview and focus group data were read several times with issues raised by both providers and focus group participants coded to themes. This was an interactive process with thematic categories added or refined with each consideration of the transcripts. These themes were identified independently by two investigators and any discrepancies in analysis were discussed amongst the investigators as the analysis progressed until a resolution regarding thematic categorisation was achieved. This process was repeated until no further themes could be identified by either investigator, suggesting thematic saturation had been achieved in this sample. The transparency of the analysis is indicated by extensive use of verbatim quotes in the text.
Ethics approval for the study was obtained from the Bond University Human Research Ethics Committee.
The age of participants ranged from 17 to 79 years old. Participants had immigrated to Australia between 1 and 38 years ago, had no to high standards of English proficiency and were from a broad range of educational backgrounds.
The proportion of participants reporting a current chronic disease ranged from 3 out of 9 participants (Chinese) to 10 out of 11 participants (Sudanese). Members within each group reported suffering from a variety of chronic conditions or had family members with chronic disease (Table 1), with hypertension, hypercholesterolemia and type 2 diabetes mellitus being well represented.
General demographic characteristics of focus group participants as established by selection criteria
No. in group
Year of birth (range)
Years since arrival (median, range)
Spoken English proficiency
Highest education achievement
No. with disease
12 years, 1–37 years
All good or better
All high school or higher
6 years, 3–14 years
4 poor or worse
5 high school or lower
All high school of lower
19.5 years, 3–38 years
Professional context of health providers
Twelve of the 14 health care providers interviewed were female, half were Australian and all worked in a variety of settings including community health and tertiary institutions (see Table 2). Exposure to CALD patients ranged from very limited to comprising the majority of clientele. The level of focus their workplaces had on treating CALD communities appeared to correspond to the proportion of CALD patients in their practice.
Health care provider profiles
Ethnic background
Exposure to CALD communities
Not CALD
Indirectly through project work
Anaesthetist, pre-admission
Public hospital
Directly, 20-30%
Community & Primary Health services
Indirectly through consultation for resource development
Community general practice
Australian (bilingual, Spanish)
Directly, 100%
Directly, <10%
Indirectly, previous direct experience
Nurse (surgery)
Private hospital
Former Yugoslav
Directly, limited (<1%)
Directly,30-40%
Private practice & refugee clinic
Directly, 100% in refugee clinic, minority in general practice
Centro-eastern European
Directly, <10% patients
Directly, 30-100% depending on project
Cardiac scientist
Coordinator, lifestyle programs
Directly, 5-10%
Workplace attitudes towards CALD patients were viewed as positive with the "attitude …getting much better." (HP13) This appeared to be particularly the case in organisations that have a greater exposure to CALD patients. In contrast, it was noted by one GP that:
""In general practice we are all individual…. I think our organisation deals better with people from our own culture than with people from CALD groups. It's not on purpose, it's just that they are a minority." (HP10)"
Perception of disease in CALD communities
All focus groups were aware of a variety of chronic and acute diseases within their communities, in particular type 2 diabetes and hypertension (see Table 3). In general, all providers who dealt with CALD patients, treated CALD patients with chronic disease. Whilst there was a perception amongst providers that the prevalence of chronic disease was lower in CALD compared to mainstream patient populations, prevalence appeared to depend on the ethnicity. For example, in some settings, disease presentation appeared to depend on patient's region of origin with "CALD clients …from Europe.. hav(ing) the same diseases that we have" (HP10) compared with, for example, "the Burmese … they don't have those problems."(HP10) The effects of acculturation were apparent in the belief that the"…chronic disease profile that is typical in the mainstream population will be adopted by the newly arrived migrants and CALD communities" (HP3) because a "lot of new arrivals in Australia adopt the lifestyle of (the) host country." (HP6)
Disease presence, perception of disease or related symptom(s) prevalence in focus group communities and health service familiarity
Disease presence in focus group participants
Disease/symptom prevalence within ethnic community
Disease/symptom prevalence within youth of ethnic community
Health service familiarity
In-Scope: Hypertension, Hypercholesterolaemia, Type 2 Diabetes Other: Arthritis, Asthma, Cancer
In-Scope & lifestyle: Type 2 Diabetes, Hypertension, Hypercholesterolaeia Other: Rheumatic heart disease, Cancer Mental Health: Depression, Stress
In-Scope: Other: AIDS, Asthma
Primary: Medical centres, GPs Specialist: general awareness Emergency & Tertiary: Hospitals Diagnostic: Pathology, Radiology Allied & Other Health: Pharmacy Community & NGO: Diabetes Centre, MCHW
In-Scope: Hypertension, Hypercholesterolaemia, Type 2 Diabetes Other: Asthma, Cancer, Stroke, unspecified liver disease
