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Home ▶ Vol 42, No 1 (2019) ▶	Hlongwa
Background of the study
Aim of the study
Objective of the study
Significance of the study
Esther N. Hlongwa
KwaZulu-Natal College of Nursing, Pietermaritzburg, South Africa
Maureen N. Sibiya
Faculty of Health Sciences, Durban University of Technology, Durban, South Africa
Hlongwa, E.N. & Sibiya, M.N., 2019, 'Challenges affecting the implementation of the Policy on Integration of Mental Health Care into primary healthcare in KwaZulu-Natal province', Curationis 42(1), a1847. https://doi.org/10.4102/curationis.v42i1.1847
Esther N. Hlongwa, Maureen N. Sibiya
Received: 23 July 2018; Accepted: 18 Mar. 2019; Published: 21 Aug. 2019
Background: Since the publication of the White Paper for the Transformation of the Health System in South Africa in 1997, which included Policy on Integration of Mental Health Care into primary health care (PHC), there has been an emphasis on the promotion of health as well as the re-engineering of PHC to include the integration of mental health care into PHC. Although South Africa has made significant advances at the level of health-related policy development and legislation in trying to bring the country in line with international trends, there have been challenges with regard to implementation of policies, including that of integration of mental health care into PHC.
Objectives: The aim of this study was to determine the challenges affecting the implementation of the Policy on Integration of Mental Health Care into PHC in KwaZulu-Natal (KZN) province of South Africa and to seek possible solutions.
Method: A qualitative exploratory descriptive design was used to determine the challenges affecting the implementation of the Policy on Integration of Mental Health Care into PHC in KZN. The sample consisted of 42 participants of whom 4 were PHC managers, 6 were operational managers and 22 were professional nurses who were directly involved in implementing the policy at the operational level.
Results: The challenges identified included lack of training in mental healthcare services for staff working in PHC, unavailability of mental health policies, inadequate resources, poor communication between management and staff, lack of skills among PHC nurses in identifying signs of mental illness and misdiagnosis of patients.
Conclusion: Considering the challenges pertaining to PHC nurses' abilities and skills to implement the Policy on Integration of Mental Health Care into PHC, PHC-trained nurses should engage in lifelong learning and be encouraged to develop their knowledge, skills and competence throughout their professional lives.
Keywords: primary healthcare; mental healthcare; health-related policies; integration of care; comprehensive care integration; service integration.
Despite the efforts of bringing South African health-related policy development and legislation in line with international trends, there have been many challenges with regard to implementation of policies, including the integration of mental healthcare into primary healthcare (PHC) (Burns 2008:1; Dube & Uys 2015:2; Kigozi & Ssebunnya 2009:37). The Policy on Integration of Mental Health Care into PHC in South Africa was published together with the White Paper for the Transformation of the Health System in South Africa in 1997 (Republic of South Africa 1997). In 2006, the National Department of Health released guidelines for the management of mental disorders (Department of Health 2006:1). In 2013, the National Department of Health in South Africa developed the National Mental Health Policy Framework and Strategic Plan 2013–2020 to guide the implementation of policy framework (Department of Health 2013:1). Many facilities in KwaZulu-Natal (KZN) province have attempted to implement the Policy on Integration of Mental Health Care into PHC, but there are reports of challenges that are facing PHC nurses (Awenva et al. 2012:184; Burns 2008:1; Dube & Uys 2015:2; Kigozi & Ssebunnya 2009:37). This study investigated the challenges that are negatively affecting the implementation of the Policy on Integration of Mental Health Care into PHC.
Prior to 1994, the healthcare system including mental healthcare in South Africa was fragmented. It was segregated by race or ethnic group and the best resourced facilities were located in urban areas, while rural areas were under-resourced (African National Congress 1994:1). Mental healthcare was characterised by violations of human rights (Burns 2008:45). In 1973, the Mental Health Care Act No. 18 of 1973 was promulgated and this act reinforced isolation of the mentally ill patients from general healthcare.
Psychiatric services were stand-alone services and not integrated into PHC (Burns 2008:46). After 1994, changes in the healthcare system as well as mental healthcare took place, and South Africa put more emphasis on comprehensive care. In keeping with the Constitution of South Africa (Republic of South Africa 1996), the White Paper for the Transformation of Health Systems in South Africa was published together with the Policy on Integration of Mental Health Care into PHC in 1997, which made provision for a new health system based on PHC principles (Republic of South Africa 1997:1). The new health system emphasised prevention and promotion instead of being curative and hospital orientated.
