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South African Journal of Psychiatry
S. Afr. j. psyc. vol.27 n.1 Pretoria 2021
http://dx.doi.org/10.4102/sajpsychiatry.v27i0.1570
Alcohol use in Tanzanians with chronic psychotic disorders and poor medication adherence
Emily SimonI; Jennifer B. LevinII, III; Jessie MbwamboIV; Carol BlixenII, III; Isaac LemaIV; Michelle AebiII, V; Godwin NjiroIV; Kristin CassidyII, V; Sylvia KaayaIV; Martha SajatovicII, V, VI
ISchool of Medicine, Case Western Reserve University, Cleveland, The United States of America
IIDepartment of Psychiatry, School of Medicine, Case Western Reserve University, Cleveland, The United States of America
IIINeurological & Behavioral Outcomes Center, School of Medicine, Case Western Reserve University, Cleveland, The United States of America
IVDepartment of Psychiatry and Mental Health, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Republic of Tanzania
VUniversity Hospitals Cleveland Medical Center, Cleveland, The United States of America
VIDepartment of Neurology, School of Medicine, Case Western Reserve University, Cleveland, The United States of America
BACKGROUND: The burden of chronic psychotic disorders (CPDs) in sub-Saharan Africa (SSA) is significant. Poorly medically adherent patients are more likely to have worse outcomes and require more resources. However, factors impacting effective treatment of CPD in this population are unclear.
AIM: Examine the relationship between alcohol use and disease management and compare alcohol risk stratification between the Alcohol Use Disorders Identification Test (AUDIT) and Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) in poorly medication adherent Tanzanians with CPD.
SETTING: Muhimbili National Hospital and ambulatory clinics in Dar es Salaam, Tanzania.
METHODS: 100 Tanzanians with CPDs and suboptimal medication adherence were dichotomized into low and moderate-to-high risk alcohol use based on AUDIT scores and compared regarding medication attitudes, adherence and psychiatric symptoms. Patients completed the ASSIST for comparison to AUDIT risk stratification.
RESULTS: Moderate-to-high risk alcohol users had worse medication attitudes (p < 0.01), medication adherence (previous week, p = 0.01; previous month, p < 0.001), and psychiatric symptoms (p = 0.03). They were younger, predominately male and more likely to have a family history of alcohol abuse. A logistic regression analysis found age, gender and family history of abuse as significant predictors of hazardous alcohol use (p = 0.02, 0.02, < 0.01, respectively). Risk stratification between AUDIT and ASSIST aligned in 85% of participants
CONCLUSION: Alcohol use is an important consideration in treating poorly adherent Tanzanians with CPD. The ASSIST was comparable to the AUDIT in stratifying risky alcohol use with the additional benefit of screening for other substances.
Keywords: schizophrenia; medication adherence; treatment adherence; alcohol abuse; AUDIT; ASSIST; chronic psychotic disorders; sub-Saharan Africa; substance abuse.
Chronic psychotic disorders (CPDs) such as schizophrenia and schizoaffective disorder can pose significant burden to affected individuals1,2 and the communities where they reside.3,4 Reduced quality of life, disorder relapse, impaired personal and professional achievement and premature mortality because of suicide or other causes characterise some of the challenges that can arise when treatment is insufficient.2,5 Concurrent psychosocial services and antipsychotic medications along with appropriate monitoring of health status are the mainstay of disease management.6 However, access and proper utilisation of mental healthcare services are a challenge globally, with estimations as dismal as 76% - 85% of patients in low- and middle-income countries going without treatment.2 Indeed, predictions indicate that mental health resources will be in continued deficit in coming years, amplified by growing disease burden.7 For example, in sub-Saharan Africa (SSA), the most disabling conditions amongst those aged 10-14 years are brain disorders.8,9 This includes regions such as Tanzania, where neuropsychiatric disorders are estimated to make up approximately 5.3% of the global burden of disease.10
In SSA, poor medication adherence is seen in approximately half of those with CPD and is a major driver of relapse.11,12,13,14 In addressing adherence, consideration must be made about factors influencing access and attitudes towards medications in this region. One potential factor is alcohol use.15 Many epidemiologic studies worldwide have demonstrated elevated prevalence of substance use disorders in individuals with schizophrenia compared with the general population.16,17,18,19 Furthermore, substance abuse contributes to poor medication adherence in those with schizophrenia15 and is a predictor of poor outcomes, including premature death, in psychiatric patients.20 Amongst the substances abused, alcohol has been cited as one of the most prevalent, often exceeded only by nicotine.17,21
Most of the available data, however, have been obtained from western countries. Less is known about the relationship between alcohol use and schizophrenia in regions of the world such as SSA where the culture around and availability of alcohol differs from that of North American or European countries. Alcohol use in SSA varies substantially based on the diversity of ethnicities, religion acceptability and political and economic stability.22,23,24 Although limited in number, studies conducted in SSA countries such as Kenya, Zimbabwe and Nigeria indicate that alcohol abuse is prevalent in those with CPD, suggesting a similar pattern to that seen globally.12,25,26,27,28
In Tanzania, substance use appears to be a growing problem. Although country-wide prevalence is less than in other affluent countries, substance use disproportionally impacts those living in poorer areas,29 with tobacco products and alcohol being the most widely used.30 In a study specific to Tanzanian psychiatric patients, this pattern remained. Alcohol and tobacco were the most commonly used substances (59.3% and 38.6%, respectively), with significantly higher rates of use in men than in women.31,32 In addition, the use of cannabis, inhalants, amphetamines and sedatives was observed, albeit in a smaller proportion of patients.
Alcohol use specific to Tanzanians with CPD appears absent in the current body of literature, warranting further exploration of this unique patient population. In addition, amongst individuals with CPD, research assessments can be burdensome given that the conditions impede concentration and one's ability to participate in more lengthy interviews. Thus, comparing the responses and characteristics of alcohol use captured by two frequently used relatively brief questionnaires, the Alcohol Use Disorders Identification Test (AUDIT) and the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), in this specific patient population could streamline the interview process and further validate the use of these measures in the unique sociocultural context of Tanzania. This study examines the relationship between patterns of alcohol use and patient demographics, medication attitudes, adherence and psychiatric symptoms in Tanzanians with CPD. In addition, it provides a comparison of the AUDIT and ASSIST, discerning how the measures complement each other and assess different or overlapping aspects of alcohol use in this population.
The data for this cross-sectional study were collected as part of a larger 3-phase/3-aim 24-month project focused on medication adherence enhancement in Tanzanians with CPDs and a history of poor medication adherence. The first phase of the study consisted of an observational mixed-methods (quantitative and qualitative) approach aimed at assessing reasons for poor treatment adherence amongst Tanzanians with CPD. The data and analysis described in this article were derived from the phase 1 quantitative assessment, collected between April and December of 2018. All study assessments and questions asked to patients were translated into Swahili and collected by research assistants trained by the study's principal investigators. A more complete methodological overview of the project is described elsewhere.33
A total of 100 individuals with CPD were recruited from Muhimbili National Hospital and its associated ambulatory clinics, a number estimated to represent 20% of individuals with CPD in that clinical setting at the time. Those who self-reported missing 20% or more of their antipsychotic medication within the last month as measured by the Tablets Routine Questionnaire (TRQ),34 an established benchmark for poor adherence,35,36 were eligible to participate. Patients were of 18 years or older with a clinical diagnosis of schizophrenia or schizoaffective disorder who had recently been hospitalised because of relapse of disease symptoms related to sub-optimal treatment adherence. Exclusion criteria included history of allergy or intolerance to haloperidol or haloperidol decanoate, immediate prior use of long-acting injectable antipsychotic medication, medical condition or illness that would interfere with the patient's ability to participate (determined by research psychiatrist), physical dependence on substances likely to lead to withdrawal reaction during the study course, immediate risk of harm to self or others, pregnancy or breastfeeding. Written informed consent was obtained from all the participants and the study was approved by the local Institutional Review Board (IRB).
