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Int. J. Environ. Res. Public Health 2014, 11(5), 4782-4798; doi:10.3390/ijerph110504782
Abstract: Tobacco use has reached epidemic levels around the World, resulting in a world-wide increase in tobacco-related deaths and disabilities. Hospitalization presents an opportunity for nurses to encourage inpatients to quit smoking. This qualitative descriptive study was aimed to explore nurse-counsellors’ perspectives of facilitators and barriers in the implementation of effective smoking cessation counselling services for inpatients. In-depth interviews were conducted with 16 nurses who were qualified smoking cessation counsellors and who were recruited from eleven health promotion hospitals that were smoke-free and located in the Greater Taipei City Area. Data were collected from May 2012 to October 2012, and then analysed using content analysis based on the grounded theory approach. From nurse-counsellors’ perspectives, an effective smoking cessation program should be patient-centred and provide a supportive environment. Another finding is that effective smoking cessation counselling involves encouraging patients to modify their lifestyles. Time constraints and inadequate resources are barriers that inhibit the effectiveness of smoking cessation counselling programs in acute-care hospitals. We suggest that hospitals should set up a smoking counselling follow-up program, including funds, facilities, and trained personnel to deliver counselling services by telephone, and build a network with community smoking cessation resources.
Tobacco use has reached epidemic levels in many developing countries and steady use has continued in some developed nations [1,2,3]. Consequently, tobacco-related disabilities have increased worldwide, and the number of deaths caused by tobacco use (primarily cigarettes) has reached approximately 5 million each year around the World . Taiwan has also been affected by the tobacco epidemic. In 2012, approximately 18,800 Taiwanese people died from smoking-related diseases, and the estimated population-attributable fraction of all-cause mortality resulting from smoking among Taiwanese citizens aged from 40 to 79 years was 27.8% for men and 6.7% for women .
There is a worldwide appeal to improve nurses’ involvement in tobacco control, particularly in cessation interventions . Compared with other health professionals in acute-care hospitals, nurses constitute the largest workforce and are in more frequent contact with inpatients. Moreover, patient education and preventive healthcare are an integral component of nursing education [6,7]. Numerous studies have supported the role and efficacy of nurses in delivering smoking cessation counselling [8,9,10,11,12]. A clinical trial involving nurse case-managed tobacco cessation counselling for inpatients showed that patients receiving counselling intervention were more likely to abstain from using tobacco (28%) than those receiving only pharmacotherapy (16%) . Another study indicated that intensive nursing counselling with telephone follow-ups was more effective than brief counselling and providing educational materials alone . The environment setting where cessation interviews are conducted is also relevant. Several previous studies have reported a high level of motivation among patients to quit smoking during hospitalization [13,14]. The restricted or no-smoking policies in hospitals interrupt patients’ smoking habits, creating a ‘teachable moment’ for inpatients who smoke [8,9,13]. Rice and Stead asserted that hospitalization creates an opportunity for nurses to provide intensive smoking cessation counselling for patients diagnosed with smoking-related illnesses.
The Taiwanese Health Promotion Administration (THPA) reported that there were approximately 4.8 million smokers in Taiwan, and that approximately 47% of them had considered quitting at least once. The success rate of quitting smoking, however, is less than 5% . Quitting tobacco use benefits the majority of smokers and their loved ones; it saves lives and reduces personal and health care costs [16,17]. Since 2002, the Taiwanese government has initiated several outpatient clinic programs in hospitals to encourage smokers to quit. These programs integrate smoking cessation counselling into routine outpatient visits. All of the programs offer financial incentives to doctors who provide outpatients with nicotine replacement therapy (NRT) and brief smoking cessation counselling during routine visits. Although the financial incentives have resulted in an increase in the number of patients who have received smoking cessation counselling from physicians, the smoking cessation rate remains unsatisfied [18,19]. The percentage of smokers that attempted to quit declined slightly in 2007 after the funding was reduced in 2006 .
An analysis of the 2004–2007 Taiwan Adult Tobacco Surveys showed that 71% of doctors in Taiwan had failed to offer smoking cessation counselling to patients, a rate that was higher than those reported in the United Kingdom (59%) and the United States (39%) . Because Taiwanese physicians typically serve more than 50 outpatients in a single morning or afternoon work shift, time limitations have been a major barrier to counselling patients on smoking cessation [18,19]. Moreover, physicians typically provide only NRT; they seldom address patients’ psychological dependence on nicotine, which contradicts previous research findings indicating that the success rate of quitting smoking is high among smokers who receive intensive advice or counselling .
The THPA implemented the New Smoking Cessation Policy on the 1st of March 2012 to expand smoking cessation counselling services to both outpatient and inpatient settings. The new policy is based on the following three evidence-based premises: (i) non-physician providers (specifically nurses) have an essential role in providing smoking cessation counselling; (ii) increasing the intensiveness of counselling services may improve the success rate of smoking cessation; and (iii) inpatient settings may facilitate intensive smoking cessation counselling. Hospitals that participate in the inpatient smoking cessation program send qualified employees, most of them nurses, to receive training to become smoking cessation counsellors. As a result of the expansion of smoking cessation counselling to inpatient settings and inclusion of nurses in the provision of cessation counselling services, the new policy has broadened the scope of effort to identify smoking patients when they are most receptive to tobacco cessation intervention as well as increased the range of patient-provider interface to allow patients be served by trained nurse-counsellors.
Previous research in the education sector showed that the perceptions of school nurses had a significant influence on school administrators and parents in the promotion of student health education . However, few studies have elucidated the perceptions of nurse-counsellors regarding smoking cessation interventions. There is also a lack of information about factors that facilitate and inhibit hospitals nurses’ provision of smoking cessation counselling services. Although being in direct contact with patients’ places nurses in an advantageous and convenient position to counsel patients on quitting tobacco products, short periods of hospitalization, increased severity of patients in acute-care setting and constraints on hospital budget may limit the effectiveness of nurse-led smoking cessation counselling programs [6,16,17]. Thus, it is important to understand from nurse-counsellors’ perspective the operation and challenges of the new smoking cessation counselling program in order to improve program implementation and inform policy change.
In this study, we employed a qualitative study design and interviewed nurse-counsellors to elucidate their perspectives on smoking cessation counselling, as well as their perceptions on the facilitators and barriers of smoking cessation programs. Specifically, the following research questions were addressed:
From the nurse-counsellors’ viewpoint, what were the factors that facilitate the provision of smoking cessation counselling services to inpatients?
From the nurse-counsellors’ viewpoint, what were barriers in the provision of smoking cessation counselling services to inpatients?
The findings of this study may assist health care providers implementing smoking cessation programs and provide a reference for the development of effective training programs for smoking cessation counsellors.
2.1. Study Aim
The aim of the study was to explore the perspectives of nurse-counsellors regarding the facilitators and barriers to implementing effective smoking cessation counselling services for inpatients.
2.2. Study Design
This qualitative descriptive study employed a grounded theory approach. We conducted in-depth interviews to explore the perspectives of nurse-counsellors regarding the environment of hospitals in which inpatient smoking cessation programs were implemented as well as their experiences in delivering inpatient smoking cessation counselling services. Previous studies have asserted that qualitative research methodologies are effective for examining novel research topics because they can assist in soliciting information from service users or providers to develop and improve health interventions through in-depth probing with questions that are meaningful and context-specific to key informants [22,23]. It could also contribute to improving novel treatment programs through recognition of the experiences and opinions of relevant health professionals and patients . Because nurse-counsellors work closely with smokers, they have an intimate understanding of the challenges that affect patients, as well as the insight regarding the necessary organizational conditions that facilitate successful counselling programs. Hence, their perceptions are critical for evaluating and improving the novel inpatient smoking cessation programs.
2.3. Participants and the Recruitment Procedure
The participants in this study were nurses who had (i) provided cessation counselling services to inpatients, (ii) received at least one of three-levels of training workshop on smoking cessation, and (iii) received counselling certification from the THPA. Nurses who meet these three criteria are called nurse-counsellors and the smoking cessation counselling services they provide are eligible for reimbursement by THPA.
Beginning in May 2012, we approached directors of departments that were responsible for the delivery of smoking cessation services at 25 smoke-free health promotion hospitals in the Greater Taipei City Area (including Taipei City and new Taipei City) in northern Taiwan and asked them to recommend nurse-counsellors. Seventeen directors agreed to our request and indicated that their hospital had one or two nurse counsellors that were eligible as study participants in accordance to our selection criteria. We contacted those nurse-counsellors to invite their participation, and 16 agreed to be interviewed. We arranged an interview at a time and a place convenient to those who agreed. By October 2012, we had interviewed all 16 nurse-counsellors at 11 health promotion hospitals and determined that the information we obtained had reached saturation. These 16 nurse-counsellors from 11 health promotion hospitals constituted the study sample.
2.4. Data Collection and Analysis
For the in-depth interviews, we developed semi-structured open-ended questions based on field observations and a review of extant literature. The questions were designed to investigate (i) facilitating factors that the nurses considered effective in helping patients to quit smoking, and (ii) barriers that nurse-counsellors experienced while delivering smoking cessation services. The interviews were conducted by two authors (CYC was a PhD candidate and YQJ had a master degree) with relevant experience in qualitative research methods and interviewing. Prior to collecting the data, one of the investigators (YCC) led a pilot study with the two interviewers (CYC & YQJ) to test the interview guide and questions. The results of the pilot test were discussed among the members of the research team and subsequently applied to improve the interview guide (Table 1).
|Tell me about your experience in performing smoking counseling services to in-patients smokers.|
|What facilitating factors are you consider effective in helping inpatients to quit smoking?|
|Any barrier you experienced while you delivering smoking cessation counseling services in hospitals?|
Within three days of completing each interview, the recorded interviews were transcribed verbatim by one of the interviewers, and the transcripts were reviewed by the other one to eliminate errors. Information that was considered ambiguous was clarified with the participants.
We conducted a content analysis using the principles of the grounded theory approach. Grounded theory is an inductive research approach; it involves the discovery of theory from ground up, through the analysis of in-depth interview data . The analysis was performed using Atlas.ti 6.2. First, we coded all of the highlighted passages that were considered relevant to the research questions. Second, the codes were compared and sorted into meaningful categories based on the key concepts of this study (i.e., strategy, effectiveness, and barriers). Third, the categories were divided into subthemes and themes, which were independently compared and reconciled by three of the authors. Finally, the authors discussed the main themes that emerged from their analyses, and compared the categories to resolve discrepancies. The review and comparison process was iterative, involving the review of specific transcripts in their entirety.