In-Scope & lifestyle: Type 2 Diabetes, Hypertension, Hypercholesterolaemia Other: Asthma, Cancer, Infectious Diseases eg Hep B, Parasitic Diseases eg Malaria, Malnutrition, unspecified abdominal & back pain Mental Health: Depression, Chronic grief, Stress
In-Scope & lifestyle: Obesity Other: Asthma, Epilepsy, Infectious Diseases eg Hep B, Parasitic Diseases eg Malaria, Malnutrition Mental Health: Depression, Chronic grief, Stress
Primary: Medical centres, GPs Specialist: general awareness Emergency & Tertiary: Ambulance, Hospitals Allied & Other Health: Occupational Therapy, Dentistry, Mid-wifery Community & NGO: Community Health Centre, Arthritis, Asthma, Kidney & Heart Foundations, MCHW
In-Scope: Hypertension Other: Arthritis
In-Scope & lifestyle: unspecified chronic disease, Type 2 Diabetes, undefined kidney disease, Pulmonary emphysema, Overweight Other: Arthritis
In-Scope & lifestyle: Other: only undefined congenital conditions & arthritis mentioned
Primary: Medical centres, GPs Specialist: Gynaecology Emergency & Tertiary: Hospitals Diagnostic: Pathology, Radiology Allied & Other Health: Dentistry, Optometry, Pharmacy Mental Health: Psychology
In-Scope: Hypertension, Hypercholesterolaemia, Type 2 Diabetes Other: Arthritis, Stroke, Hepatitis B
In-Scope & lifestyle: unspecified chronic disease Other: Joint-related disorders, dementia Mental Health: Depression, Stress
In-Scope & lifestyle: Smoking & alcohol related diseases Other: Chronic back pain
Primary: GPs Specialist: general awareness Emergency & Tertiary: Hospitals Diagnostic: Pathology, Radiology Allied & Other Health: Physiotherapy, Podiatry, Dentistry, Optometry, Midwifery, Occupational Therapy, Acupuncture Community & NGO: Home nurse, Hot line health service, Community Health Centre, MCHW
None cited
In-scope & lifestyle: Overweight Hypertension, Type 2 Diabetes, Hypercholesterolaemia, Smoking & alcohol related disease Other: Cancer, Dementia Mental health: not different from broader community
In-scope & lifestyle: Overweight, alcohol related problems Other: Asthma, Eczema
Primary: Medical centre, GPs Emergency & Tertiary: Ambulance, Hospitals Allied: Physiotherapy Community & NGO: Community Health Centre Mental Health: Counselling, Psychiatry
Chronic disease and the younger members of CALD communities
Asthma was regarded more as a problem in younger members of the Arabic, Sudanese and Tongan communities (Table 3). The importance of infectious and parasitic disease was raised by the Sudanese community along with malnutrition. Vietnamese and Tongan communities perceived their youth as being at risk of acquiring lifestyle related problems. There was no particular mention of disease prevalence in younger members of the CALD communities in the health-provider interviews.
Perception of mental health problems in CALD communities
Arabic and Sudanese participants emphasized the importance of mental health. Both communities identified war in their region of origin as one of the causes of "depression, stress and anger." (Arabic)
""The war has affected us and many of us are traumatised and have gone through agony/suffering and torture, we came here with high hope of good opportunities unfortunately it did not work out as we expected due to cultural differences". (Sudanese)"
The Sudanese focus group mentioned loneliness, dislocation and isolation from relatives in Sudan as reasons for chronic grief, stress and depression. They perceived their youth as being particularly vulnerable to mental health problems citing the high level of frustration with the challenges presented at school as a key contributing factor.
Concerns about mental health were also raised by health-providers who treated traumatised CALD patients. There was a perception that previous trauma experienced by refugees who "have been victimised or tortured in their own country" (HP14) had a negative impact on assimilation. This, in addition to the lack of appropriate interpreting services, was believed to impact on their capacity to provide adequate treatment to these patients:
""They have a lot of traumatisation symptoms and it is a difficult task to ask them about the sort of sexual abuse or abuse when they were younger or their background, and then I am limited with the phone interpreter who's often male asking them big questions." (HP5)"
Providers indicated they needed support either through appropriate training or knowing where to refer traumatised patients.
Familiarity with health services
All focus group participants were familiar with a variety of health services (Table 3). These included providers such as GPs, dental clinics and hospitals as well as some allied health services. Mental health services were only mentioned by the Chinese and Tongan participants. Only Vietnamese, Arabic and Sudanese participants consulted multicultural health workers (MHW) or clinicians. In general, with the exception of the Arabic and Sudanese community, knowledge of community based Non-Governmental Organisations (NGOs) providing health care services was poor. Despite a generalised knowledge of health services, some focus groups (Sudanese, Tongan and Chinese) reported a lack of understanding of how the health care system in Australia worked. Furthermore, a low level of health care system literacy was cited by some health care providers as having a detrimental impact on health care for members of the CALD communities.