Alcohol Use Disorders Identification Test and Alcohol, Smoking and Substance Involvement Screening Test assessment, scoring and indications
Substance use was measured using the AUDIT37 and ASSIST38 tests. Both measures were developed by the World Health Organization (WHO) and have been validated in settings globally.39,40
Since the original development, the AUDIT has become one of the most heavily studied and widely used screening measures for risky alcohol consumption,41,42 with sensitivity in the mid-0.90s and specificity around 0.80s in the test development samples.39 The AUDIT consists of 10-items specific to alcohol use. The questions are categorised by the WHO as capturing three domains of drinking behaviours: hazardous alcohol use (frequency and quantity), symptoms of alcohol dependence (control over drinking, prominence of behaviour and morning consumption) and harmful alcohol use (emotional impact of drinking, memory loss, injuries and others' concern).
Scores of 8 or more are considered indicators of hazardous (8-15), harmful (16-19), high risk (20 or more) and/or dependent alcohol use, with a total possible score of 40. The categories provide indications for varying levels of intervention, such as simple advice (hazardous, score of 8-15), brief counselling and continued monitoring (harmful, score of 16-19) or referral to a specialist for diagnostic evaluation and treatment (high risk, score of 20-40). Alcohol dependency is scored independently by adding up the scores of questions 4-6, with a score of 4 or more (maximum score = 12) indicating the need to assess for dependency, even if in a lower risk category.39
The 8-item ASSIST evaluates a range of substances, including alcohol, tobacco, cannabis, cocaine, amphetamines, inhalants, sedatives and hallucinogens. The first question assesses whether a respondent has ever used a given substance using a binary 'yes/no' response. Responses of 'no' terminate further questioning about that particular substance. Questions 2-7 assess frequency, craving, use-related problems, others' concern and control over use. The questions are repeated for any substance a respondent indicated as having used previously in question 1. The final question asks whether the participant has ever used any substance via injection.
Each substance is scored individually. For alcohol, scores of 0-10 indicate low risk and no need for intervention, scores of 11-26 indicate moderate risk and receiving a brief intervention and scores of 27 indicate high risk and the need for more intensive treatment. All other substances are divided into similar categories of low, moderate and high risk, but with cut-off scores of 0-3, 4-26 and 27 or more, respectively.40
Additional data collection
Information on demographic and clinical characteristics relevant to CPD relapse was collected using several previously validated measures. The degree of adherence was assessed using the TRQ,34 which captures the proportion of days with medication doses missed in the past 1 week and 1 month. The questions are answered for each of a patient's prescribed medications. A higher score indicates worse adherence.34
In order to assess the barriers to adherence and attitudes towards medication, participants completed the Rating of Medication Influences (ROMI),43 the Attitudes towards Mood Stabilisers Questionnaire (AMSQ),44,45 and the Drug Attitude Inventory (DAI).46 The ROMI was originally developed for populations with schizophrenia, in which it was found to be reliable, clinically sound and valid when compared with other independent measures of attitudes and adherence.43 For the current project, only Part II of the questionnaire was administered, which is comprised of 10 items that ask directly about influences leading to non-adherence (including how medications make one feel, medications' effect on goals and appearance to others, support system's opinion on medications, access to medications). The AMSQ is a modification of the Lithium Attitudes Questionnaire45 that evaluates attitudes towards psychiatric medication, consisting of 19 items grouped into 7 subscales (general opposition to prophylaxis [4 items], denial of therapeutic effectiveness [2 items], fear of side effects [2 items], difficulty with medication routines [4 items], denial of illness severity [3 items], negative attitudes towards drugs in general [3 items] and lack of information about psychiatric medication [1 item]). Higher scores indicate more negative attitudes towards mood stabilisers. Recent work found the AMSQ to be valid (with test-retest reliability of p = 0.73) and sensitive to changes in time as evidenced by changing scores correlating with changes in the TRQ.47 Finally, the DAI was used to assess attitudes towards medication in individuals with serious mental illness, consisting of 10 items in a 'true or false' format.46 It has been shown to be relatively unaffected by psychiatric symptom severity48 and is scored via a continuum, ranging from -10 to +10, with higher scores indicating better attitudes. Reliability was determined by the developers to be 0.93.49
Chronic psychotic disorders symptoms were assessed using the Brief Psychiatric Rating Scale (BPRS),50 which consists of 18 items scored on a 1-7 scale. It assesses both the major psychotic and non-psychotic symptoms in those with serious mental illnesses. The measure has been widely researched and validated, with reliability coefficients reported to be between 0.63 and 0.87.49
Global psychopathology was measured using the Clinical Global Impressions (CGI) scale,51 which evaluates illness severity on a 1-7 point scale. Reported reliability scores for severity illness range from 0.41 to 0.60.49
Life and work functional status were evaluated using the Social and Occupational Functioning Assessment Scale (SOFAS).52 The SOFAS is derived from the Global Assessment of Functioning (GAF), which consists of a 100-point single-item scale that measures global functioning of psychiatric patients. Lower scores indicate lower functioning. It has been shown to be reliable and valid in studies involving patients with serious mental illness,53 with reliability coefficients ranging from 0.62 to 0.82.49
Alcohol abuse risk dichotomisation and statistical analysis
Participants were dichotomised into groups based on AUDIT scores. Participants who scored 7 or less were deemed 'low risk', whilst those who scored 8 or more were deemed 'moderate to high risk'. Given the small number of participants with scores 8 and above, all such participants were merged into a single group. These risk groups were compared on attitudes towards medication, medication adherence, psychiatric symptoms and demographics. Comparisons were made using two-tailed t-tests for normally distributed variables and Mann-Whitney U for non-normal TRQ distribution. A chi-square test was used for comparisons of tobacco and cannabis use between dichotomised alcohol risk groups.
The UH IRB operates under HHS Federalwide Assurance (FWA) number 00003937 and IRB registration numbers 00000684, 00001691 and 00008600. The CWRU IRB operates under DHHS FWA00004428 and IRB registration number 00000683.
Alcohol use risk groups
Table 1 reflects the AUDIT risk categorisation based on the WHO scoring guidelines. Of the 100 participants, 72 scored 7 and below (defining the study's 'low risk' participants), whilst 28 scored 8 and above (defining the study's 'moderate to high risk' participants). Of those in the latter group, nine participants scored as 'almost certainly dependent on alcohol' in the dependency subscale.
Table 2 presents the analysis of demographics by alcohol use group. No statistically significant differences were observed between low risk versus moderate to high risk participants in marital status, education level or employment status. The ages of the moderate to high risk users were significantly younger than the low risk participants (32.39 vs. 36.99 years, respectively; p = 0.02) and moderate to high risk users were less likely to have children than low risk participants (39.3% vs. 63.9%, respectively; p = 0.04). Furthermore, a significantly higher proportion of moderate to high risk users were male as compared to female (p < 0.01).
With regard to CPD variables, there was no significant difference in the age of onset, illness duration, medication prescribed or lifetime hospitalisations. Although family history of mental illness did not significantly differ between groups, there was a significant difference in family history of alcohol abuse, with 64.3% of moderate to high risk participants reporting a family history of alcohol abuse as opposed to 34.7% of low-risk participants (p < 0.01).