Throughout the data analysis, the authors worked collaboratively and iteratively to develop and revise the codes and categories. Following the process of reflection and discussion, a consensus was reached on the appropriate and meaningful approach to sorting and grouping the codes, as well as formulating the categories into subthemes and main themes.
There are four issues of trustworthiness that demand attention in qualitative research: credibility, transferability, dependability, and conformability . To increase credibility, interviews were independently coded. Other strategies include member checking (clarifying with participants during the interviews) and peer checking (discussing data until a consensus was reached). Furthermore, all of the authors had experience in tobacco cessation and qualitative research, which increased the credibility of the study. Transferability was met through careful selection of participants using explicit inclusion and exclusion criteria. Dependability was ensured by the investigator’s completion of verbatim transcriptions from audiotapes in a timely manner. Conformability was achieved by maintaining an audit trail and research reflection log.
2.6. Ethical Considerations
The research protocol was approved by the Institutional Review Board at National Yang-Ming University in Taiwan. The IRB approval number is 2012-07-036 BCY. Prior to conducting the interviews, we informed the participants regarding the research purpose and procedures, as well as their rights. All of the participants signed an informed consent form, with an understanding that their participation was entirely voluntarily. We also had the participants’ permission to audio-record the interview. To assure anonymity, we used a unique numeric identifier to replace the name of each participant on the documents of study and the citations of results.
Participant characteristics are reported in Table 2. The mean age of the 16 interviewed nurse-counsellors was 36.5 years (SD = 9.8) and all of them were women. Half of them were university graduates, and all reported that they had successfully completed formal training on smoking cessation counselling. None of them had a history of smoking. The mean number of years working as a registered nurse was 12.7 (SD = 11.0), and the mean number of years being involved in smoking cessation counselling was 3.0 (SD = 2.3). They all claimed to provide smoking cessation counselling services in accordance to the guidelines designed by the TBHP in Taiwan. Our content analysis revealed the following themes and subthemes.
3.1. Theme 1: Facilitators that Enhance the Success of Smoking Cessation
Hospitalization is a crucial moment or occasion that triggers patients’ motivation to quit smoking. The following facilitators emerged from the interviews with nurse-counsellors: (i) building work teams to create a supportive smoking cessation environment; (ii) shifting the focus to the modification of smokers’ lifestyles; (iii) selecting an appropriate time to initiate counselling; (iv) providing patient-centred counselling; and (v) referring patients to other resources when necessary.
|Items||n (%)/Mean (±SD)|
|Registered nurse work experience (year)||12.7 (±11.0)|
|Smoking cessation counselor position|
|Full time||11 (68.8%)|
|Part time||5 (31.2%)|
|Experience as a smoking cessation counselor (years)||3.0 (±2.3)|
3.1.1. Collaboration with Other Health Professionals to Develop a Supportive Cessation-Oriented Environment
When health professionals work cooperatively in emphasizing the benefits of quitting smoking to patients during patient interactions, they are more effective at promoting smoking cessation counselling and motivating patients to quit smoking. This assessment, exemplified by the following responses, was shared among all of the interviewed nurse-counsellors:
‘If all hospital staff—including professional health workers, paraprofessionals, and volunteers—who meet with the patients emphasize that smoking has caused their illness and [if the staff] inform them that quitting smoking would be beneficial for treating their diseases, the patients would have the strongest motivation to quit smoking.’ (Counsellor B)
‘When a patient comes to the hospital reporting chest pain, a doctor could ask them if they [smoke]. If they confirm that they [smoke], the doctor should [inform] the patient of the correlation between chest pain and smoking…afterward, the pathology staff may ask these patients whether they [smoke], and then advise them to quit during the process of physical examination.’ (Counsellor A)
Moreover, the majority of the interviewed counsellors emphasized the importance of employing a team approach to creating a cessation-oriented environment in order to effectively help patients to quit smoking:
‘For patients to quit smoking, they require a whole team of health professionals to support and assist them.’ (Counsellor N)
‘Collaboration is the best strategy for all hospital health professionals, including physicians, nurses, medical equipment operators, pharmacists, and even health volunteers and priests because a positive and supportive smoking cessation environment helps inpatients quit [smoking].’ (Counsellor D)
3.1.2. Timing for Initiating Smoking Cessation after Hospitalization
To improve the success rate of patients quitting smoking, the nurse-counsellors indicated that the timing for initiating counselling services was a crucial aspect of effective smoking cessation strategies:
‘[It is crucial] to contact smokers as quickly as possible when they are admitted [to] the hospital…frontline nurses and physicians should immediately provide advice if the patients report that they are smokers during the admission assessment of [newly] admitted patients…, which gives them the best opportunity to provide counselling services for smokers.’ (Counsellor A)
‘If primary nurses inquire about the patients’ smoking history when they are admitted, then physicians should also tell them that [whether their condition] is related to smoking, offer advice on quitting, and refer [them] to [smoking] cessation counsellors. That would improve the patients’ intention to use cessation service.’ (Counsellor J)
‘If we have good timing, then patients are more likely to be willing to quit.’ (Counsellor D)
‘Usually, we contact [newly] admitted patients within 24 hours after their primary nurses have marked them as smokers... if we do not [attend to smokers] punctually, they will be discharged soon. Then, we [would miss a] good chance [to intervene].’ (Counsellor B)
3.1.3. Modifying a Smoker’s Lifestyle is Essential
To assist smokers in quitting, it is critical that healthcare providers promote a healthful lifestyle that includes regular exercise, a healthy balanced diet, and stress management. Several of the nurse-counsellors reported the following observations:
‘Smoking is not only a physiological dependency but is also a psychological dependency. [Moreover], the psychological dependency is the primary reason that smokers continue [to smoke]; even when they have [been provided] the necessary advice, health information, and motivation to [modify their behaviour], it is easy for them to relapse if they do not change their lifestyle... Smokers must adjust [their] behaviour and lifestyle to cope with the stress [associated with quitting]. Moreover, they require a therapist for psychological treatment.’ (Counsellor F)
‘Healthcare providers should not only emphasize how crucial quitting smoking is for promoting patient’s health, but they should also shift their emphasis to other health-promoting behaviours such as exercising, maintaining a healthy diet, and managing stress.’ (Counsellor D)
3.1.4. Application of Patient-Centred Techniques, Useful Information, and Teaching Resources
Although the time constraint appeared to be universal, the interviewed nurse-counsellors advocated that the intervention approach—specifically, providing patients with information and education on quitting smoking—must be individualized and patient-centred to address each patient’s specific needs.
‘It is useless if the counsellors educate smokers on quitting based only on their professional knowledge and do not assess smokers’ specific needs and difficulties.’ (Counsellor P)
‘[Quitting smoking], I think, is an individual experience. The situation varies among patients…There are different stages for smoking cessation. Healthcare providers need to provide different patients with different things; you need to help them identify better ways [to quit] by providing patients with the appropriate information for their stage [of quitting].’ (Counsellor A)
‘Providing patients with various educational materials that [are] relevant to the patient’s stage of quitting…Some patients are still hesitant; they need to [be more determined]…Those who have decided to quit should go directly to the process [commence counselling immediately]; that is, the patient needs information on how to quit smoking and the type of problems they [will] face.’ (Counsellor D)
3.1.5. Referring Patients to Other Counselling Resources
Consistent with the patient-centred approach, the interviewed nurse-counsellors recognized that patients may have special needs that could be better addressed elsewhere or with alternative resources. Thus, referrals to other appropriate smoking cessation resources are necessary when a counsellor feels unqualified to address a specific question or the personnel, knowledge, or resources in the hospital are limited:
‘When I encountered something I did not know, I did not answer the patients; rather, I provided a hotline for quitting smoking.’(Counsellor M)
‘When there are some problems we do not know the answers to, we try to find an answer. I often read a research paper or ask professionals.’(Counsellor O)
‘Professional counsellors must learn constantly and accumulate experience to become more confident and capable of identifying solutions and resources [that can] assist their patients. If they are [neither confident nor capable], then they have to make a referral.’ (Counsellor K)
3.2. Theme 2: Barriers to Providing Counselling Services
The nurse-counsellors were confronted with substantial organizational-level barriers, including a lack of full support from the hospital administration, a lack of commitment from other professionals, as well as a shortage of time and personnel.
3.2.1. Lack of Full Support from Hospital Administration
Although it is recognized that the promotion of a supportive smoking cessation environment in hospitals can improve the successful delivery of smoking cessation counselling services, the nurse-counsellors indicated that there was a lack of complete support from hospital administration:
‘The cost of providing this type of counselling service for smoking cessation, which is allocated by the administrators, is very low.’ (Counsellor H)
‘If an administrator always mentions the smoking cessation program during the hospital meeting and [informs the] physicians to advise patients to quit, then the program can go on providing service to patients well and the program will succeed.’ (Counsellor O)
‘Just a little more support [for the smoking cessation program] from the managers would be sufficient.’ (Counsellor E)
3.2.2. Insufficient Time and Personnel Support in Hospitals
The nurse-counsellors reported that their time and effort were stretched thin.
‘Because we are short of staff, the nurses are already [overloaded] with tasks. It is impossible to provide patients with all of their health education needs. [The trained nurse-counsellors] really do not have time to persuade patients not to smoke.’ (Counsellor H)
‘Most of the counsellors in hospitals have several duties. We not only need to follow various cases and [manage] new cases, but we must also provide regular care to other inpatients... Usually, we feel unwilling to do this because we are not full-time counsellors.’ (Counsellor O)
‘Because we lack a sufficient number of nursing staff, we often work for many [consecutive] days. We sometimes need to work night shifts, and we occasionally work for more than 12 hours... It is really difficult to allocate time to do this. In fact, it is a difficult job.’ (Counsellor L)
‘If [counsellors were employed] full-time, [then they would] do a much better job. We can follow the cases after we discharge the patients from the hospital to provide health education and guidance on how to prevent them from relapsing…’ (Counsellor N)
3.2.3. Lack of Commitment from Other Health Professionals
Consistent with the aforementioned subthemes, other hospital health professionals, such as doctors, social workers, nutritionists, and pharmacists, were unaware of how crucial and effective their advice was for smokers during hospitalization. Consequently, the following nurse-counsellors’ reports indicated that there was a general lack of clear commitment from these health professionals:
‘The advice provided by doctors is very useful for helping smokers to quit. However, not every doctor has the incentive to advise smokers… [Similarly], primary care nurses typically do not think they are responsible for advising patients on smoking cessation and do not consider advising patients to be a part of their duty.’ (Counsellor F)