Accessibility to health care services
Accessibility to health care services were analysed in terms of proximity, availability of services and affordability. These themes are summarised in Table 4.
Summary of perceptions of the accessibility of health care services by focus group participants and providers
EMERGENT THEMES
Health-care Providers
Proximity of health services
Will travel to preferred provider
Lack of available providers overall
Long waiting list for specialists
Long waiting time for treatment in emergency departments
Long operation waiting lists
Shortage of beds in hospitals
Lack of knowledge of health system/services
Socioeconomic factors impacting on access to healthcare
Expense of services
Expense of medication
Restricted access to bulk-billing services
Limited access to appropriate health care services was cited as a significant problem for CALD populations in South-East Queensland. Whilst many focus group participants perceived health services easy to physically access, Sudanese participants found public transport services inadequate and taxi cabs too expensive. The difficulty in physically accessing health services was also raised by health care providers not only for CALD communities but also the mainstream population.
Focus group participants cited the inadequate supply of doctors and nurses as a primary causative factor underlying restricted access to services. This was reported as contributing to long waiting lists for specialist services, elective surgery and the time wasted waiting in the Emergency Department. Health providers mentioned this was not only impacting CALD communities:
""a lot of people …not hav(ing) access to primary and secondary prevention of chronic disease." (HP6) "
Restricted access to health care services for CALD patients was seen to be further compounded by the perceived reluctance of practices willing to treat CALD patients as it "would affect their demographics and their payments from the Government and they don't bulkbill." (HP5)
Access to adequate services was also seen to be limited by a lack of health care providers capable of servicing CALD communities, for example:
""…in Brisbane, I think, there are four or five Spanish speaking doctors providing primary care.. I think they have difficulties with access". (HP4) "
Socioeconomic factors affecting access
Expense of services or treatment was raised by a number of focus group participants, with medications, for example, being too expensive, regardless of socioeconomic circumstances. Specialist services (Sudanese), dental (Vietnamese) and private tertiary treatment (Chinese, Arabic) were also regarded as prohibitively expensive. Restricted access to bulk-billing services (where there is no out-of-pocket contribution from the patient) was also of concern to providers given the low socio-economic status of a significant proportion of the CALD community.
Impoverished circumstances were seen to not only impact access to appropriate health care but also to adequate nutrition, for example:
""…a number of CALD people find it difficult to get a job, so financial income, financial problems, access to affordable and healthy food is also a problem…" (HP6) "
Perceptions of patient-provider interactions
In general, focus group participants and providers were positive about their experiences. Nevertheless, all parties perceived linguistic and cultural incompatibilities had a detrimental impact on the provision of care. The extent to which these impacted on the perception of competency of the provider cannot be determined, however, concerns were raised regarding the professionalism of health care providers. These issues are discussed in further detail below and summarised in Table 5.
Summary of perceptions of patient-provider interactions by focus group participants and providers
Communication problems between patient and provider
Problems with interpreter
Not understanding accent of non-Western providers
Lack of translated &/or health-related information
Cultural issues impacting on treatment
General cultural misunderstanding on behalf of provider
Cultural differences decreasing compliance to treatment
Outright Discrimination
Feeling disrespected &/or undermined
Discriminated against by non-Western providers
General problematic patient-provider interactions
Lack of professionalism on behalf of provider
Erroneous diagnoses
Problems with health provider not operating to appointment schedule
Patients not keeping appointments or often rescheduling
Lack of rapport
Inadequate provision of information of diagnosis/therapy by health provider
Inadequate treatment in hospitals
Lack of training or referral services to enable delivery of appropriate care to trauma victims
Positive interactions between patient and provider
Generally satisfied with treatment
Rapport established with provider
Adequate provision of information regarding diagnosis/therapy by health provider
Communication problems
Like access, the language barrier presented the main impediment to providing adequate health care to members of the CALD community. The extent to which linguistic incompatibilities impacted on the provision of health care varied within and across focus groups. Arabic participants did not report a problem with general communication to the same extent as the Sudanese, for example, but did cite difficulties in understanding the accents of English-speaking Indian or Chinese doctors.