Medication adherence, psychiatric symptoms and attitudes towards medication
Table 3 presents the scores on various questionnaires. Those with moderate to high risk had significantly higher scores on the TRQ, indicating a greater percentage of days in which at least one dose of medication was missed, in both the past 1 week and the past 1 month (p = 0.01 and p < 0.001, respectively). Moderate to high risk users also scored significantly higher on the AMSQ and ROMI, both of which indicate more negative attitudes towards medication (p < 0.01 and p < 0.01, respectively). On the BPRS, reflecting the severity of psychiatric symptoms, moderate to high risk users scored significantly higher (p < 0.05). No significant difference was observed on the CGI, SOFAS or DAI.
When separated by gender, moderate to high risk men had significantly higher scores on the TRQ for adherence over the past 1 month and on the AMSQ than low-risk men, but all other measures did not show any statistical difference. Given that so few women were in the moderate to high risk category (n = 4), further interpretation was not possible for women (data not shown).
Logistic regression model
A logistic regression model was performed with eight variables used to predict moderate to high risk alcohol use. The variables selected were significantly correlated with moderate to high risk alcohol use on bivariate analysis and included age, gender, having children, family history of alcohol abuse, medication adherence over the past month (as determined by the TRQ), psychiatric symptoms (as determined by BPRS) and two measures of medication attitudes (AMSQ and ROMI). The model fit the data well (omnibus test of model coefficients, chi-square = 41.50, degrees of freedom = 8, p < 0.001; Nagelkerke R-square = 0.502; Hosmer and Lemeshow test, chi-square= 10.59, degrees of freedom = 8, p = 0.226) and correctly classified 83.5% of study participants.
Age, gender and family history of abuse were significant predictors. According to the model, for every increase in age by 1 year, individuals have a 9.7% decrease in odds of moderate to high risk alcohol use (odds ratio [OR] = 0.903; 95% confidence interval [CI], 0.83-0.99; p = 0.02). Men are 7.01 times more likely than women to have a moderate to high risk alcohol use (OR = 7.01, 95% CI, 1.46-33.82, p = 0.02). Individuals with a family history of alcohol abuse are 6.46 times more likely to have a moderate to high risk alcohol use (OR = 6.46, 95% CI, 1.77-23.59, p < 0.01). All other predictors were not significant.
Additional substance use
Table 4 presents reported substance use on the ASSIST. Alcohol, tobacco, and cannabis had the highest risk use rates (moderate to high risk users).
Table 5 presents the tobacco and cannabis use compared between low and moderate to high risk drinkers. Those with moderate to high risk alcohol consumption reported significantly higher rates of both tobacco and cannabis use on the ASSIST when compared with the low-risk participants (p < 0.01 and p < 0.001, respectively; Table 5).
Alcohol Use Disorders Identification Test versus Alcohol, Smoking and Substance Involvement Screening Test responses
Table 6 presents a comparison between the AUDIT and the alcohol-specific ASSIST responses. Of the 100 participants, 85 were assessed as having similar risk in drinking behaviour via both measures (i.e. scored to be in an equivalent risk categorisation). Of the 15 participants who were discrepant between the two measures, only one participant was discrepant by two risk categories, scoring high risk on the AUDIT but low risk on the ASSIST.
The results of this study suggest that alcohol use is an important consideration in the landscape of disease management for those with CPD and poor medication adherence in Tanzania. In 100 patients experiencing relapse of their disorder, over a quarter presented with appreciable risk in terms of alcohol consumption (28%) as defined by the AUDIT. Interestingly, of those who reported any alcohol use at all, that is, including low-risk drinkers, over half were assessed to be at moderate-to-high risk for abuse (58.3%). This may reflect the significant population of lifetime abstainers commonly seen in Tanzania,39 as 52 of the participants reported no alcohol use whatsoever (scoring a zero on the AUDIT), representing the majority of the low-risk participants. This has important clinical implications as the apparent prevalence of risky alcohol use may be masked by large numbers of lifetime abstainers. If the absolute prevalence impacts clinical screening practices, the significant minority of patients with alcohol use problems may be missed and the opportunity for appropriate interventions may be lost.
Evidence for this pitfall has been recorded elsewhere in SSA. In a study at Mathari Psychiatric Hospital in Kenya, of the 238 patients who met Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for substance abuse disorder, only 49 had 'substance use disorder' as part of their current admission differential diagnosis. Furthermore, despite alcohol dependency being the most common Structured Clinical Interview for the DM (SCID) substance abuse disorder, the authors noted that this was rarely recorded in the hospital diagnosis and only 12 patients were receiving drug rehabilitative treatment.25
Demographically, moderate to high risk users differed significantly in terms of age, number of children, family history of substance abuse and gender. Of the significant bivariate differences, age, gender and family history of alcohol abuse were found to be significant predictors of moderate to high risk alcohol use (whilst the number of children was not) in our logistic regression model. The trend towards risky drinking in younger participants is congruent with recent work suggesting high rates of alcohol consumption in youth in Tanzania.54,55 The observed association between moderate to high risk alcohol consumption and family history of substance abuse is consistent with a large body of work suggesting family history as a predictor of substance abuse.56,57 Finally, male predominance in patients reporting moderate to high risk alcohol consumption is consistent with that observed in other populations throughout Tanzania,55,58,59 including the previous study involving Tanzanian psychiatric patients.31 Women with schizophrenia have been found to have lower rates of substance abuse across many diverse regions of the world.60
Risky alcohol use in those with CPD was associated with poorer medication adherence, worse attitudes towards medication (as measured by the AMSQ and ROMI) and greater severity of psychiatric symptoms. This aligns with other studies examining non-adherence to antipsychotic medications. In one systemic review, negative attitudes towards medication and substance abuse emerged as the most consistent correlates to poor adherence.15 Although the causality between these factors cannot be determined from this study, it is reasonable to assume that addressing risky alcohol use would be a logical addition to the treatment plan for those with CPD and poor adherence, particularly in light of the correlation with symptom severity.
The study's findings are better appreciated when compared with the general Tanzanian population. The 2018 WHO report on alcohol estimated 47.1% of the population aged 15 years and older to be lifetime abstainers and 63.6% to have abstained from drinking alcohol over the past 1 year. This is consistent with this study population, where 63 (63%) participants reported 'Never' on the AUDIT to the question 'How often do you have a drink containing alcohol?' However, rates of alcohol use disorders (as defined by the WHO report as 'including alcohol dependence and harmful use of alcohol') and alcohol dependence were greater in the study population. A total of 13% of participants had 'high-risk or harmful level' or 'dependent on alcohol' categorisation via the AUDIT, compared with WHO estimates of 6.8% for alcohol use disorder in the general population. In addition, 9% of the study population were almost certainly dependent on alcohol, whilst only 2.4% of the general population were predicted to have alcohol dependency.58 Although such comparisons are crude, they provide an important sociocultural context. The trend that those with CPD have higher rates of substance abuse than the general public is consistent with that seen in westernised countries.17 However, without comparing the rates seen in Tanzanians with CPD against the background estimates of Tanzanians in general, this trend might be missed, as the absolute rates (13% and 9%) are much lower than those seen, for example, in the United States of America (one study reported, as a comparison, 33.7% of those diagnosed with schizophrenia or schizophreniform disorder to meet the criteria for alcohol disorder17). One might suspect that, based on the findings of the WHO report, the lower rates seen in Tanzanians with CPD in this study than those seen in westernised countries is a function of the underlying accessibility, normative use and disposable income driving alcohol consumption practices in a more underdeveloped country - however, more work is needed to determine that conclusively.