‘Most physicians are not interested in providing smoking cessation service—even brief advise… they won’t receive any [funding] from National Health Insurance [for offering these services], so they lack the financial incentive.’ (Counsellor C)
This is the first study in Taiwan to understand from nurse-counsellors’ perspective facilitators and barriers for smoking cessation counselling services in inpatient settings. A total of sixteen trained nurse-counsellors from 11 acute hospitals participated in this study. They proposed several facilitators to effectively promote and implement smoking cessation counselling programs: collaborate with other health professionals in hospitals to create a supportive cessation-oriented environment, visit smoking inpatients and provide them counselling services as quickly as they are admitted, modify smokers’ behaviours to promote a healthy lifestyle, apply patient-centred techniques in smoking cessation counselling services, and refer hospitalized smokers to other counselling resources when they are discharged from hospitals. From nurse-counsellors’ perspectives, barriers to implement smoking cessation services include the lack of full support from hospital administration, insufficient time and personnel support, and lack of commitment from other health professionals in hospitals.
Although hospitalization provides a window of opportunity for smoking cessation [16,17], delivery of cessation counselling services is challenging. In addition to the aforementioned barriers, hospitalized patients have increased acuity that needs intensive treatment and smoking cessation is secondary to their medical priorities. This perhaps explains why nurse-counsellors pointed out consistently that timing and a comprehensive approach involving the entire hospital to promote smoking cessation are critical for the success of the smoking cessation counselling services program. Ideally, when patients are admitted to hospital, nurses should determine whether they smoke, and immediately initiate smoking cessation counselling services for those who do. Previous studies similarly indicated that routine medical charting during the admission process should include smoking assessment, thereby assisting healthcare providers in identifying smokers and initiating smoking cessation services . New efforts that capitalize on the use of electronic medical records (EMRs) by adding a smoking module to the EMR system to make the inquiry of patients’ smoking status a routine procedure may increase quitting among the patient population .
From nurse-counsellors’ perspective, a comprehensive counselling program must include lifestyle modifications (e.g., healthy diet, regular exercise, and stress management), rather than providing only health education and pharmacotherapy for physiological dependence. This idea is consistent with other studies. May et al. , Kotz et al. , and Chang and Wang  have contended that smoking cessation is a behaviour modification process, and that it requires personal motivation to be succesful. Current approaches to smoking cessation recognize that cigarette smoking is not a simple habit, but a complex physiologic addiction that requires a multi-faceted intervention scheme from a variety of sources in order to encourage lifestyle change to overcome nicotine addiction and prevent relapse [31,32]. Hospital nurses’ practice of health education, through individual nurse-patient interactions, can make an important contribution to health promotion . However, short hospital stays and changing patterns of patient care make it difficult to combine nursing care with patient-oriented and time-intensive behavioural interventions [6,17]. This is one of the barriers to effective smoking cessation counselling services reported by nurse-counsellors in this study.
The interviewed nurse counsellors all reported feeling frustrated as a result of several barriers, all of which were directly or indirectly related to the lack of support and resources for delivering smoking cessation services in hospitals. Consequently, the nurse-counsellors reported having insufficient time and inadequate competence to provide these services, which supported the findings reported by Sarna et al. . In Sarna et al.’s study, the barriers identified by nurses involved in providing smoking cessation services included a lack of competence, referral options, and resources, as well as time constraints. Two other studies showed that nurses felt competent and were effective at assisting smokers to quit when they were able to commit full time to providing smoking cessation services [8,33]. A meta-analysis also indicated that brief smoking cessation counselling provided by nurses who combined smoking cessation work with other duties were less effective than long-period interventions delivered by nurses with a full-time role in health promotion . Having sufficient staff time to provide smoking cessation services also appears to be a key factor of successful cessation programs.
The interviewed nurse-counsellors reported concerns regarding the commitment of other healthcare providers to providing inpatient smoking cessation services. Physicians, for example, did not consider offering advice to patients on quitting smoking as a part of their duty, partially because they were doubtful of the effect of their advice and their patients’ receptivity. Another reason could be that the assessment of their patients’ smoking status had not been incorporated into routine care processes . A study in Hong Kong found that smoking cessation practice was influenced by healthcare providers’ attitudes and expectations of their roles and their self-perceived competence. Educating healthcare providers about the importance and effectiveness of smoking cessation programs might encourage them to become involved in delivering these services [34,35]. Multidisciplinary collaboration among healthcare providers may foster a sense of collective competence and increase providers’ commitment to smoking cessation services .
Based on comments of the interviewed nurse-counsellors, future administrative support and resources must be invested to: (i) educate healthcare providers, (ii) implement a hospital-wide smoking cessation policy that incorporates the assessment of smokers into routine care practices, (iii) develop health education materials for patients, (iv) allow sufficient time for healthcare professionals to provide smoking cessation counselling to their patients, and (v) establish a referral system for patients to receive smoking cessation services. Furthermore, follow-up counselling services are needed to reduce relapse of smoking patients after their discharge from the hospital. A Cochrane review on studies of hospitalized smokers suggests that interventions need to last at least one month post-discharge to have a statistically detectable effect . An alternative approach to continuing the counselling is through telephone, which is convenient and can be delivered proactively. Similar to inpatient counselling services, the design of telephone counselling would also need to be tailored to the specific needs of individual smokers.
Several features of this study design need to be discussed. First, the study sample is small. Considering the exploratory nature of the study, the small sample size may be justifiable. Second, the interviewed nurse-counsellors were from different hospitals, which may influence nurse-counsellors’ perceptions of smoking cessation programs. It is important to note, however, all the programs served similar patient groups and were located in hospitals that shared the same mission of health promotion. To the extent that organizational attributes of hospitals affected the implementation and effectiveness of smoking cessation counselling services, a high degree of consistency in the perceptions and recommendations of nurse-counsellors interviewed suggests that findings of the study are robust and have good generality to other hospitals in Taiwan. Finally, the nurse-counsellors interviewed in the study were referred by their supervisor in the hospital. They were likely to be highly motivated and actively involved in the inpatient smoking cessation counselling program. Our findings may be limited by not including nurse-counsellors who were not fully committed to the counseling program and who may have provided useful information that highlight additional barriers that prevent their active involvement in the smoking cessation counselling program.
Hospitalization provides a unique opportunity for nurses to deliver smoking cessation counselling services. There is a broad consensus among nurses-counsellors who provide smoking cessation counselling that more emphasis should be placed on lifestyle changes than on pharmacotherapy. Nurse-counsellors believe that a supportive environment, teamwork, and provision of patient-centred care are key elements of successful smoking cessation programs for inpatients. Barriers to smoking cessation services exist primarily at the organizational level; they include the lack of full support from hospital administration level, insufficient time and personnel support, and lack of commitment from other health professionals in hospitals.
The study has several practice implications. First, nurse-counsellors must assess the needs of smokers throughout the cessation process by using more advanced technology like electronic medical records. Second, to increase the involvement of other healthcare professionals, they need to be informed on the smoking cessation program and its effectiveness. Third, nurse-counsellor training programs should include modules on health education and behavioural modification to improve their competence in helping smokers to quit. Finally, increasing the reimbursement for smoking cessation services might encourage hospital administrators to allocate additional resources to smoking cessation programs. For hospital administrators, they may consider the provision of follow-up counselling services to discharged patients. Establishment of a network with community smoking cessation resources is another strategy to continue the smoking cessation services post-discharge.
A report issued by the Health Behaviour Export Panel of the American Academy of Nursing (AAN) advocated efforts to increase nurses’ visibility and influence in tobacco control services . The inpatient smoking cessation counselling program, in a way, is designed to heed the call of the ANA expert panel. The program is nurse-led and nurse-delivered. It demonstrates that nurses, indeed, can be trained to take a lead in providing smoking cessation counselling services and that they play a unique role in inpatient smoking cessation because of their frequent contact with patients and their “professional instinct” to pay attention to individual needs of patients. Almost all the facilitators and barriers revealed in the interviews with nurse counsellors’ organizational or system-wide factors. We suspect that those factors are prevalent in hospitals and health care organizations in other countries.
Another important finding of the study is recognition among nurse counsellors that inpatient smoking cessation services are but the beginning of a patient’s long journey of ridding a hardwired habit. The occasion of hospitalization opens a window of opportunity. The opening is slim, however, and it is likely to become smaller as cost-cutting efforts in many countries are reducing the length of hospital stays. Continuing interventions that extend beyond the hospital stay are needed and they would require the investment of hospitals in follow-up services and in building collaboration with outpatient clinical settings and community-based social service agencies and advocacy groups.
Based on the study findings, we urge that hospitals, community organizations, nursing organizations, and governmental funding agencies work together to ensure that nurse-counsellors be involved in tobacco control network. Smoking cessation training program should provide nurse-counsellors the skills to mobilize community resources. We also recommend future research to examine the various designs of inpatient smoking cessation counselling. An example of such research is the application of electric medical records in smoking cessation programs, which may enhance the identification and recruitment of smoking inpatients and improve the coordination of nurse-counsellors with other health professionals.
The authors would like to thank all the nurse counsellors for their cooperation. This research was supported through financial assistance from the Health Promotion Administration, Ministry of Health and Welfare, Taiwan, ROC (Grant number CCY1009-1).
Yu-Chi Chen and I-Chuan Li conceived and designed the study. Yu-Chi Chen, I-Chuan Li, Chiu-Yen Chen, and Yu-Qian Jeng conducted the interviews and analysis. I-Chuan Li led the writing of the manuscript. Yu-Chi Chen, I-Chuan Li, and Shoou-Yih D. Lee prepared the draft manuscript. All authors contributed to and approved the final.
Conflicts of Interest
The authors declare no conflict of interest.
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© 2014 by the authors; licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution license (http://creativecommons.org/licenses/by/3.0/).