When language presented a problem it affected all levels of treatment with communication breaking down between participants, support staff and health care providers:
""Some receptionists are not friendly and are very rude especially when you cannot communicate properly due to language barrier of an African". (Sudanese)"
The Tongan and Chinese communities also believed their elderly were particularly vulnerable to linguistic incompatibilities:
""…people from Logan drive to Stafford to see Tongan doctor. It is the elderly who want to speak in Tongan. A language issue…" (Tongan)"
Language or communication barriers impacted on the patient's capacity to convey health care needs even when the patient had a reasonable degree of English proficiency:
""The doctor will ask you to describe what kinds of pains you have - I don't know how to do that. So language is an obstacle for me, there are some professional words I don't know" (Chinese)"
It was also perceived as having a detrimental effect not only on the patient's understanding of the disease but also on compliance with treatment:
""…people therefore don't do the proper treatment because they don't quite understand what it's about due to the, just because of the language barrier." (HP9)"
Overall, the provision of adequate interpreting services was seen by both focus group participants and health care providers as critical in improving delivery of services and increasing patients' satisfaction with their care. Merely increasing interpreting services was recognised, however, as an overly simplistic solution to the complexities of delivering adequate health care to this patient population. Using interpreters presented its own difficulties:
""We certainly have had conflict in the past with our qualified health professionals trying to assist and then the breakdown has been around the cultural worker...For example, I can say one sentence about chronic disease and then the health worker can spend fifteen minutes talking about the one sentence supposedly interpreting." (HP14)"
Access to appropriate interpreting services was seen as especially critical when treating traumatised patients. Moreover, if interpreters who did not understand medical terminology were used, the consultation process was regarded as unsatisfactory. Chinese participants in particular felt it was important that interpreters had a good working knowledge of medical issues and terminology:
""…at least the interpreters should have some medical background…" (Chinese)"
The impact of cultural incompatibility
The problems posed by cultural differences went beyond the language barriers, with cultural incompatibility being perceived as a major contributor to many of the misunderstandings between CALD patients and health care providers:
""If there's not cross understanding of the position of the patient, there can be miscommunication, misjudgement, and that can play a part as well….You don't want your clinician to be making a judgement on something that's actually a cultural issue rather than an attitude." (HP8)"
Most focus group participants mentioned cultural differences between patient and provider as being problematic. Cultural incompatibilities between patient and provider were perceived by focus group participants to range from a simple lack of awareness on behalf of the GP:to racism in the primary care context:
" "…lack of cultural awareness for doctors, they don't understand how I feel." (Sudanese) to not sharing cultural norms with mainstream culture:"
" "I think there maybe also a cultural difference, for Australian, people who provide the service they still have their own right you know don't like the doctor or something like that, but in Asian cultures they can't do that." (Chinese), to expressing the need for the health professionals with same cultural background:"
""Involve experiences health practitioners from the Sudanese community who have knowledge on tropical diseases or common diseases in Sudan and addition understands the culture." (Sudanese)"
""Big problem-we are black and doctor white"(Tongan) or at the institutional level with support staff and providers being perceived as "bureaucratic and discriminating." (Vietnamese)."
Chinese and Vietnamese focus group participants felt discriminated against by Asian and Australian providers. When faced with discrimination, participants felt undermined, disrespected and intimidated and felt that it had a negative influence on the perception of their care and the provider. Similar to language difficulties, cultural differences also impacted on compliance with treatment. For example, cultural reasons were seen to underpin non-attendance at appointments and non-compliance with treatment programs with "some people depending on their cultural differences (being) reluctant to take on doctor's advice." (HP11)
Failure to follow medication regimens was seen as a cultural issue, as well as patient preference for alternative methods of treatment. Concern was raised that "they don't often manage their chronic disease well because they're trying to use alternative methods that don't work in this culture where they now live." (HP9)
Perception of lack of professionalism
Whilst members of all groups reported feeling generally satisfied with their medical treatment and/or health services, many focus group participants believed that a lack of professionalism on behalf of providers detracted from or decreased the quality of their care. These problems were widespread and encompassed primary and tertiary health care settings and manifested mainly as diagnostic incompetence:
""My father had been seeing his GP for long time but no improvement in his health, one of the community members advised us to see another GP or a specialist. I took my father to a specialist and he was diagnosed …with cancer." (Sudanese);"
""Three GPs diagnosed three different things" (Tongan);"
The inability or reluctance of health professionals to impart information regarding their diagnoses and treatments was stressed:
"".if you didn't ask them you cannot get the answer. For some people who don't go to the doctor usually, they don't know how to ask these questions. In my view, the doctor should tell you how to prevent directly." (Chinese)"
Whether this perceived lack of professionalism was a consequence of linguistic and/or cultural incompatibility was not clear.
Regardless of the difficulties encountered while providing health care to members of CALD communities, both focus group participants and providers believed their experiences were mutually beneficial, with many focus group participants often being satisfied with their care. The perception of racism or ill-treatment was not pervasive with Arabic, Chinese and Vietnamese participants reporting a high regard for Australian doctors, particularly those who took the time to treat them appropriately. When adequate information or treatment was provided, participants across the focus groups were satisfied:Interactions with patients from diverse backgrounds were reported by providers as being "very positive and a huge learning curve", a "rich experience" and "very rewarding".
""The GP was patient with me and explained in depth and I was contented with the information". (Sudanese)"
Suggestions to improve health care provision for CALD communities
Both focus groups participants and healthcare providers believed improvements could be made in the delivery of health care services to members of the CALD community. In particular, these centred on improvements to human resourcing and increasing the provision of health-related information via various media and methods of dissemination (Table 6). These will be discussed in further detail below.