An important consideration in detecting substance abuse in any patient population (and particularly in vulnerable patients with CPD who struggle with medication adherence) is the efficiency and validity of the screening measure used. The ASSIST, similar to the AUDIT, was developed by the WHO as a response to the global burden of psychoactive substance use.40 Screening for risky substance use over a range of substances, including alcohol, it offers an opportunity to streamline the clinical assessment whilst capturing a more complete picture of substance use than the AUDIT. For example, tobacco and cannabis were also used by many patients and those with riskier alcohol consumption were more likely to smoke tobacco and use cannabis (Table 5).
This study showed overlap in the risk categorisation between the AUDIT and ASSIST (Table 6), suggesting that the ASSIST captures an individual's alcohol risk similar to the AUDIT. Most of the participants had an equivalent risk stratification between the two measures (85%) and of the 15% who were incongruent, only one participant was incongruent by more than one risk categorisation (one participant scored 'high and harmful risk' on the AUDIT but 'low risk' on the ASSIST). The WHO outlines similar interventions for low, hazardous, high/harmful risk drinking on the AUDIT with that of low, moderate and high-risk drinking on the ASSIST. Thus, despite questions differing between the measures, the high degree of overlap with regard to these categorisations should, clinically speaking, reflect similar outcomes for patients if screening tools are followed as advised. Paired with the additional information provided by the ASSIST - in particular, the risky use of tobacco and cannabis - this early work suggests that the ASSIST may help to streamline the clinical interview by capturing a more complete picture of substance use without compromising information on a patient's pattern of drinking.
This study highlights that substance use, and in particular alcohol use, is a factor in the clinical picture of Tanzanians with CPD and poor medication adherence. As adherence has important implications for individual, family and societal burden of disease, managing the factors that intersect with worse adherence is a logical step in disease management. The work presented in this article represents some of the first data to support this claim in the unique study population.
Limitations and future work
This study has several limitations. Firstly, despite the study population constituting particularly vulnerable patients, likely in need of greater assistance and treatment resources, they represent a fairly specific subset of those in Tanzania with CPD. All the participants had recently been hospitalised and all had reported significant troubles adhering to their medications. Thus, although a potentially high-risk group, their pattern of substance use and unique distribution of attitudes towards adherence and psychiatric symptoms may not generalise to others with CPD in Tanzania.
Secondly, this study is limited in commenting on what disease management might include. What has been learnt about patterns of substance use and attitudes towards adherence, along with known interventions and previous research, must be translated into a tangible, individualised and comprehensive treatment plan. This should include assessing attitudes and willingness of Tanzanians with comorbid CPD and substance abuse to engage in treatment specific to substance use. Future work is needed in order to create substance abuse interventions that are appropriate to the unique sociocultural context experienced by those living with CPD in Tanzania.
There are limitations inherent in the sample size of the study as well. For example, comparisons were only made between low and moderate to high risk alcohol use despite the AUDIT outlining four categories of risk regarding alcohol consumption, given the small number of participants in some of the risk groups. Furthermore, this study is limited in terms of the number of female participants, particularly those at high risk of alcohol abuse. Although consistent with low rates of use seen nationally, it prevents interpretation of how alcohol use impacts treatment adherence specific to women with CPD in Tanzania.
Finally, many measures used in this study have been extensively validated in western countries, but similar validation in comparable African populations is scarce. Our study offers a preliminary comparison between the ASSIST and AUDIT, suggesting that the ASSIST is sufficient in capturing risky alcohol use in Tanzanians with CPD whilst offering the opportunity to capture additional substance use. However, the relatively small sample size and exploratory nature of this study limited more complex psychometric analyses. Also, practical implications (the time it takes to administer each questionnaire, participant's receptivity to taking the questionnaire and usability for those administering the questionnaire) were not captured in this study. Future work is necessary to strengthen the argument for the use of the ASSIST as a streamlined instrument in the clinical practice of capturing alcohol and other substance use in Tanzanians with CPD.
This study highlights hazardous alcohol use and its relationship with health behaviours and outcomes in those with serious mental illness, even in areas of the world where the sociocultural context around alcohol consumption varies from that of developed countries. This study observed the nexus between treatment non-adherence in CPD and that of alcohol use. Finally, this study provides evidence to support screening for alcohol substance use with validated, brief questionnaires such as the AUDIT and ASSIST in those with CPD in SSA.
Dr Martha Sajatovic has received grants from Nuromate, Otsuka, Alkermes, and the International Society for Bipolar Disorders (ISBD); is a consultant for Alkermes, Otsuka, Janssen, Myriad, Health Analytics, and Frontline Medical Communications; has royalties with Springer Press, Johns Hopkins University Press, Oxford Press, and UpToDate; and has been compensated for preparation of the following CME activities: American Physician's Institute, MCM Education, CMEology, Potomac Center for Medical Education, Global Medical Education, Creative Educational Concepts, and Psychopharmacology Institute. The other authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Ms Simon, Drs Sajatovic, Kaaya, Mbwambo, Blixen, Levin and Lema, Mr Njiro, Ms Cassidy, and Ms Aebi all contributed to either the initial design or refinement of the project design. All authors have approved the manuscript and the report is a reflection of team consensus.
This work was supported by a grant from the National Institute of Mental Health (grant number: R21MH1114700-01) (Principal investigators: Mbwambo and Sajatovic).
The data that support the findings of this study are available from the Tanzanian National Medical Research Institute but restrictions apply to the availability of these data, which are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Tanzanian National Medical Research Institute.
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any affiliated agency of the authors.
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33 . Mbwambo J, Kaaya S, Lema I, et al. A customized adherence enhancement program combined with long-acting injectable antipsychotic medication (CAE-L) for poorly adherent patients with chronic psychotic disorder in Tanzania: A pilot study methodological report. Heliyon. 2019;5(6):e01763. https://doi.org/10.1016/j.heliyon.2019.e01763 [ Links ]
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35 . Velligan DI, Weiden PJ, Sajatovic M, et al. Strategies for addressing adherence problems in patients with serious and persistent mental illness: Recommendations from the expert consensus guidelines. J Psychiatr Pract. 2010;16(5):306-324. https://doi.org/10.1097/01.pra.0000388626.98662.a0 [ Links ]
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41 . Higgins-Biddle JC, Babor TF. A review of the Alcohol Use Disorders Identification Test (AUDIT), AUDIT-C, and USAUDIT for screening in the United States: Past issues and future directions. Am J Drug Alcohol Abuse. 2018;44(6):578-586. https://doi.org/10.1080/00952990.2018.1456545 [ Links ]
42 . De Meneses-Gaya C, Zuardi AW, Loureiro SR, Crippa JAS. Alcohol Use Disorders Identification Test (AUDIT): An updated systematic review of psychometric properties. Psychol Neurosci. 2009;2(1):83-97. https://doi.org/10.3922/j.psns.2009.1.12 [ Links ]
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54 . Francis JM, Weiss HA, Helander A, Kapiga SH, Changalucha J, Grosskurth H. Comparison of self-reported alcohol use with the alcohol biomarker phosphatidylethanol among young people in northern Tanzania. Drug Alcohol Depend. 2015;156: 289-296. https://doi.org/10.1016/j.drugalcdep.2015.09.027 [ Links ]
55 . Francis JM, Weiss HA, Mshana G, Baisley K, Grosskurth H, Kapiga SH. The epidemiology of alcohol use and alcohol use disorders among young people in Northern Tanzania. PLoS One. 2015;10(10):e0140041. https://doi.org/10.1371/journal.pone.0140041 [ Links ]
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Emily Simon
efs67@case.edu
Accepted: 28 Jan. 2021
Published: 19 Mar. 2021
Project Number: CR00002972
AOSIS Publishing
15 Oxford Street, Durbanville, Cape Town, Western Cape Province, ZA, 7550,
publishing@aosis.co.za


When we hear STEM, we think of the traditional science, technology, engineering and math disciplines. But STEM fields open a world of opportunities for careers. Susanne Lettner is a marketing specialist (focus: corporate communications) working at a mechanical engineering company. She is an ambassador for the Berlin-based initiative "MINT Zukunft schaffen" (MINT is the German translation for STEM). Furthermore, she is an ambassador for the Vienna based initiative "Young Science". "Young Science" is a Center for the Cooperation of Science and School. We spoke with Susanne about her promotion of STEM for boys and girls.