domain: medical


text: A canine coronavirus infection CCV is a highly contagious intestinal disease that can be found in dogs all around the world. This particular virus is specific to .Canine coronavirus is a highly contagious intestinal infection. To date, several strains of canine coronavirus have been isolated from the outbreaks of diarrheal .New coronavirus can spread between humansbut it started in a wildlife obtaining video that allegedly shows racoon dogs and deer housed .Canine coronavirus is a virus of the family Coronaviridae that causes a highly contagious intestinal disease worldwide in dogs. It was discovered in in .Questions and answers about canine respiratory coronavirus What is it? How is it transmitted, diagnosed and treated? Can it be prevented? Is there a vaccine?.Canine coronavirus CCoV is usually responsible for mild, self limiting infections restricted to the enteric tract. We report an outbreak of fatal disease in puppies .Often marked by fever, vomiting and loss of appetite, coronavirus in dogs is caused by a virus. Here s need to know information on helping your .

domain: pet


text:
Ivory powder or flake solid, it can be dispersed into the hot water, can be dissolved into the ethanol and hot grease. It is a non-ionic emulsifier, HLB value is 3-4.
Characteristics and Applications
It has emulsifying, resist aging and control the fat coacervation function Assist to defoam in the foam killer, assist to foam in Ice cream, it is used in the candy, cake, bread etc. as additive, and prevents granulated sugar crystallization and the separation between the water and oil.
1.Used in the butterine and made the latex stabilization.
2.Increase emulsification in creamy sweet and galactosidase.
3.It is used in bread to improve the construction of tissue, augment storage life and increase the soft feeling and pliability.
4.Can be used in emulsified oil, just like meat products, ice cream.
1.Directly mixed well with flour for use.
2.Put this product into warm water at about 60℃ with proportion of 1:6 to get paste shaped substance, then add it into flour in proportion to obtain better effect.
3.Melted together with the thermal grease, and do more further processing with other materials.
Kraft paper bag, 25kg/bag.
Storage & Transportation
Sealed and stored in the low temperature, dry, cool and well-ventilated place, in order to prevent from moisture and caking. Strictly forbid storing and transporting with materials that is explosive, combustible or deleterious. The shelf life is 12 months.

domain: food


text:
NobelCPA provides tax management service in Turkey according to the clients’ tax obligations in accordance with the Turkish Tax System. Financial legal documents of clients are examined under taxation law in Turkey. By providing tax advisory services in Turkey, solutions are offered to meet any financial obligation that has been observed during such audit, as well as any possible tax risk that are anticipated.
As an accounting firm, our company’s services allow our clients to act freely by managing their VAT, corporate tax and income taxobligations to ensure that they are the good standing within the government at all times.
According to our business mentality, while serving our clients as a tax advisor in Turkey, we aim to approach tax issues professionally by understanding our clients’ tax obligations.
- VAT Advisory, VAT Return, VAT Refund
- Corporate Tax Advisory, Corporate Tax Return
- Income Tax Advisory, Income Tax Return
- Tax Agreement
- Tax Advisory for Foreigners
- Tax Exemptions and Exception Consultancy
- Tax Dispute Resolution Advisory

domain: law


text:
This is not a drill. KathNiel is back! Kathryn Bernardo and Daniel Padilla will lead the cast of the teleserye ‘Tanging Mahal,’ scheduled for release this year.
Further articles on the same subject
Kathryn Bernardo Daniel Padilla / Mahal
Biden selects transgender doctor, Rachel Levine, as assistant health secretary
GOP Rep. Lauren Boebert gave Capitol tour to "large" group before the riots, Democratic lawmaker says
Maryland man arrested after GPS ankle monitor places him at Capitol riot
Navalny releases a massive investigation into what he calls the "biggest bribe in history," a 100 billion ruble palace on the Black Sea allegedly built for Putin . His team says now that they've published the architectural plans, he'll be afraid to use it.
Fortified US statehouses see some small protests ahead of Joe Biden's inauguration
Today marks 31 years of the final ethnic cleansing of Kashmiri Hindus from their ancient homeland. They had earlier been devastated 6 times in history. Do web-search & read about this genteel, accomplished community's horrific tribulations. Do reflect on the apathy they've faced.

domain: news


Signal is an open source project now found in WhatsApp, Facebook Messenger and Google Allo. Starting today, Skype is testing out a new feature called Private Conversations that delivers end-to-end encryption to your chats. They can only send emoticons, files, and audio messages from the chat window.
The Skype Insider app for Windows, macOS and Linux is available to download on this page, and the Android app can be found in the Google Play Store (Microsoft is no longer accepting beta testers on iOS).
In order to further protect privacy, Private Conversations will not be shown in Chats or in any form of notification. Those encrypted messages can only be read by people involved in the communication.
Several popular services have added encrypted messaging for their products, such as WhatsApp and Facebook Messenger, while other apps like Threema specialize in it. Skype, despite its popularity, has been slow to offer its users this option.
Give it a try by selecting "New Private Conversation" from the compose menu or from the recipient's profile.
Signal, the company behind the encrypted messaging app by the same name, has announced a new partnership with Microsoft.
Microsoft has not revealed when the feature will be implemented in the main Skype client, but it's safe to assume that it'll be at least a few weeks/months before all the kinks are ironed out. You can only participate in a private conversation from a single device at a time.
The feature will initiate encrypted private chats only with other users on the Insider build, according to a report by The Verge. The researchers recommend that WhatsApp add an additional authentication mechanism for group chats, but in the meantime users may want to stick to one-on-one conversations when discussing sensitive information.
Skype is rolling out a new feature soon. Take note that the feature is device-specific.