Summary of suggestions for improvements to healthcare delivery by focus group participants and healthcare providers
SUGGESTIONS FOR IMPROVEMENTS
Increases in human resourcing
More effective interpreters
More multicultural health professionals
More health providers in general
Increase in provision of health-related information
General need for literacy
Common disease in Australia
Prevention of back pain
Prevention/causes of illness
Preferred medium of health-related information
TV/audio
Preferred method of dissemination of health-related information
Community associations/churches
GP or other health provider
Government via community association or directly
Improved interpreting services
Even though there was a general feeling that access to interpreter services had improved over time, many providers and focus groups participants still felt that such services should be expanded to provide a more comprehensive service (especially after-hours and for the elderly), that is gender-sensitive and extended to the relatives of the patient.
Increasing the cultural sensitivity of the health care system
Increasing cultural competence across the health care system was cited as essential. Many providers and focus group participants felt that health care provision would be facilitated if training in cultural awareness was made available or increased, in particular regarding patients from regions of political and religious unrest.
A low level of representation of CALD populations within the workforce was seen as contributing to a lack of resources being directed at CALD communities. This lack of cultural diversity or appreciation of multiculturalism within the wider community was seen by both providers and focus group participants to underlie the problem of cultural incompetence:
""Australians are very ethnocentric and they're not very culturally competent, the ones in Queensland anyway." (HP3)"
""Yes, sometimes the misunderstanding comes from cultural difference." (Chinese)"
In addition to training existing staff, recruiting health-care workers from CALD communities was perceived as essential to improving health care delivery:
""We need to train staff, but we must make sure that within our workforce we have more CALD people, more culturally diverse, so we can train staff that can work with CALD patients, but if we do not have those people, we need to work with the people from CALD groups to work in the area, primary and secondary prevention and treatment of chronic disease." (HP6)"
Consequently, it was believed that the government should "drive a multicultural agenda" to engender a "genuine reflection of our population in our workforce", in an effort to help improve health care outcomes for CALD communities. This solution was also cited by focus group participants at the more prosaic level and was seen to not only make service provision more efficient:to more empowering for the patient:and also more likely to be an acceptable form of intervention for CALD patients:
""…three doctors came for us but they couldn't identify the problem until a Taiwanese doctor came. In only a few minutes he was clear about the problem." (Chinese)"
""The patient can have the confidence to communicate with GPs in regard to their conditions because someone who understands them is there and can help." (Sudanese)"
""Health promotion campaign developed by the Tongan community, more Tongan participate." (Tongan)"
"Health awareness sessions or campaigns similar to those conducted by you can help us because you bring our attention to things we are not aware of" (Arabic, where the speaker is referring to health promotion sessions conducted by Arabic speaking health workers).
Improving health promotion and community services
Health care providers bemoaned the lack of culturally appropriate courses and resources in general, particularly given their utility in Anglo-communities. It was generally acknowledged that "people view their illnesses through their cultural awareness" and that simply providing translation of material directed at the mainstream population was inadequate. Focus group participants wanted more culturally tailored health-related information made available to them using a variety of media ranging from leaflets, newspapers, radio and audio/visual means.It was apparent that an increase in community-based education programs was essential:
""…in terms of health, one of the better things would be to form community organisations that got people togetherrdquo; so "that (the) CALD community can actually change with the support of their family and community." (HP4)"
In particular, "that community group could have that chronic disease focus where people get together and do things together in a culturally safe sort of way." (HP4) and for CALD communities where family is a crucial reference point the need to: "Encourage family based physical activity." (Tongan) reflecting the need for lifestyle management interventions to be accordingly tailored to cultural needs.
Participants suggested making information available through health care providers, community and church organizations. Government organizations should liaise with these communities in order to improve health promotion.
This study highlights the importance of attention to culture, language and health literacy to enable adequate delivery of health services to people from culturally and linguistically diverse communities. A striking finding is the level of concordance between the CALD community members and health care providers regarding their perception of the provision of health-related services. Both groups were generally positive about their interactions with one another, whilst being aware of discriminatory practices within the health care system. Of particular concern to both parties were the barriers presented by language difficulties, cultural differences, health beliefs, lack of culturally competent health providers, limited educational resources, health literacy and low socio-economic status.
Our study emphasises that developing cultural awareness needs to focus on factors other than language. Simply overcoming the language barrier is insufficient to resolve the problems presented by cultural incompetence on behalf of the provider. Cultural competence is critical to understanding a patient's needs and attitudes to health-related issues [16]. This includes appreciating dietary differences, perception of health and disease management [17] and is especially important in the context of treating populations where religious or strong cultural practices influence behaviour, for example integrating the requirement to fast during Ramadan in treatment plans for Type 2 diabetes mellitus in Muslims. Thus lack of culturally tailored information significantly impairs the ability of the CALD populations to make an informed decision about their health [18]. Participants of this study mention that should this approach be adopted, comprehension of disease and adherence to treatment plans would improve. Participants of this study indicated that when a culturally competent or tailored approach is adopted (which they describe for example as having access to health providers from their own cultural community or supporting grass roots community organisations) comprehension of disease and management and their willingness to engage in health-promotional activities increases.