"STEM is an important field and it helps to shape our future through technology. For that we need smart, creative and bright people working on solutions. People in STEM are the inventors and they work to make our planet a better place for everyone", says Susanne. She and other ambassadors of the Berlin-based initiative, MINT Zukunft schaffen, help boys and girls to find their way into the STEM field. For that "MINT Zukunft schaffen" works together with schools, Universities and companies across all industries.
Age-related STEM events are a great way to spark young people's interest in a STEM profession. Susanne Lettner has planned and organised different STEM events for boys and girls. She enjoys inspiring pupils and students with science, technology, engineering and math disciplines and to give them an understanding of STEM fields. "My experience has shown, that STEM events should be diversified. A STEM event can include a tour through the company, a discussion and a practical part. The discussion is important. Young people can ask many questions and the employees can talk authentically about their occupational history and their workday. Also the employees can explain the young visitors their daily work challenges or they can present their exciting projects. The practical part is fun! Boys and girls have the possibility to spring into action. The exercises should be co-ordinated to the different age levels. Young people have to try out to arouse curiosity".
That STEM events to be able to come about at all, good cooperation between the companies, schools and universities are important. On the one hand, potential employers have to budget time for the STEM events and take a welcoming, open attitude. On the other hand, it is necessary that motivated teachers and lecturers from schools and colleges participate and playfully introduce young people to the STEM area. Therefore, companies, as well as schools and universities should meet in partnership, because the cooperation benefits both sides sustainably. So the hope is, that one or the other participant is motivated by the STEM event and starts a STEM training.
In order to get a positive image for the STEM field, good examples from practice are helpful. Media coverage can show that a STEM job is creative and diversified. This allows reporting on outstanding, innovative projects or ideas of people who authentically present their professional activity. Especially to show that women in the field of STEM are actively represented, help girls to self-confidently decide in this area. A rethinking in the public occurs when good examples are known. Authentic information removes stereotypes.
Susanne Lettner earned her Bachelor's Degree in Journalism and PR, and Master's Degree in Dance Studies from Free University Berlin. She also took part in the International Business Program "International Strategy and Structure" at the Business School ESCP Europe, Business School Berlin. Additionally, she completed her studies as Online-Marketing-Manager at the German Press Academy Berlin. Susanne Lettner is a marketing specialist with a focus on corporate communications and she works at a mechanical engineering company. In her professional career, she writes about topics such as e-mobility, autonomous driving, digitization or Industry 4.0. She is an ambassador for the Berlin based initiative "MINT Zukunft schaffen" (MINT is the German translation for STEM). Furthermore she is an ambassador for the Vienna based initiative "Young Science". "Young Science" is a Center for the Cooperation of Science and School.


TIFF wouldn't be TIFF without the NFB. In fact, cinema history in Canada effectively starts with the formation of the Board 75 years ago this year. Veterans of the festival (back in the day when it was called the Festival of Festivals) will fondly recall that the Canadian film party was hosted by the Board for many years before it was supplanted by the even more extravagant "schmooze" hosted by our own Moses Znaimer at CityTV. Early festivals premiered many NFB films and that practice continues this year with the launch of two strong documentary features, The Wanted 18 and Trick or Treaty?
Before getting into discussing them, it's nice to note that TIFF is paying a small tribute on his centenary to the NFB's first animator, the great Norman McLaren, with the screening of his wonderfully abstract and innovative 3-D piece Around is Around. McLaren was Canada's first star director, winning an Oscar, a Palme d'Or at Cannes and a Silver Bear at the Berlin Film Festival for three of his films—Neighbours, Blinkity Blank and Rhythmatic—during his heyday in the 1950s.
Still going strong in her 80s is one of the Film Board's icons, Alanis Obomsawin. The preeminent First Nation's filmmaker in the world, she was recruited by the Board in the late "60s and has remained with them for well over 40 years creating a remarkable body of work that has cast a clear light on the injustice system that has created an impoverished way of life for many of Canada's indigenous peoples. There's love, wit and passion in Obomsawin's film—they're not dry and solely didactic. But it's fair to say that her films do burn with a righteous anger at the ongoing treatment of her people in this supposedly enlightened country. (Mind you, Canada does have the NFB, her employers; we're not all bad).
Obomsawin's new film Trick or Treaty? is one of her best documentary features. It takes on a difficult subject, the infamous 1905 Treaty number 9 and the equally nefarious Bill C-45 (proposed and passed by the current Harper administration). She makes these two legal documents relevant to a contemporary film-going audience by placing them in a controversial and newsworthy event, the Idle No More rise-up in 2012 when Chief Theresa Spence of the Attawapiskat nation staged a hunger strike in protest of Harper's Bill C-45 bill.
Cutting between scenes of the massive demonstrations held in Ottawa with Spence present and talks with other prominent First Nation's figures—often chiefs—about the pernicious effect of the 1905 Treaty, the NFB's masterful director dramatizes to what extent politics can affect people. The 1905 Treaty is a notorious example of how an imperialist power and a mega-corporation—Canada, through the British Empire and the Hudson's Bay company—manipulated naïve Chiefs to give away the exclusive rights to much of Northern Ontario and parts of Quebec in exchange for more financing for reserves and the reassurance that a partnership would ensue.
Shot mainly in verité style, Obomsawin's film reaches a superb peak in a highly pictorial and emotional climax that evokes the power of the land and the claims of First Nation's peoples to it.
The Wanted 18 tackles another major topic, the conflict between Israeli authorities and the Palestinians. Set during the first Intifada in the late 1980s, it relates one of those crazy documentary stories that can only work because it's true. With the Israeli occupation at its height, Palestinians in the West Bank town of Beit Sahour were bereft of dairy products. Town leaders bought 18 cows and set up a collective farm to answer a basic need—to have milk.
The Israelis tried to seize the cows only to find that they'd disappeared into the mountains and rough terrain in the area. Countless attempts proved unsuccessful as the cows and their Palestinian farmers became masters at finding new, inaccessible spots where they could hide—leaving the milk to flow and the Israelis to become angrier and angrier.
This amazing tale is recreated by Palestinian artist Amer Shomali and veteran Canadian doc director Paul Cowan using stop-motion animation, interviews and drawings to illustrate how people can survive nearly anything if they have imagination and faith.
Co-produced with foreign partners and Montreal's Ina Fichman of Intuitive Pictures, this NFB film is bound to draw attention at the Festival. With its combination of animation, drama and documentary, The Wanted 18 fulfills the NFB's promise of presenting human rights issues through a diverse set of genres and styles—to properly inform Canada about the world around them.