Offaly people made 44 complaints of unfair treatment to the Ombudsman
There were 44 complaints from Offaly people to the Office of the Ombudsman in 2021. Ombudsman Ger Deering said the number of complaints received across Ireland reached a record high in 2021 with 4,004 people contacting his office.
Mr Deering said that complaints about local authorities accounted for the largest proportion of the increase, with 1,290 complaints - an increase of 45% on 2020. These mainly related to housing and planning issues.
The role of the Ombudsman is to investigate complaints from people who feel they have been unfairly treated by certain providers of public services, these include government departments, local authorities, the HSE, public hospitals, publicly funded third level education institutions, public and private nursing homes and direct provision accommodation centres. The services of the office are free to use.
One example of a complaint received was from Norah who complained to a private nursing home when her mother was found on her own, with facial injuries, around three kilometres from her nursing home. Her mother was in her late 70s and had dementia. The nursing home initially refused to engage with Norah or her family saying that they could not make a complaint on behalf of her mother. Norah brought her case to the Ombudsman when the private nursing home refused to provide a written response to her complaint.
When the Ombudsman sought information from the nursing home as part of his investigation, it said it was not obliged to respond to his Office. Once the Ombudsman clarified that under the Ombudsman Act 1980, the nursing home was obliged to provide his Office with the information, it provided the information, but continued to refuse to write to the family. The Ombudsman pointed out that the home was in breach of its own complaints policy by not responding in writing.
It became apparent to the Ombudsman that the nursing home had already carried out an investigation into the incident, and that it had made a number of recommendations aimed at avoiding the situation arising in the future. However, the nursing home’s investigation was not carried out in accordance with its own complaints policy
As a result of the Ombudsman’s intervention the nursing home wrote to Norah apologising for the incident. However, it continued to refuse to respond to Norah in writing to the issues raised in her complaint. The Ombudsman provided a full written account of what had happened on the day of the incident to Norah, and her family. He has also spoken with the Department of Health, with a view to having the requirement for private nursing homes to provide written responses to complaints put on a statutory basis
Before complainants bring their complaints to our Office they must first take steps to resolve their complaint with the public service provider concerned.
Another example was when a man complained to the Ombudsman when Tipperary County Council said that his two businesses would be assessed as one for the Government’s COVID-related business ‘Restart’ grants. The Council said that as his two businesses were linked, and shared the same tax number, the man would be entitled to one grant only in respect of his two operations.
The Restart scheme provides that businesses can be entitled to more than one grant if they have separate ‘rated properties’ or ‘operating from a number of properties’. The Ombudsman noted that the Council had issued separate rate demands in relation to the man’s two businesses and their activities were quite different in nature. In addition, the businesses were registered separately with the Companies Registration Office. The Ombudsman asked the Council to review its decision. The Council awarded the man an additional €3,100 in respect of his second business.
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text:
Great gift for the Fireman's Wife. I'm Just A Woman That Loves Her Firefighter Ceramic Coffee Mug
Picture is printed and heat pressed on both sides of the mug, this is not vinyl. Microwave and Dishwasher safe (top rack). Please note that color may vary from photos due to different monitor settings.
Looking for a custom mug or would like a design personalized please send me a note and I'll be glad to see what I can come up with for you.
Love your Firefighter? I have a vinyl decal you might like to take a look at as well. https://michellesvarietyshop.com/collections/lifestyle-decal/products/my-heart-belongs-to-a-firefighter-vinyl-decal

domain: design


text:
Tracy Briggs, Published September 08 2009
Parenting Perspectives: Quality child care includes healthy learning environmentToday I sent my baby to kindergarten.
I won’t go into the gory details. It’s not easy being a mushball mom. I cry at the drop of a hat and, of course, that includes tearing up as I help my daughter sling her SpongeBob Squarepants backpack over her tiny shoulder.
She starts a new chapter in her life, but it’s us parents who can’t help but look back with sentiment. Her first words, her first steps, her first time telling me “I DO IT MYSELF!” That walk down memory lane includes a look at those people who’ve gotten her this far.
We’ve been fortunate to have remarkable child care providers over the past seven years; people who are committed to not just the care but the education of our two daughters.
I saw firsthand how my older daughter hit the ground running when she started kindergarten, thanks in part to the education she received prior to the age of 5. It’s an opportunity that every child should have.
These are important years. In fact, between birth and age 5, children’s brains are developing faster than at any other point in their life. They’re like little sponges ready to absorb all that you will teach them.
The United Way of Cass Clay hopes to capitalize on this window of opportunity with their Success by Six initiative that helps “ensure children have positive and enriching experiences necessary to begin school prepared to succeed.”
It’s not just children who benefit with quality early childhood education. Overwhelming research shows that society benefits as well, with lowered rates of crime, teenage pregnancy and welfare dependency. What a child learns before the age of 6 sets the stage for future success, behavior and achievement.
According to a recent report from Childcare Resource and Referral about “80 percent of North Dakota children spend most of their waking hours with people other than their parents.” They are our future leaders. We must ensure they are spending time with adults who will foster their development and help their brains grow.
A friend of mine who worked in the child care field told me it drove her nuts when people called her a “day care” provider. She used to say, “We’re not taking care of your days, we’re taking care of your child!”
Too often, child care workers are simply seen as caretakers or baby sitters. Sadly, that is an accurate description for some poor-quality providers who merely make sure no harm comes to your child while you are at work. But most child care workers should be seen for what they truly are: educators.
They don’t work in calculus equations or term papers, but in fingerpaints and macaroni necklaces. They don’t use flashcards to drill numbers or letters into our children’s heads, but they awaken young minds to sensations, ideas and a love of learning.
They get paid too little for such an important job, yet parents often struggle to even pay that small salary. There are no easy answers in these tight budgetary times, but states simply need to allocate more resources to early childhood education.
The payoff is real. One decades-long study out of Michigan showed that for every dollar invested in high-quality early education and care programs $17 would be saved down the road with lowered crime and higher individual education and earnings.
So today, as I get ready to send my daughter – and her friend SpongeBob – off to school, I’m grateful that, through luck and circumstance, her dad and I, together with some great early education teachers, have been able to give her a running start toward kindergarten.
And I hope that in the coming years every child will have the same opportunity.
Tracy Briggs is a mother of two and a personality for WDAY AM 970.

domain: sociology


text:
In today's hunt, I will talk about Thaler.one
Thaler.one is the first global commercial real estate marketplace, that work's basing on the blockchain technology as a transport for assets.
This benefits real estates investors, landlords, and tenants.
With this platform, everyone can become an investor in real estate despite your levels of income.
One can also own a property in a country he or she as never leave in. Say for example I can invest in a property that is in America despite the fact that I have been leaving in Uganda for all my life. You do not first become a citizen of a country to own a property. Even your great grandkids will form your efforts. that's what the blockchain is about.
How Does It Work?
- Qualified investors purchase Thaler.One Fund digital units and effectively become unitholders of the Fund. Digital units are sold in rounds reflective investors demand.
- Thaler.One uses proceeds from sales of Fund units to acquire real estate assets.
- Individual real estate assets in the Fund are securitized, get listed on the Marketplace and digital asset-backed units sold to qualified retail investors with mark-ups. Investors receive rental income pro-rata their % of asset ownership.
- Digital asset-backed units are traded on an internal exchange, people can buy and sell them easily at any time.
- Real estate owners who want to sell or raise capital contribute their assets to Thaler.One Marketplace and Thaler.One Fund unit holders receive origination fees for successful transactions.
- Unit holders of Thaler.One Fund receive regular distribution of income, which comes from real estate in the Fund, profits from securitization of individual assets and origination fees charged to real estate owners.
Thaler.one platform allows individuals to access global real estate market worldwide and benefit from recurring income generated by the underlying properties.
Thaler.one uses blockchain technology as a transport for the assets. In its operations the platform uses digital units Thaler (TLR), which represent shares in the Thaler.One Platform. TLR is a convenient financial instrument ideal for savings, hedging against inflation and using as a future means of payment.
If you are a landlord by this time, you are also catered for by the platform.
You can check out this platform.
That is today's hunt.
Batte Billy Jackson