Adopting a multicultural agenda across all levels of the health care system is also reported as essential in improving outcomes for CALD patients in Queensland's strategic health plan [19]. Developing overall cultural and linguistic sensitivity requires change at the system, institutional, professional and individual provider levels, which encompasses shared responsibility by consumer and community engagement, gathering information, refining appropriate methodologies, evaluating the projects and sharing the findings. This recommendation reflects proposals outlined in the Australian National Health and Medical Research Council (NHMRC) Guide on Cultural Competence [20].
The role the community plays in providing support, particularly in the elderly, was also highlighted. The existing evidence indicates that some elderly people from non-English speaking backgrounds may present later than average to specialised services like memory clinics, although there is a bilingual specialist available [21]. Health providers emphasised the need to exploit existing or established community support networks that have a focus on health for CALD populations. Community support groups would provide a culturally sensitive arena from which patients could garner emotional support and access health-related information [22]. The success of community support is evident in the treatment of Type 2 diabetes mellitus in migrant populations [23] for example, and also depression in East African communities [24].
Participants in our study very clearly state that increasing CALD representation within the health workforce should not just be limited to increasing the number of interpreters, but extend to all health care professions [20]. Focus group participants and health care providers have had experiences with multicultural health workers and believe that increasing their availability would mitigate many of the problems both providers and patients face during cross-cultural interactions. Multicultural Health Workers (MHW) are trusted members of the CALD community who are trained to act as front line liaisons with their communities. The shared cultural and linguistic background creates mutual understanding between the patient and the worker which enables them to facilitate access to health services and to deliver culturally competent and quality health services to their community. The model is similar to that of Aboriginal Health Workers which has been developed to improve health care delivery for Indigenous Australians [25]. Perhaps lessons learned from the Indigenous health model can serve as a guideline for improving service delivery to CALD communities.
Health literacy was perceived as an important issue. Focus group participants found medical terminology particularly problematic despite some demonstrating high levels of English-proficiency. This has also been raised elsewhere [26]. Furthermore, translating medical terminology into simple language is particularly challenging if there is no language or conceptual equivalent of certain medical conditions in other cultures, for instance, when treating East African refugees for mental illness as the there is no word for 'depression' in Sudanese or Ethiopian [24]. These examples highlight not only the importance of limiting the use of medical terminology when treating CALD patients, but also recognising that Western medical concepts may not readily translate across cultures [26]. Educational resources are also needed to help develop health literacy in CALD populations. Improvements are not just required in the provision of services per se, but should also be geared towards amending the low levels health literacy of CALD populations [16, 22, 27].
Furthermore, taking these factors into consideration, we are ensuring that health inequities and inequalities, and social constructs of illness are addressed within preventative and primary health care, particularly in lifestyle related chronic conditions for CALD populations [16, 17].
Although, this paper has highlighted some of the unmet health care needs for particular CALD communities they are important to understand the issues around delivery of the comprehensive health care services to multicultural society through monoculturally designed health care system [28].
Limitations and strengths of the study
The main limitation of this study was that we used convenience sampling thereby possibly introducing bias according to Bryman [29]. Our focus group sample was limited to self-referred community members and who reside in the urban area of south east Queensland. We were careful to interview a range of health professionals who had varied experience servicing CALD communities. Nevertheless our sampling technique raises the possibility that not all concerns and opinions regarding health service delivery to members of the CALD population in this setting were uncovered by this study and that the accounts may be biased. The broad range of both positive and negative views and perceived issues raised are consistent, however, with other findings reported in the literature. The other limitation of the study was the lack of no comparisons with mainstream English speaking background population. This will be addressed in a future study. The strength of this research is that focus groups were conducted in the native languages and allowed community members at any level of English language proficiency to participate and express their views. It has minimised loss of data that often happens while using interpreters.
Most importantly this study examined the perceptions of both sides of the health care equation namely the patient and health practitioner. The striking degree in concordance between both parties regarding the provision of healthcare to CALD populations lends further weight to the assertion that improvements need to be made in providing care to these communities.
Our study highlights the need for a different approach to cultural competence of health care services across all levels of the health system in order to improve health outcomes for members of CALD communities [30]. Linguistic and cultural incompatibilities between patient and health care provider need to be redressed in addition to providing resources for patients to understand health-related issues and manage their health [20]. Cultural competencies include recognising the multiple diversities within diversity which supports developing culturally tailored interventions and results in recognising all migrants and refugees being different in terms of health status and health care experiences, cultural and social and environmental determinants of health. Providing a culturally safe and sensitive environment and relevant multicultural workforce for patients to prevent, detect early or self-manage their chronic disease by establishing appropriate community support is also recommended.