Proper care of your office equipment will keep your business running smoothly. Regular maintenance may reduce maintenance calls for your computers, printers and fax machines.
Before doing anything, you need to turn off your device. Unplug it as well. This is the most important step. If you don't follow it you could do some serious damage to the hardware.
Take a soft cloth (a microfiber cloth is recommended), slightly dampen it with water and start scrubbing. Be careful when going around ports, you don't want any liquid getting in there.
Start cleaning the screen by wiping it down with a dry cloth. Go from corner to corner. Next, take the cloth and dampen it with some water. If you don't think plain old water will get the job done, you could make a cleaning solution with 50 percent vinegar and 50 percent water. But don't use cleaning solutions! In fact there are a lot of "don'ts" when cleaning computers, so it's best just to follow these instructions. Speaking of which, don't drench the cloth. If it's dripping wet, you overdid it.
If you're a multitasking heathen who eats while using the computer... well, you're just like everyone else. It also means you have crumbs between, on, or inside your keys. You need to get those out before you come in with the damp cloth—like sweeping the floor before mopping.
Use a can of compressed air to clear the crumbs from the surface. If you don't have one, a small fan may work. If you're really desperate, you could employ a drinking straw and use lung-generated wind power. Just get the crumbs out.
Next, take out a clean cloth, the isopropyl alcohol, and some Q-tips. Take the cloth and dampen it with the alcohol. Run the cloth over the keys and make them shiny. Then take the Q-tip and get in-between the keys. You can dip the Q-tip in alcohol, but stop short of a full soak; you don't want a puddle of alcohol to spew out when you press down.
Once you've run the key maze, the alcohol should dry within a matter of minutes. Voila, you're halfway done to completely cleaning your computer.
Keep ventilation holes on the computer clear of blockages from dust or other items on the desk to prevent overheating. Use compressed air to blow dust and debris from all vents.
Open removable parts of the printer and wipe the insides with a dry, clean cloth.
Keep a fax machine in a dry room. Humidity can cause paper to stick together. Place fax machines at least six inches from walls for adequate ventilation around the equipment. Fan paper with your hand before inserting it in the fax machine. This prevents the machine from taking too much paper and jamming in operation.
Never force ANY office machine to open. When doing maintenance cleaning, only access parts of the machine that open easily.


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ELCA presiding bishop, other faith leaders call for arms reduction agreement extension
ELCA Presiding Bishop Elizabeth Eaton has been joined by 21 U.S. religious leaders in a Jan. 19 statement to President-elect Biden's transition team calling for an extension of the New Strategic Arms Reduction Treaty (New START) agreement. This is a nuclear arms reduction treaty, jointly agreed to by the United States and the Russian Federation 10 years ago, that will automatically expire on Feb. 5, 2021, unless the two parties agree to extend it.
In signing on to the agreement, Eaton recalled the words of the prophet Isaiah: "[The Lord] shall judge between the nations, and shall arbitrate for many peoples; they shall beat their swords into plowshares, and their spears into pruning hooks; nation shall not lift up sword against nation, neither shall they learn war any more" (Isaiah 2:4).
Eaton also noted that, according to the 1995 ELCA social statement "For Peace in God's World," this church would give priority to "agreements among the leading nuclear powers to reduce their nuclear stockpiles and to decrease the possibility of nuclear confrontation or accident"—precisely what New START addresses.
In the statement, Eaton and the other religious leaders said:
"We call for an immediate five-year extension of the New START treaty, in order to avoid a nuclear crisis interfering with the other urgent priorities facing the nation and the world—from containing the pandemic to restarting the economy. Equally, a five-year extension would provide a period of predictability for new negotiations on further steps to reduce nuclear dangers."
For the past 18 months, ELCA churchwide organization staff have been participating in informal discussions among leading U.S. and Russian arms control experts aimed at reducing the danger of nuclear war. The experts have encouraged initiatives by the religious leaders―such as the statement―as a first, important step toward restoring a basis for official, longer-term talks on reducing the respective nuclear arsenals of the United States and Russia. While some official U.S.-Russia talks have been held in recent months, they have not produced clear results.
"We hope this, and future, initiatives can lead to concrete steps by the U.S., Russia and, eventually, other nuclear powers to reduce the danger of an unimaginable nuclear confrontation and lay a path instead for meeting urgent human needs," said Dennis Frado, director of the Lutheran Office for World Community at the United Nations. "It reflects the importance of moral leadership to promote confidence-building measures that help adversaries to re-create a basis for a more secure world."
The informal discussions by arms control experts are a recent effort by the Global Priorities campaign, an interreligious group that aims to secure the common good of all people by reducing global military spending and redirecting resources to unmet human needs. The latest endeavor has involved representatives of the Vatican and the Russian Orthodox Church. The campaign has previously been endorsed by the Lutheran World Federation (Eleventh Assembly, Stuttgart, Germany, 2010), Church World Service, the U.S. Committee of the World Council of Churches, and others. The ELCA has provided support to the campaign for several years.
Religious news & social issues Ecumenism, Faith and spirituality, Peace, Presiding Bishop Elizabeth Eaton
Biden visits Augusta Victoria Hospital
Beyond a resolution

redpajama_set_name: RedPajamaCommonCrawl


Communications Authority (CA) will seek expert advice from manufacturers of mobile phone SIM cards in deciding a case filed by Safaricom challenging Equity Bank's intended use of embedded cards to roll out its own mobile banking and cash transfer service.
Equity had intended to launch the SIM technology later this month through its subsidiary Finserve.
The SIM card in contention is paper-thin and embedded with a chip. Users overlay it on their primary SIM card, regardless of the network, and can subsequently receive services from two mobile service providers simultaneously.
The Communications Authority (CA) will seek expert advice from manufacturers of mobile phone SIM cards in deciding a case filed by Safaricom challenging Equity Bank's intended use of embedded cards to roll out its own mobile banking and cash transfer service.
CA director-general Francis Wangusi said the regulator will seek to establish whether use of the ultra slim phone cards, which ride on mobile phone subscribers' primary SIM cards, poses potential security threats.
Mr Wangusi said in an interview Wednesday the CA also plans to meet with Safaricom, which is seeking an order barring Equity Bank from rolling out the mobile banking service.
"We have received the letter from Safaricom. We are going to find out from them what security threats using such a technology poses, talk to SIM card manufacturers and also look at industry best practices before we make our ruling," said Mr Wangusi.
Mr Wangusi said that it was premature to comment on whether Safaricom had a case or not, adding that CA would also have to carry out research to get the best global practices on where the technology has worked or is being used.
"It is very premature to comment on the likely decision that the authority will take," he added.
In a letter dated June 26, Safaricom CEO Bob Collymore wants Finserve to be prohibited from issuing thin SIM cards arguing the move could expose subscribers to financial fraud and intercepted communication.
Its use means Equity Bank does not have to issue its own SIM cards but could ride on existing ones.
"It is clear that with the thin SIM's capability no single operator can guarantee the privacy of communication between the handset and SIM cards," reads part of the letter signed by Mr Collymore.
"The thin SIM is designed to attack the most essential component of the SIM card," it added.
Finserve Africa Ltd was in April granted an MVNO licence alongside Mobile Pay Ltd and Zioncell. Equity plans to use the Finserve licence to roll out mobile banking services independent of any operator.


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text:
Home COVID-19 COVID: Bangladesh records two deaths and 31 cases in just 24 hours
COVID: Bangladesh records two deaths and 31 cases in just 24 hours
The infection rate is 0.67% every day.