domain: finance


Apple to Launch Public Beta Testing Programs for iOS 8.3 and iOS 9 [Updated]
Following up on the public beta program used for OS X Yosemite that allowed non-developers to try out and offer feedback on the operating system before its release, Apple will be launching similar programs for iOS 8.3 next month and iOS 9 later this year, reports 9to5Mac.
...Apple intends to release the upcoming iOS 8.3 as a public beta via the company’s existing AppleSeed program in mid-March, according to the sources. This release will match the third iOS 8.3 beta for developers, which is planned for release the same week. Apple then expects to debut iOS 9 at its June Worldwide Developer Conference, with a public beta release during the summer, and final release in the fall.
iOS 8.2 is still in developer testing as Apple gears up for an April launch of the Apple Watch, but the company has also begun seeding iOS 8.3 to developers. The update includes a number of tweaks including support for wireless CarPlay, two-step verification on Google accounts, a new emoji picker, and Apple Pay through China UnionPay.
After a dramatic visual overhaul with iOS 7 in 2013 and a number of new features such as Continuity in iOS 8 last year, iOS 9 will reportedly focus on stability and optimization, although some new features are likely to be included.
Update 4:21 PM PT: Re/code has confirmed that Apple has plans to offer a public beta testing program for iOS 8.3 beginning in mid-March.
Top Rated Comments
I unfortunately don't have time to test unreliable beta software anymore (though I always enjoyed it), but it makes me excited to think about the bugs that will get ironed out before the official release. Especially the little ones like the menu bar sticking to the top of the photos app, or iPads getting suck in one orientation, or UI lag on new devices.
The It-Already-Started Hall Of Fame:
According to the article, it'll be through the AppleSeed program (https://appleseed.apple.com/sp/betaprogram/).
But in all seriousness, I ain't about that beta life no mo. It's overrated.


Last year, there were devastating bushfires, in 2020, the turmoil produced by the COVID-19 pandemic and in 2021, La Nina.
While La Nina has not translated into wet conditions over the spring season, businesses should still be vigilant over the coming months. A Niña is a phenomenon associated with cooler sea surface temperature anomalies in the equatorial East Pacific region. The phrases La Niña and its opposite El Niño – which is associated with a drier climate – were coined by Peruvian fishermen who first spotted these phenomena in South America long before modern science and instrumentation caught up.
“Simplistically, a La Niña event translates into wetter conditions for Eastern Australia, but dryer conditions on the opposite side of the Pacific,” says Dr Alexander Pui, Head of Nat Cat and Sustainability (APAC) at Swiss Re Corporate Solutions.
But he says, a single La Niña event does not absolutely guarantee increased rainfall and more damaging floods and cyclones, although there was an increased risk of these perils during previous La Ninas.
“A Niña is a phenomenon associated with cooler sea surface temperature anomalies in the equatorial East Pacific region”
Although the current La Niña has yet to produce significant rainfall events to date, Pui says it’s important to consider other climate modes rather than La Nina in isolation. “Australia is flanked by the Indian Ocean to the west, the Southern Ocean to the south and the Pacific Ocean to the east. So, we need to look at how climate drivers from each ocean are taking hold.” For now, there is no ‘reinforcing’ support from the Indian Ocean dipole (IOD), which is in neutral, and the Southern Annular Mode (SAM) has also yet to swing positive.
Nevertheless, the La Niña weather pattern, which peaks at about Christmas, is typically a major factor in seasonal climate forecasting because its impacts are significant and its longer lead time in predictability.
“Normally we start to see La Niña manifest from September or October. But that hasn’t happened due to more localised climate drivers. It’s been really warm across most of Australia over the past few months and dry as well. But we expect that dry weather to stop and give way to more rain-producing events. It’s a big call, but I don’t see a repeat of the 2010/11 La Niña event that resulted in the Brisbane floods this season, just because soil antecedent conditions are much dryer compared to that event – however that does not exclude more localised flash flood events”, Pui adds.
Understanding La Niña’s consequences
Based on analysis of Insurance Council of Australia claims data, a La Niña year is significantly more costly in terms of insurance events compared to a neutral year, and also more expensive than an El Nino year. For small businesses, this means it’s essential to be ready.
Says Pui: “Just because it appears that this La Niña has not produced increased storm activity to date, that doesn’t mean they won’t happen and it’s essential to be properly equipped. Businesses that tend to be less prepared are the ones that have not experienced a natural disaster before and assume it won’t happen to them. For this reason, they are most at risk.”
Counterintuitively, businesses located in areas that have previously experienced cyclones are often less exposed – with Port Hedland and much of the Pilbara coast being case in point. This is because it’s likely construction standards were improved as a result of the previous catastrophe, making buildings more able to weather bad storms versus areas that have not faced similar tempests.
“Businesses in areas such as Cairns or Port Douglas tend to be more well-built because they are known cyclone landing areas. But businesses in places not as far north such as Bundaberg and further south may be more exposed,” he adds.
With cyclones expected to migrate further south in the east coast to hit places such as the Gold Coast in the future due to climate change, the message to businesses in these areas is get ready. Here are some steps businesses can take to do this:
- Identify your risks
Look at the Insurance Council of Australia data globe, which is free and open source. Check whether your property is in a flood zone.
- Mitigate your risks
Check and fix roofs, place stock and electrical equipment above the ground floor and install a pump in the basement. “Encourage other local businesses to take similar steps, because if everyone does it the community recovers faster,” says Pui.
- Check your insurance policy
Don’t assume you’re covered for flood, rain or storm water damage. Clarify how much cover you have with your broker.
Governments and local authorities also have a role to play. They have a responsibility to be aware of the latest science on seasonal forecasts of rainfalls and reservoir management. Undertaking state emergency drills also helps communities to be ready for major weather events.
“It will be harder to prepare for natural catastrophes with the current COVID focus, and restrictions. However, we can ill afford to disregard the real risk of natural catastrophe at a time when societal resilience is already being challenged. Governments and businesses have to make sure they are ready,” he adds.
Important notice – Steadfast Group Limited ABN 98 073 659 677 and Steadfast Network Brokers
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Readers write about Bush's diplomacy, Benazir Bhutto's will, racial bias in soccer, and the overload of information in schools.
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text:
Eva’s Home is a separate house one step away from Elia beach in Gerakini. It can accommodate up to seven people and offers the comfort and equipment of a true family home. Internet access is provided.
The accommodation is about 800m away from the market at Kouyoni campsite and about two kilometers from the center of Gerakini. The sandy beach of Elia is only 50 meters away.
The apartment is fully equipped. Guests have at their disposal two bedrooms with one double bed each, a gallery with two single beds, a living room with a sofa, kitchen, TV, WiFi internet and a bathroom with a shower cabin. The unit has a veranda and a terrace with a seating area. The kitchen has a stove, a large fridge with freezer, a washing machine, and necessary utensils.
In front of the house is a garden with lawn and greenery, as well as a parking space.
Right next to the road, near Elia Beach Bar, you’ll find Eva’s Home.
If you need comfortable, neat, well-equipped and decent accommodation close to the beach - Eva’s Home can be a great choice.
You can find out more about Gerakini in our Tourist guide to Sithonia.
We strive to be as accurate as possible in the description of accommodation, but we cannot guarantee that all descriptions are complete and error free.
Eva’s Home is an air-conditioned house for seven people, at a 2-minute walk from the sea and a popular restaurant and beach bar Elia.
Guests have at their disposal two bedrooms with a double bed, a loft-gallery with two single beds, a living room with a sofa bed, a kitchen, WiFi internet and a bathroom.
Close to beach
Prices and room types
Prices are per room per night. Air conditioner usage is included in the price. There are no fixed dates. You can choose the dates of arrival and departure. Send us an email to see if there is any discount for periods longer than two weeks.
Overnight stay tax is not included in prices.
7 Bed Duplex Apartment
Capacity: 7 adults
Cancellation and payment policy
Deposit of 30% of total price of the reservation is required to confirm a booking. The remaining balance will be paid first day upon arrival. If a guest arrives after the arrival date of the reservation or if he leaves before the departure date of the reservation, property owner keeps the right to charge the total price of the reservation. If cancelled up to 21 days before the date of arrival, deposit will be refunded, less administrative fee which in most cases is 35€ but could be more (depending on bank). If cancelled later, or in case of no-show, deposit will not be refunded.
Glossary of terms
Description by the owner is a description provided by property owner. Properties with owner's descriptions only are objects which we have not seen personally. For additional information on accommodation please ask in comments or contact us via email email@example.com
- plain room, without kitchen
- with kitchen, unique space, without separated bedroom
- with one separate bedroom
- with two or more separated bedrooms
- in two levels, with one or more separate bedrooms
- accommodation unit in semi-basement
- Bed Only
- Bed and Breakfast
- Half Board - bed, breakfast and one more meal per day (lunch or dinner)
- Full Board - bed, breakfast, lunch and dinner
- All Inclusive - full board with additional benefits, depending on a hotel

domain: travel


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York County’s Katie Shaw, left, and Gloucester’s Fran Musick, right, hold their home-made signs as they join the Women’s March on Washington in Washington D.C. on Saturday, Jan. 21, 2017. Rally goers fills the steps of a building in the National Mall during the Women’s March on Washington in Washington D.C. on Saturday, Jan. 21, 2017. A young rally goer holds a home-made female venus symbol during the Women’s March on Washington in Washington D.C. on Saturday, Jan. 21, 2017. (Aileen Devlin) MORE PHOTOS VIDEO
Daily Press archival photos from the Civil Rights era will be on display at the Peninsula Fine Arts Center in Newport News as a part of the “Looking Both Ways” exhibit beginning January 17. The exhibition will also include work by contemporary African-American artists and traditional African art. (Photos from Daily Press archives)
For more information on the exhibit, click here.
A demonstrator, protesting the shooting death of teenager Michael Brown, stands his ground as police fire tear gas on August 13, 2014 in Ferguson, Missouri. Brown was shot and killed by a Ferguson police officer on Saturday. Ferguson, a St. Louis suburb, is experiencing its fourth day of violent protests since the killing. (Photo by Scott Olson/Getty Images)