NK was employed by ECCQ as chronic disease program manager at the time of the data collection. She is currently supported by a PHCRED novice research fellowship. SB is a post-doctoral researcher at the Discipline of General Practice, School of Medicine, The University of Queensland. She is also a visiting fellow at the Australian National University. MVD is Professor, Head of Discipline of General Practice, School of Medicine, The University of Queensland and visiting professor at Ghent University, Belgium. She was Professor of General Practice and Associate Dean of Research, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia at the time of data collection.
This project was funded by unrestricted grants from the Ethnic Communities Council Queensland and the Primary Health Care Research Evaluation and Development (PHCRED) Program at Bond University, Queensland, Australia. We would like to thank all focus group participants and interviewed health care professionals for their time and valuable input. We thank all involved in organising and carrying out the focus group discussions, transcribing and translating the scripts for their commitment.
The author(s) declare that they have no competing interests.
NK conceived the project and facilitated funding from ECCQ. NK supervised the focus group facilitators. MVD obtained funding through the Primary Health Care Research Evaluation and Development Program at Bond University (PHCRED) and facilitated training of focus group facilitators. SB analysed the data with NK. SB wrote the first draft, edited subsequent drafts and all authors contributed to the manuscript. MVD supervised and guided the project. All authors read and approved the final manuscript.
Faculty of Health Sciences and Medicine, Bond University, Gold Coast, QLD, Australia
Discipline of General Practice, School of Medicine, The University of Queensland, Brisbane, Australia
Department of General Practice and Primary Health Care, Ghent University, Ghent, Belgium
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text:
Alfredo Lim Siojo (Tondó, Manila, 21 de diciembre de 1929-Ib., 8 de agosto de 2020) fue un político y oficial de policía filipino que sirvió como Senador de la República de Filipinas de 2004 a 2007 y como alcalde de Manila en dos ocasiones: la primera de 1992 a 1998 y la segunda de 2007 a 2013.

Carrera
Antes de entrar en la política, Lim sirvió como agente policía durante tres décadas. Durante la administración de la presidenta Corazón Aquino fue nombrado director de la Oficina Nacional de Investigación, cargo que ocupó de 1989 a 1992. Ese año fue elegido alcalde de Manila, sirviendo por dos períodos consecutivos. Posteriormente se presentó sin éxito a la presidencia en 1998. Dos años más tarde fue nombrado por el presidente Joseph Estrada como secretario del Departamento del Interior y de Administración Local.

En 2001 se presentó de nuevo a la alcaldía de Manila pero perdió ante el entonces presidente de la república, Lito Atienza. En las elecciones de 2004 se presentó a senador y resultó elegido. A los tres años de su mandato en el senado, renunció para presentarse como candidato nuevamente a la alcaldía de Manila, donde cumplió dos mandatos consecutivos de 2007 a 2013. En las siguientes elecciones fue derrotado por el expresidente Estrada. En 2019, tanto Lim como Estrada perdieron las elecciones de alcalde contra Isko Moreno.

Debido a su dura postura contra los presuntos criminales, Lim se ganó el apodo de "Harry el sucio" en alusión al personaje interpretado por Clint Eastwood en varias películas.

Fallecimiento
Falleció el 8 de agosto de 2020 a los 90 años, por complicaciones con la enfermedad ocasionada por el COVID-19. Previamente estuvo confinado en un hospital en Manila la capital filipina.

Referencias

Enlaces externos

Senadores de Filipinas
Fallecidos por pandemia de COVID-19 en Filipinas
Policías de Filipinas
Alcaldes de Manila
Fallecidos en Manila
Políticos del Partido Liberal (Filipinas)


text:
Civilian witness contradicts Myanmar police on Reuters reporters' arrest – defense
Detained Reuters journalist Kyaw Soe Oo hugs his daughter as he is escorted by police, to a court hearing in Yangon, Myanmar. (Reuters)
YANGON — The first civilian to testify in the case of two Reuters reporters accused of violating Myanmar's Official Secrets Act contradicted police and prosecutors on Wednesday about where the pair were arrested, a defense lawyer said.
Wa Lone, 31, and Kyaw Soe Oo, 27, were detained on December 12 for allegedly possessing confidential documents, after they had been invited to meet police officers over dinner in the northern outskirts of Yangon.
Win Lwin Oo, 50, a neighborhood chief from another part of north Yangon, was the latest prosecution witness to give evidence in proceedings to decide whether they should be charged under the colonial-era law.
He said he was accompanying police as they conducted traffic searches and witnessed the reporters' detention.
The exact location of the arrests has emerged as a point of contention in the proceedings.
The reporters have told relatives they were arrested almost immediately after being handed some papers at the Saung Yeik Mon restaurant by two police officers they had not met before.