Bangladeshi health officials reported two Covid-19-related deaths and 31 illnesses in the 24 hours coming up to Monday morning.
Another 193 persons recovered from the infectious disease, raising the overall recovery rate to 97.33 percent, according to the Directorate General of Health Services.
According to the most recent figures, the overall number of cases in the country is 1,953,264, the total number of recoveries is 1,901,157, and the death toll is 29,130.
4,569 samples were tested across the country in a 24-hour period, yielding a positive result of 0.67 percent.
On Sunday, 29 coronavirus infections were reported across the country.
Bangladesh has reported zero deaths from Covid since the pandemic began in March 2020, along with 178 cases.
On January 28, Bangladesh had its highest day positive rate of 33.37 percent, with 15,440 cases and 20 deaths.
Furthermore, the country had the largest daily caseload of 16,230 cases and the greatest number of daily fatalities of 264 on July 28, last year.
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Saint Pierre and Miquelon – Go light on health measures
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Watch Online Drôles de petites bêtes
(334) IMDb 4.5 88 min 2017
Drôles de petites bêtes is a movie starring Virginie Efira, Kev Adams, and Emmanuel Curtil. When his beloved Queen bee Marguerite is kidnapped, vagabond cricket Apollo who has been framed for the crime, teams up with the other bugs...
Virginie Efira, Anne Tilloy, Kev Adams, Emmanuel Curtil
Family, Animation, Adventure, Comedy
Antoon Krings, Arnaud Bouron
Antoon Krings, Antoon Krings, Christel Gonnard, Antoon Krings, Arnaud Delalande, Arnaud Delalande
O Vale Encantado, Kukaiņu slepenā dzīve, Balagan ba'Ka'veret, Ο μαγικός κήπος, Co w trawie piszczy, Taikapuutarhan pikkuötökät, Småkrypenes magiske hage, Vabaliuku istorijos, Honning Margrethe og eventyrhaven, ¡Vaya bichos!, Tall Tales from the Magical Garden of Antoon Krings, Lustiga små kryp, Dế Apollo và Nữ Hoàng, Tall Tales: The Magical Garden
When his beloved Queen bee Marguerite is kidnapped, vagabond cricket Apollo who has been framed for the crime, teams up with the other bugs to save the Queen and the entire kingdom.
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14 customer reviews about animation «Drôles de petites bêtes»
3 out of 5 stars 3 out of 5 stars
Ronald H.
Wednesday, 23 Sep 2020 22:51
My friends and I watched this film with some friends on a Friday night. It was a nice experience, the first time we had watched a French film. The animation was nice, but the storyline was not too bad. My friends and I could not really tell what was going on, because it was all quite confusing. The plot is not too complex, but we had to fill in the blanks. The story has to do with a girl named Arlette, who is an orphan. Her aunt makes her an orphan by making her stay in the orphanage for a while. She is kept locked up in the room where the orphans eat, and she is forced to listen to the stories of the other orphans. It is like a movie with the orphans in it, but it was much better than I expected it to be. It is a good film to watch with your friends on a Friday night. It is not very good for kids, but if you have the time, I would recommend it. The music is not very good, but it is not too bad. There are some good songs, and the music that the kids like is not that bad either.
It's hard to say if this is a classic children's cartoon or a "real" children's cartoon, but I've always felt that this is a great movie for kids of all ages, and not only because of the excellent voice cast. The movie is a bit slow to start, but once it gets going, it's always interesting and funny, even when the action is relatively "simple." This is a great film for kids of all ages, even if you are a bit older than that. (7/10)
Friday, 11 Sep 2020 09:23
I saw this movie for the first time at the cinema in 2003, and it was so nice. The story was interesting and the animation was amazing. I loved the characters and their development and how the characters were connected to each other. I am a little disappointed that there were no girls in the movie, but that is not my problem. I have seen this movie many times and it is still enjoyable. I hope they make a sequel, because it is a beautiful movie that deserves to be watched.
Saturday, 05 Sep 2020 15:09
This is a very entertaining children's film, and in some ways is better than the film I reviewed for kids. My favorite part of the film is the part where "Bertrand" is a dog that takes up residence in the cat's head. The cat gives him a song and dance number that is so clever, and they both sing it with a very "French" (in my opinion) singing voice. They do a number in the cat's head, and then Bertrand starts singing the song. The entire movie is very entertaining, and I recommend it for kids ages 5 and up. The movie is also very enjoyable for adults. I have seen it about 20 times, and it never gets old. I have also seen the film on TV, and I have been able to follow it in the same way. I have also seen the film on a "high school" level, and have had the same success. It is very funny, and has a very fun story line. The music is also very good. I do not understand why it has such a low rating on IMDb. This is a good film for kids, and parents can also enjoy it.
Gerald W.
The films plot is simple, but the way they have created it is great. The story is not so much about the "greatest bird on the planet" but the "greatest pet in the world". A boy and a girl, who were the best of friends, get separated and they have to find each other again. The boy's parents have no idea how to deal with the situation, and the girl's parents are just as confused. They do everything they can to make things right, but there are so many complications in the way that it just gets very hard to do so. The movie is just full of love, friendship, and acceptance. The characters are very well developed and have a very well-developed story. They have a lot of depth to them and the story makes you care for them. The animation is great, it is animated beautifully. The soundtrack is very beautiful, and the soundtrack is not too long. The sound effects are also good. Overall, this is a great animated movie and is a must see. I give this a B+.
Tuesday, 25 Aug 2020 05:45
Sneezing and farting, I was a little disappointed in this one. The funniest moment in the movie was probably the farting between Paris and Auntie. The plot is a little hard to follow and some of the jokes fall flat. It's hard to tell what the movie is about, because there is no real plot, just a bunch of things happening. The characters are not developed enough, and the movie is too short. It's nice to see a film with a lot of dogs, but it's hard to tell what it's about. I was disappointed that the dog in the movie wasn't more involved. I liked the movie, but it wasn't good enough to be a cult classic. I'll give it a 7/10.
Sunday, 09 Aug 2020 00:36
A great movie. It's definitely not a child friendly film, but I don't see why it is rated so low. If you're a fan of the film, you'll enjoy it. It has some funny parts, some emotional parts, and a few action parts. I thought the characters were great and they played well off each other. I enjoyed the actors, especially the leads. I liked the film, it's definitely worth a watch.
I had the opportunity to see this movie at the Toronto International Film Festival, and I am glad I did. The movie is about a dog named Felix, who is forced to find a home after his owner dies. He gets a job at the zoo, where he meets Koda, a young girl, who wants to help him with his tasks. Koda has her own problem, her family has recently lost their home, and she is now living with a family that does not appreciate her. The movie is very funny and full of different funny situations. The movie also contains many cute animals, like the mouse, the pig, the turtle, the frog, and the rabbit. I recommend this movie to anyone who likes animated movies.
First off, let me start off by saying that I am not a kid's movie person. But I am a grown man, so I can honestly say that this is one of my favorite movies of all time. I love it because it is very well written and has a very original plot. It also has great animation and a beautiful background score. It also has a very special moment where the main character gets lost. It also has some pretty cool story lines and some nice humour in it. I think the animation is really great and the characters are very unique. The main character's name is Riddick and he's an extremely unlucky guy. He's a bounty hunter who is so unlucky, in fact, that he only knows one thing. He can't get his hands on the bounty he's looking for. He's kind of in the same league as the bad guy from the Matrix. Riddick meets a guy named Lambert, who's a bounty hunter and a good friend of his. He gives him the code to the secret temple of the dead, but Riddick has to go find it. Riddick meets up with Lambert and his friend, and they all go to the secret temple. The temple is a giant maze with all kinds of things that Riddick has to find and complete. This is the movie that got me into watching animated movies. I think it is a very good movie and I have watched it many times. I think it's a really good movie. It's like the Matrix meets Dune meets Lord of the Rings meets The Phantom Menace. It's really great.