In line with international trends, the Mental Health Care Act No. 17 of 2002 was promulgated in South Africa based on a number of principles, the fundamental one being that mental healthcare should be integrated into PHC and should be located close to residential areas (Department of Health 2002:1). The Policy on Integration of Mental Health Care into PHC also stipulates that mental healthcare patients should receive treatment at clinics in their residential areas and mental healthcare services must be integrated into PHC (Republic of South Africa 1997:1). This demands that PHC-trained professional nurses, working at the clinic, should be able to assess all patients, identify patients with mental illness and provide the necessary treatment. Although South Africa has made significant advances at the level of health-related policy development and legislation in trying to bring the country in line with international trends, there have been challenges with regard to implementation of policies, including that of integration of mental healthcare into PHC.
Since the publication of the White Paper for the Transformation of the Health System in South Africa in 1997, which included Policy on Integration of Mental Health Care into PHC, there has been an emphasis on the promotion of health as well as the re-engineering of PHC to include the integration of mental healthcare into PHC. Primary healthcare engineering in South Africa is a national strategy which was launched in 2010 by the National Minister of Health, aimed at improving PHC and promoting healthcare which is more practical, integrated and based on the needs of the population (Department of Health 2010:1). In a PHC clinic, nurses are responsible for the management, administration and counselling of patients (Department of Health 2010:2). Since the publication of the Policy on Integration of Mental Health Care into PHC, there have been many challenges (Burns 2008:1; Dube & Uys 2015:2; Kigozi & Ssebunnya 2009:37). Challenges reported included insufficient support and information to guide PHC-trained nurses on the implementation of the policy, and PHC-trained nurses lacking the necessary skills to provide quality mental healthcare (Awenva et al. 2012:184; Petersen et al. 2011:4; Williams et al. 2008:211). This prompted a need to identify, investigate and address these challenges that are affecting the integration of mental healthcare, and facilitate implementation of the integration of mental healthcare into PHC in KZN.
The aim of the study was to determine the challenges affecting the implementation of the Policy on Integration of Mental Health Care into PHC in KZN.
The objectives of the study were to:
Explore challenges that hinder the implementation of the policy on integration of mental healthcare into PHC as perceived by PHC nurses in KZN province.
Explore possible solutions from the perspective of PHC nurses to effectively implement the Policy on Integration of Mental Health Care into PHC in KZN province.
The study was guided by the following questions:
What are the challenges that affect the implementation of the policy on the integration of mental healthcare into PHC?
What are the possible solutions for ineffective implementation of the Policy on Integration of Mental Health Care into PHC?
From the literature review, it was evident that there is poor integration of mental healthcare into PHC. Various studies have indicated that PHC services are ineffective in managing mental healthcare users, despite all the guidelines that have been developed (Burns 2008:1; Dube & Uys 2015:2). Primary healthcare–trained nurses are at the forefront of the provision of PHC at the clinics. No previous study has been conducted to determine challenges affecting the implementation of the Policy on Integration of Mental Health Care into PHC by PHC nurses in KZN. The findings of this study will provide insight into the challenges experienced by the PHC nurses in implementing the Policy on Integration of Mental Health Care into PHC and offer possible solutions.
For the purpose of this study, it is necessary to define the concepts that were used throughout the article to ensure that the readers and the researchers share the same meaning attached to specific concepts.
Mental healthcare is a human clinical science based on a variety of theoretical frameworks with emphasis on the psychosocial and bio-physical sciences. It constitutes knowledge regarding promotion of mental health and primary, secondary and tertiary prevention of mental illness (Townsend 2015:908). For the purpose of this study, mental healthcare refers to the care given to mentally ill patients by nurses working in PHC clinics.
Primary healthcare is usually the first point of contact people have with the healthcare system that provides essential health services accessible to individuals, families and community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development. This includes a broad spectrum of services from promotion of health to prevention of illnesses and management of chronic diseases (World Health Organization 2018:1). For the purposes of the study, PHC refers to the comprehensive care given to all patients at the nearest clinic.
Townsend (2015:907) defines mental health as a successful adaptation to stressors from internal or external environments evidenced by thoughts, feelings and behaviours that are age appropriate and congruent with local and cultural norms. For the purposes of this study, mental health means to be successful in working, loving, resolving conflicts and adapting well to the environment.
Service integration
Service integration is defined as bringing together of services and activities that share common goals (Sibiya & Gwele 2009:31).
Policy implementation is defined as a complex change process whereby government decisions are transformed into programmes, procedures, regulations and practices that are aimed at the betterment of society and the community at large (Khan & Khandaker 2016:1).
A qualitative, exploratory, descriptive and contextual design was used to explore the challenges affecting the implementation of the Policy for the Integration of Mental Health Care into PHC in KZN. The design was chosen to achieve the aim of the study, which was to provide an in-depth description of the phenomenon under study. The design was followed for this study considering that very little is known about the challenges that affect the implementation of the policy on the integration of mental healthcare into PHC.