The prosecution and earlier police witnesses have testified the journalists were arrested after they were stopped and searched at a checkpoint at the junction of No. 3 Main Road and Nilar Road, several hundred metres from the restaurant, by officers who were unaware they were journalists. The prosecution has made no reference to a meeting with police prior to their detention.
"We kept arguing about it and during the examination today the witness Win Lwin Oo said it is not No.3 road but Sin Gyi restaurant, which is beside Saung Yeik Mon," defense lawyer Khin Maung Zaw told reporters after the hearing.
Prosecutor Kyaw Min Aung declined to answer questions from reporters. Government spokespeople have routinely declined to comment on the details of the case, citing the ongoing court proceedings.
Earlier on Wednesday, police corporal Kyaw Lwin gave evidence about a discrepancy in police paperwork. He said Kyaw Soe Oo's arrest was recorded as taking place in front of Saung Yeik Mon because the journalist had otherwise refused to sign the form, but like the other police insisted they were arrested at the checkpoint.
At previous hearings, the court has been told that one police officer had burned his notes from the time of the arrest. Another police witness said he was not familiar with police procedures for recording arrests.
Another police witness, Major Min Thant, agreed that the information in the documents Wa Lone and Kyaw Soe Oo were holding in their hands at the time of their arrest had already been published in newspaper reports.
On Wednesday, as the reporters left court during the lunch break, Wa Lone, speaking in English, told reporters: "I should be in the newsroom. I am a journalist. I never did anything wrong. So, I am trying to be strong."
The two reporters had been working on a Reuters investigation into the killing of 10 Rohingya Muslim men who were buried in a mass grave in northern Rakhine state after being hacked to death or shot by ethnic Rakhine Buddhist neighbours and soldiers.
After Reuters published its report on the killings on February 8, calls have mounted for the release of the two reporters.
The United States told a recent meeting of the United Nations Security Council that Myanmar had "the gall to blame the media" for the situation in Rakhine and demanded that the reporters be freed.
Myanmar's U.N. Ambassador Hau Do Suan said the country recognizes freedom of the press and the journalists were not arrested for reporting a story, but were accused of "illegally possessing confidential government documents."
Nearly 690,000 Rohingya have fled Rakhine and taken refuge in neighboring Bangladesh since the Myanmar military launched a crackdown on insurgents at the end of August, according to the U.N.
The U.N. has said the military campaign against the Rohingya may amount to genocide. Myanmar says its security forces mounted legitimate counter-insurgency clearance operations.
U.N. Secretary-General Antonio Guterres has urged the international community "to do whatever it can" to secure the release of two Reuters journalists.
The date of the next hearing was set for February 28.
official secrets act
COVID-19 controls turn Asia into global surveillance hotspot, analysts say
NUJP launches 'Masked Media' movement to raise defense fund for Filipino journalists
'We are a battleground now': In Southeast Asia, US-China tensions flare on social media
New ban on ABS-CBN's digital TV, satellite services fuels press freedom worries
For 'new normal,' local bus firm to upgrade business class with toilet, bath facilities
'All my dreams are shattered': coronavirus crushes Asia's garment industry


So it's Inspiration Monday and today my two birdie friends made it easy for us again - just post a New Year's Eve outfit. While our celebration will be very low key, I still had to add a little bling today and this new sparkly/sequined sweatshirt from Target is just the ticket. I had a gift card, so this entire outfit is courtesy of that gift card! Well ok, I had the boots already, but the rest of it, yay for clearance and gift cards!
2012 was a pretty good year all things considered, I'm actually kind of sad to see it go. I feel like I really got my blogging groove this year and have found my style - though I still don't think I can actually put a "name" to my style. I have had so much fun getting to know more and more of you and am so excited to say I met a bunch of you in person this year - that was really a highlight for me and I hope just the start of more of that to come!
I am not making resolutions, I find I never stick to them anyway. I just want to continue to share my life and my daily style and see where each day takes me. Every day is a new adventure!
And again, I just can't say it enough, thank you so much to all of you who come here and join me for the ride. You're all an inspiration to me and encourage me to keep going - I hope you'll stick around for the fun in 2013!
Love the top - clearance and sale are my two favorite words when shopping! Happy New Year to my very, VERY dear friend.
Awesome night out look! Hope you have a stupendous NYE and a very happy New Year!!
Hurray for sparkles! I hope you have a great New Year's, Beth! It's been great getting to know you and to watch your style evolve.
happy new year!!! it's been a great year, and we are both so happy that you have been a real life friend to us!!
I like the sparkles. Have a Happy New Year!
Hope you have a great evening and a wonderful new year.
Happy New Year lovely Bethie, I've really enjoyed reading your blog over the last few months and your outfit is really lovely for New Year!
Love your top! Sequin stripes are so cute!
Your outfit is adorable! Love the black on black, and the sequins are the perfect touch!