At least twice during the movie, I had to pause to catch my breath. The plot, drawn out so slowly that I wasn't sure I'd ever get through it, was intriguing. The animation was beautiful, with some imaginative scenes and backgrounds, but it was also slow and monotonous. I can't say I liked the ending, but I didn't like the characters. The characters were the most interesting part of the film, but they were also the most undeveloped. One of the most interesting things about this movie is that it is truly about the importance of family. It's also about respecting the feelings of others, especially your mother. I was surprised to see that the "my mother is alive" message was a strong point in this movie. I can't say that I'm a fan of Disney, but I'm definitely a fan of this movie. I think it's worth seeing, but I won't go out of my way to see it.
Christopher M.
The basic premise of this movie is that the three main characters are teenagers in the year 1985. Each is an ordinary kid in his own way, except for one. That kid is an inventor, which has an unusual ability. The premise is what makes this movie interesting. It is well acted and the story is the core of the movie. I like the way the story develops. It doesn't feel rushed. It is like a movie that you watch on a Saturday night, then watch it again on Sunday. There are a lot of scenes that you won't remember. But, it is a nice movie for a rainy Saturday. It is about kids and inventors, and they get along. They get along in an interesting way. This movie is fun, and there is some action. I give it a 7. It is a good movie to watch on a rainy Saturday night. I hope you enjoy it as much as I did.
Michelle S.
Sunday, 14 Jun 2020 09:46
I was very disappointed to see that I had not seen this movie before it was shown in a theater in France. The movie is very funny and has a nice story to it. The characters are very likable and the story is very charming. The jokes are mostly random, but the animation is very good and all of the characters are very charming. I am glad that I saw this movie. It is very entertaining and has a nice story to it. I recommend this movie to anyone who enjoys animated movies. The story is very appealing and very funny. 7/10
The title of this film is based on the children's book of the same name. A little girl who has been orphaned by the war comes to Paris to get her inheritance and is taken in by a circus. She meets the old circus master who teaches her many things about being a child. He also teaches her about the world and its many traditions. This is a good film for children but also for adults. It is not for the kids but for adults who appreciate good animation. It is a good story and well-written.
At the beginning of the film, the head of the "Animal Liberation Front" (Alfonso Brescia) addresses a huge crowd with the famous "Je suis Charlie" slogan. There was a lot of publicity about the movie and I have to say that it was an excellent movie with an amazing message about animal rights and the importance of speaking out against factory farming. The character of Marisol, voiced by Renee Zellweger, was well-written and the voice of the head of the "Animal Liberation Front" was really well-chosen. All in all, I really liked the movie, and I would recommend it to anyone who is into movies that are based on real events.


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Post 50 post50life handbookbest places to retire
The 5 Absolute Best And Worst States To Retire
Yagana Shah
Huff/Post 50 Editor, The Huffington Post
Mar 23, 2015, 07:18 AM EDT | Updated Dec 6, 2017
Teton Range and Snake River, national park Grand Teton, Wyoming, USA
It appears Americans value the great outdoors and a low cost of living much more than the beach when considering where they should retire. Bankrate.com released its annual list of the best and worst states to retire today and Wyoming topped the list, while Arkansas ranked the lowest.
"The Cowboy State" took the top spot in the rankings after factors such as cost of living, taxes, health care, crime rates, climate and overall well-being were considered.
The survey of around 1,000 adults in the U.S. questioned what Americans' priorities are when it comes to retirement. Nearly a quarter of those surveyed said being close to family was the deciding factor. But when it came to climate, it seems we should rethink the stereotype of retirees lounging on the beach with a fruity drink. The survey revealed that while around a quarter prefer being close to a beach, nearly 40 percent of people want access to the great outdoors, rivers and mountains -- which Wyoming has plenty of. Sorry, Florida.
Besides offering several national parks, fishing, hiking and winter sports, Wyoming boasts no personal income taxes as well as low crime rates and excellent medical facilities.
"Warm weather may be an initial draw, but all the sunny days in the world won't make you happy if you're constantly stretching your budget or don't have access to quality health care," said Chris Kahn, Bankrate.com's research and statistics analyst, in a statement.
Meanwhile, Arkansas was at the very bottom of the list despite a low cost of living, since it was among the worst states in terms of crime, community well-being and quality health care, according to data gathered from the FBI, the Gallup-Healthways Well-Being Index and the U.S. Department of Health and Human Services. New York, Alaska, West Virginia and Louisiana also were in the bottom five.
"There are many factors retirees should consider before deciding where to put down their roots. Deciding where to live in the golden years is still a very personal decision," Kahn said. "This list is meant to help inform, rather than choose a state for you. For example, if you want to retire on the beach and need top-notch health care, this can help narrow down your choices."
Check out the top five states to retire in and go to Bankrate.com to see where your state ranks.
Robert Alexander via Getty Images
Besides Wyoming's breathtaking natural beauty -- it's home to both Grand Teton National Park and Yellowstone National Park -- the western state ranks high thanks to its low crime and tax rates, as well as pleasant weather.
Colorado comes in second place thanks to a strong ranking for community well-being. It's also one of the most popular states due to its weather. While Colorado is known for its winter activities, such as skiing in world-renowned Aspen, it has many cultural offerings such as Native American heritage sites and sites related to the Gold Rush.
Mlenny via Getty Images
You can't go wrong with Utah's combination of a low cost of living and high quality health care. Besides its variety of outdoor offerings, including hiking, skiing and wildlife, the state has a strong Mormon community, beautiful temples and even one of the world's best-known annual film festivals -- Sundance.
Glen Allison via Getty Images
Idaho ranked high for having a good cost of living and low crime rates. According to Zillow, the median home value and home prices are both under $200,000.
Andy Ryan via Getty Images
The only coastal state to make the top five, Virginia ranks high for its low crime rates and appealing weather. Virginia offers plenty for history buffs, being the birthplace of many presidents and home to several Civil War sites. It also has gorgeous beaches for the grandkids to enjoy.
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Cyberbreaches
Cyber threats increases by 41% in India: Survey
Cyberbreaches or insider threats have increased to 41% in India, and 83% are using forensic data analytics for investigating these frauds.ET Bureau | January 21, 2016, 09:21 IST
Cyberbreaches or insider threats have increased to 41% in India, and 83% are using forensic data analytics for investigating these frauds, a global survey by consultancy EY has found.
In a survey of 665 respondents across 17 countries with organisations actively using forensic data analytics, EY found that there is a long way to go for Indian enterprises.
"It was noted that organisational reluctance to invest significantly in forensic data analytics is partly due to lack of management buying around its potential return on investment," said Arpinder Singh, partner and national leader, fraud investigation & dispute services, EY.
He, however, said forensic data analytics (FDA) is a critical component that can have a significant impact on growing threats such as internal fraud, cyber crime, corruption and money laundering.
EY said FDA "is a science used to proactively seek opportunities to prevent and detect fraud, waste and abuse by leveraging information in corporate data assets".
Tags : Internet, EY, Cyberbreaches, Cyber threats, cyber crime