Melissa Gorga’s household just got a little bit bigger. At the end of the season finale of Real Housewives of New Jersey, the Love Italian Style author’s latest update was that she hired an au pair.
Melissa, 40, revealed that she hired an au pair, who is expected to move in with the Gorga family. The reality star shares three children with Joe Gorga — sons Gino and Joe, along with daughter Antonia.
With the live-in help, the mother-of-three will now have more time to focus on Envy, her Montclair-based boutique. The store sells fashionable, high-end designer tops, dresses, shoes and accessories.
“Melissa Gorga’s eye for fashion and style truly reflects the boutique, as she hand picks pieces from an array of emerging designers to prestigious fashion forward brands. With that in mind, you will be sure to find something for almost everyone,” the shop’s website stated.
“Quality, style, and unique choices are top priority, but second to our customer service and the impeccable experience,” the boutique’s page continued. “She, and her team of fashion stylists are talented, creative, energetic, and knowledgeable. At Envy the atmosphere is vibrant, lively, and one you will be sure never to forget. For the experience alone, one should give it a look. The Reality is – Gorga Delivers!”
- Melissa Gorga Teases 'RHONJ' Season 12 Moment That Is 'As Crazy As The Table Flip', Reveals Which Housewife She Hit It Off With While Filming Peacock Spinoff
- Melissa Gorga Reveals Watching Marriage Struggles Play Out On Season 11 Of 'RHONJ' Brought Her & Husband Joe Gorga Closer
- Melissa Gorga Says She Has A 'Gut Feeling' That Teresa Giudice Will Not Stay With Husband Joe
During the RHONJ season finale, Melissa also stirred up old drama by bringing up the infamous hair-pulling incident during a party. Danielle Staub previously told her that Teresa Giudice egged her on to pull Margaret Josephs’ ponytail. Teresa confirmed the information to her fellow housewives. “Danielle said she was on the fence and said, ''I don't know—should I? Should I?'” Melissa recounted. She looked at Teresa, 47. She added, “And then you said, '’Do it.’”
“I remember her saying something to me,” Teresa replied, as her friends' jaws dropped. “I was drinking and everything happened so fast.” The Standing Strong author said that she felt bad about the incident, and hoped the segment wouldn’t wind up part of the finale.
Melissa insisted otherwise. “They are going to use it,” she said, referring to the camera crew for the reality show. Teresa subsequently flipped off the camera and threw her drink before she shoved all of the drinks off the table and ran upstairs in a fit of rage.
The first of three Real Housewives of New Jersey reunion episodes will air next week on Bravo.
What do you think of Melissa hiring an au pair? Sound off in the comments below!


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As per Indian Income Tax Act 1961, income of Charitable trust is exempt from tax.
The trust must apply 85% of income derived for its activities or the object of the trust the balance can be accumulated and used in later years.
Any donation made to such notified trust is allowed as deduction under section 80G of Income Tax Act of the Donor.
All the trust has to register under section 12AA of income tax act, they have to maintain accounts and get their accounts audited by a Chartered Accountant if their income is more than Rs.1, 80,000. Along with that they should also file Income Tax returns.
Elim Church Support Services – Accounting Services
Elim Church Support Services prepare accounts for all types and size of Business, Churches & Mission Organizations, NGO, Associations & Individuals.
All accounts are prepared by qualified accountants, ensuring the highest standards. Our accounting services includes:
- Assistance in maintenance of the necessary books of accounts.
- Finalization of accounts on a monthly / quarterly & annual basis
- Furnishing necessary MIS Reports as per mutually agreed formats
- Liaison with the Auditors for finalization of accounts (If needed)
- Supervision of the accounting transactions of the Organization to ensure compliance with best accounting practices
- Recommending and implementing suitable internal control systems and procedures to suit the requirements of the Client.
Preparation of Tax & TDS Returns
- Tax compliance and representation before tax authorities.
- Filing of Appeals & representation before Appellate Authorities
- Tax planning services
- Preparing and filing of annual returns and other statutory documents with appropriate authorities.
Elim provides comprehensive incorporation services including:
- Drafting of Memorandum & Articles of Association, Trust Deeds & Association Deeds.
- Registration of Trust, Associations & Societies.
- Maintenance of Statutory Records & Registers
- Preparation of notices & minutes and associated documentation for board meetings and general meetings


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Double Bass Showdown: Some of the world’s best double bass players are squaring off in Denton this week for the Bradetich Foundation International Double Bass Competition. It’s a Van Cliburn-like contest designed to spotlight the bulky instrument, reward those who’ve mastered it and encourage its use in solos. So far the plan is working: the contest has captured the the BBC’s attention. The performances are all free and continue through Sunday. Details here.
Birth of Boogie: Coming home to Marshall to play a concert feels like “being abducted by alien spaceships,” says Omar Shariff. A part-time historian from San Antonio identified Shariff, 72 and down on his luck in California, as a kind of missing link to East Texas’ claim as the birthplace of boogie woogie. Marshall’s leaders invited Shariff to return to his birthplace as part of their new tourism plan: “Marshall, Texas: Center Stage”
Sad news: Ridglea Music in Fort Worth is going out of business after 50 years.
Golden Ticket: Today’s the last day to enter KXT 91.7’s drawing for a pair of tickets to each of more than 30 shows this summer. While you’re checking out the details, consider making a contribution to support commercial-free music radio.


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When you meet Monish, Shikha, Subhojit, Rupa, Sujit or Salim, it is hard to recognise them as children from the slums. Well-turned out, polite, and speaking fluently in English, they speak in well-modulated voices about their aspirations, college life and the work they are busy doing at Prayasam.
Monish, of course, is already interning as a Junior Technical Executive at the Prayasam studio in Salt Lake. Of course, it has taken years for these youngsters to reach here. Hailing from slum colonies on the fringe areas of Kolkata, these youngsters have played an important role in transforming their filthy environment into healthy spaces as part of a group called Dakabuko (Daredevils) organised by the NGO (Prayasam) bringing down the incidence of gastrointestinal and malarial diseases drastically. Visual and alternative media such as masks, and hand-held cones through which they appealed, played an important role here.
Organised into groups as per age, from the nursery level, through middle-school and teenage, the children played an important role in educating their adults and peers on the importance of vaccination, cleaning up garbage, and prevention of littering as ‘area health minders’.
Being a trained choreographer himself, Founder-Director Amlan Kusum Ganguly saw the performing arts as the best medium to bring in a change in the thinking of slum communities and usher in a better life for the underprivileged ever since 1996, when he set up Prayasam.
Through training in dance and music, the girls and boys learnt to fight the social evils of domestic violence, child marriage, and discrimination against girl children. At the same time, they were helped with basic social skills and to converse in English by the Prayasam staff.
Over the years, these children have performed several dance ballets at several prestigious functions, depicting themes of social concern. Meanwhile, they also learnt to document their achievements through photography.
Once Prayasam set up a studio at its Salt Lake premises, the children were mentored into producing short films on simple themes under the guidance of Lead Educator Saptarshi Roy. Soon, they graduated into making films on social themes to put across messages on the evils that plagued them in their slum environment. The project was spurred on through funds received from the Global Fund for Children and the Bill and Melinda Gates Foundation in 2011-12. In 2013, Adobe pitched in with the latest software under their Adobe Youth Voices programme, which saw the studio get equipped with the latest in equipment. Thanks to Google, which sponsored the organisation’s endeavours through 13 tablets that were handed over in 2014, films could be shown to slum communities through tablet-tops. These short films cover myriad issues and are used to educate slum communities on their strengths, weakness as also the threats they face in their midst.
With the help of their newly-acquired skills, five of the most promising youngsters have managed to get 10-month long USIS scholarships to study at various community colleges in the US, such as the Arizona Scottsdale Community College, the Virginia Community College and the Arizona Mesa Community College. Monish Chowdhury did a course in Community Media in 2015-16, Salim Sheikh and Sujit Datta have specialised in Early childhood Education in 2016-17, while Subhojit Saha and Saddam Hussain have specialised in Social Media.
The ones, who have trained abroad, are now gainfully contributing to the work being done at Prayasam, and mentoring others now. Thus, Monish is now working hands-on at the studio, as a Junior Technical Executive, along with Salim and Sujit, all of whom are engaged in taking things ahead.
Sponsored by Adobe, each of the youngsters training at the Prayasam studio, is making short films on matters that they have experienced, and want to focus attention on. Rupa Biswas, who experienced the trauma of being lured by traffickers in the past, has made Chorabali (Quicksand) on the modus operandi involved, Sujit Datta has made Chhap (Branding) on the kind of isolation felt by an effeminate boy when branded and bullied by schoolmates, Gopal Roy has made Niruddesh (Missing) on those who get lost forever, while Salim Shaikh has made Aaste, Ladies (Slowly, Ladies) on the social norms imposed on women.
Meanwhile, the commitment and hard work put in by founders Amlan Kusum Ganguly and Piyali Majumdar have already helped usher in collaborative interests from abroad. “It was as an Ashoka Fellow that I was invited to South Africa for a week. FK Norway collaborates on an exchange programme with Kenya. This was how we got to get in touch with Slum Dwellers International, Kenya, and embark on an exchange programme since 2016,” Ganguly tells me.
The youngsters at Prayasam have managed to pick up the finer points of microfinance from the Kenyan team of youngsters - Rose, Nijodi and Calvin, even as the latter got the opportunity to learn film-making and handling equipment at the Prayasam studio.
Similarly, Prayasam also had international hip-hop artiste, Rashidi, coming over to share some moves with the youngsters here. Shikha Bagchi, a promising dancer who has been leading in many of the Prayasam’s dance ballets, mastered hip-hop during Rashidi’s brief sojourn in Kolkata and is now a mentor to many aspiring dancers in the troupe.
The arts have clearly opened up new vistas for these children who have now embarked on the threshold of a profession even as they continue with their education. Rupa Biswas attends Sealdah College to do her BA (2nd year), while Shikha Bagchi is busy doing her B Com (3rd year) at Rammohan College even as they train at the Prayasam studio to learn the finer aspects of film-making. Each of the youngsters learn to budget, propose stories and scripts and pitch their films.
Prayasam has been participating with its films at the Bad and the Beautiful World Film Festival since 2014. This year, eight of its films were selected for the Mumbai International Film Festival (MIFF).
Besides films, Prayasam has also been undertaking media projects on a commercial basis. The media projects undertaken comprise calendars, brochures, short videos or corporate films. This ensures that the youngsters training under Prayasam earn a small amount even as they learn their vocation. Clearly, the arts and media have gifted them a life far ahead of anything they could have dreamt of a decade ago in their slums.

domain: artistic


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Welcome to Shelf Life, ELLE.com’s books column, in which authors share their most memorable reads. Whether you’re on the hunt for a book to console you, move you profoundly, or make you laugh, consider a recommendation from the writers in our series, who, like you (since you’re here), love books. Perhaps one of their favorite titles will become one of yours, too.
N.K. Jemisin understands that to build worlds, you must understand this one. The only person to win three Best Novel Hugo Awards in a row (for each title in the post-apocalypse Broken Earth trilogy), the NYT-bestselling science fiction and fantasy author has just published The World We Make (Orbit), the second in her Great Cities duology (first was The City We Became), among her many books. She also won a Best Short Novelette Hugo for Emergency Skin and Best Graphic Story Hugo for Far Sector, a Green Lantern spinoff for DC Comics and wrote the script for the film adaptation of the Broken Earth series, to be produced by Michael B. Jordan’s Outlier Society.
The Iowa-born Jemisin grew up between Mobile, Alabama and Brooklyn, where she now lives. A psychology major at Tulane who got a master’s in education at the University of Maryland, she was a college career counselor and academic advisor, wrote the Otherworldly SFF column for the New York Times Books Review, and received a MacArthur Fellowship.
She’s a gamer and gardener, has a ginger cat named King Ozzymandias (Ozzy for short) and tuxedo cat named The Marvelous Master Magpie (Maggie for short), teaches a MasterClass on world-building, has a Patreon, was on Time’s 100 Most Influential People list (write-up by Stacey Abrams), once toasted Spam sushi over a heat vent on a Hawaiian volcanic crater, is into anime, manga, and sentai, is cousins with W. Kamau Bell, and likes candy corn.
Good at: Writing fan fiction under pseudonyms. Not so good at: Double dutch, texting fast. Her book recs below YW.
The book that…
…kept me up way too late:
Tailchaser’s Song by Tad Williams, which starts like a children’s story and then becomes something Very Dark.
…shaped my worldview:
Dawn by Octavia E. Butler.
…I read in one sitting, it was that good:
Mechanique by Genevieve Valentine.
…currently sits on my nightstand:
The 1619 Project by Nikole Hannah-Jones.
…I’d pass on to a kid:
Stamped by Jason Reynolds and Ibram X. Kendi.
…I first bought:
Pippi Longstocking by Astrid Lindgren. I have it on good authority that when I was about four, I bought this with gift money.
…should be on every college syllabus:
Why Are All The Black Kids Sitting Together in the Cafeteria? by Beverly Daniel Tatum, PhD.
…I never returned to the library (mea culpa):
I scrupulously returned books to the library and must defend myself on this point!
…sealed a friendship:
A first edition of The Lord of the Rings, which I lent to a friend who recently contacted me about them, sparking the friendship again after a decade!
…features the most beautiful book jacket:
A copy of The Rubáiyát of Omar Khayyám with a damask cover of grapevines in ruby and black.
…everyone should read:
One of the many books by queer and POC authors that are under challenge by conservatives, via your local library. If they’re no longer available at your library because the conservatives got there first, join your local Library Board and fight to reinstate them. Reading–and the freedom to speak truth to power–is part of a framework of equity and justice that is under attack in a way not seen for a generation. Fight for all books. Or else.
…that holds the recipe to a favorite dish:
Salt Acid Fat Heat by Samin Nosrat. After a lifetime of food defined by what it didn’t have, this book is a revelation–it’s less about a specific recipe from the book than it was about changing my relationship to ingredients and preparation.
Riza Cruz is an editor and writer based in New York.

domain: library


Impact 2.0'' End Jaw Vise Grip by Impact at Chicago Lighting Design. MPN: ME113. Hurry! Limited time offer. Offer valid only while supplies last. The Impact 2.0'' End Jaw Vise Grip is a fast way to mount a light or accessory with a 5/8'' Baby receiver to pipe or other tubular support up to 2.0'' in diameter. The Vise Grip's shaft is made of chrome-plated steel and its aluminum alloy jaws are rubber padded to protect mounting surfaces from damage.Construction: Chrome-plated steel and aluminum alloyDimensions: 2.0'' (5.0 cm) JawWeight: Not specified by manufacturerAluminum Alloy Construction. Steel Shaft. 5/8'' Baby Pin. Limited 1-Year Warr
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UPDATE: On June 12, 2018, the Seattle City Council repealed the recently passed employee hours tax in a seven-to-two vote.
On May 16, 2018, the mayor of Seattle signed City Ordinance Number 125578, which imposes an employee hours tax—also known as a head tax—on businesses having more than $20 million of taxable income sourced to the City of Seattle, based on the most recent calendar year. It’s effective January 1, 2019, through December 31, 2023.
Businesses having taxable gross income of more than $20 million under the City of Seattle business license tax are generally subject to the head tax.
- Not-for-profit organizations that hold a current tax-exempt status under Section 501(c)(3) of the Internal Revenue Code
- Hospitals as defined in Revised Code of Washington (RCW) 70.41.020
- Businesses primarily engaged in comprehensive healthcare services that provide at least 25% of their services to patients covered by Medicaid or Medicare and to patients who have no third-party payer.
- Federal and state government agencies and subdivisions
- Insurance businesses and their agents whose total revenue are exempt under the City of Seattle business license tax
- Businesses that only sell, manufacture, or distribute motor vehicle fuel
- Businesses that only distribute or sell liquor
How It Works
A business may choose to calculate its quarterly head tax based on one of the following two measures:
- The number of full-time and part-time employee hours worked within the city of Seattle during each quarter of the calendar year multiplied by $0.14323.
- The number of full-time employees plus hours worked by part-time employees divided by 480, the sum of which is multiplied by $68.75.
Based on either method of computing, the maximum tax for each full-time employee is $275 per year.
Defining an Employee
Under the new tax, an employee is defined as any person who performs work, labor, or services for a business, is on the business’s payroll, and performs any part of their duties within the City of Seattle. This includes full-time, part-time, and temporary employees or workers on a business’s payroll. Anyone who works at least 480 hours in a quarter of a calendar year is considered a full-time employee.
A business’s payroll includes the payroll of any related company that acts as a paymaster for the related entities. Members of limited liability companies, professional limited liability companies, and partners are also considered employees.
Because the head tax is an additional tax imposed by the City of Seattle, businesses that file and pay their business license tax on a quarterly basis must file and pay the head tax on a quarterly basis.
We’re Here to Help
For more information about how the new head tax may affect you or your business or for assistance in determining the appropriate amounts to report, contact your Moss Adams professional or email email@example.com.

domain: economics