The study took place in health districts in KZN which were purposefully selected, according to their geographical location, because the boundaries of these health districts coincide with the district and metropolitan municipal boundaries. The districts selected included: central (eThekwini), midlands (uMgungundlovu), north (iLembe) and south (uGu). eThekwini and uMgungundlovu health districts are situated in urban areas and iLembe and uGu health districts are situated in semi-rural areas. It is often assumed that health facilities that are located in urban areas are better resourced than facilities located in rural areas. All four districts had implemented the policy on the integration of mental healthcare into PHC at their clinics.
Population and sampling process
A three-stage sampling approach was applied: the first stage was selecting health districts in KZN which included central (eThekwini), midlands (uMgungundlovu), north (iLembe) and south (uGu). All four districts had implemented the Policy on the Integration of Mental Health Care into PHC at their clinics.
The second stage of sampling was to select clinics located within the districts of eThekwini, uGu, uMgungundlovu and iLembe. Purposive sampling was used to select four clinics. Two clinics in the rural areas and two in the urban areas were selected, and the criteria for selection were as follows: the clinics should provide comprehensive care and have implemented the Policy on Integration of Mental Health Care into PHC. The researcher purposefully selected one central and accessible clinic per district that provides comprehensive care, and which had implemented the Policy on Integration of Mental Health Care. The clinics that were purposefully selected were KwaDabeka Clinic in eThekwini, Gamalakhe Clinic in the uGu district, Mbalenhle Clinic in the uMgungundlovu district and Ndwedwe Clinic in the iLembe district.
The third stage of sampling was to select participants who were willing to take part in the study. Purposeful sampling was used to select participants. Primary healthcare managers, operational managers as well as professional nurses at the selected clinics participated in this study. Purposeful sampling was the ideal sampling technique to select participants as the cadres of healthcare workers selected are involved in the implementation of the Policy on Integration of Mental Health Care into PHC at the selected clinics.
After the researcher had obtained ethical clearance from the university and the KZN Department of Health, data were collected from the four PHC clinics in each district. The sample consisted of 42 participants of whom 4 were PHC managers, 6 were operational managers and 32 were professional nurses who were directly involved in implementing the policy at the operational level. The researcher interviewed the PHC managers and the operational managers, and a total of five focus group interviews were conducted with the professional nurses, four with six participants and one with eight participants. The researcher continued with interviews and focus group discussions until data saturation was reached. Data saturation occurs when sampling provides no new information and the data collected become redundant (Grove, Burns & Gray 2013:371). In this study, data saturation was reached when the researcher interviewed the third PHC manager, the fifth operational manager and conducted the seventh focus group interview. This is when the researcher realised that the participants were repeatedly giving the same information.
A guide was used to facilitate the one-on-one interviews and focus group discussions. Data obtained during the one-on-one interviews and focus group discussions were voice-recorded using field notes as a backup. Data collection and analysis occurred concurrently, allowing the researcher to constantly compare similarities and variations to determine common categories and subcategories.
The recorded one-on-one interviews and focus group interviews were transcribed and analysed according to Tesch's method of open coding (Creswell 2012:191). Data from the participants were coded together and checked by the supervisor who has experience in qualitative research. The main themes and sub-themes were identified. Conclusions and recommendations were then drawn from the data.
To ensure trustworthiness of the study, Lincoln and Guba's model was used (Polit & Beck 2012:584). The strategies used in the study to ensure trustworthiness were credibility, transferability, dependability and conformability. Credibility was achieved in this study by double checking of audio-recording, field notes and member checking. The researcher gave feedback to the participants regarding the themes that were emerging from the data in order to obtain reactions and to explore if these interpretations were a good representation of the participants' reality. To give the reader a full understanding of the study, a full description of the research process was provided. This is supported by Brink, Van der Walt and Van Rensburg (2012:57) who state that before processing of data, the researcher must examine them for completeness and accuracy. Transferability was ensured by ensuring that there was a description of the research setting, the participants of the study and a full description of results.
To ensure dependability of the study, the research process was carefully documented through the use of field notes, voice recordings and the description of the role of the researcher. Different methods of collecting data were used which included one-on-one interviews and focus group interviews. Conformability was achieved by ensuring that the results were confirmable, procedures were correctly documented and data checked during data collection and analysis.
Ethical approval for conducting this study was obtained from the ethics committee (Ethical clearance reference number: REC 46/16). Permission to conduct the study was requested from the District Manager and the KZN Department of Health. All participants in the study were given a letter of information and consent form to consent to participate in the study. Participation was voluntary and the participants were told that they can withdraw from the study at any time without any penalty. The researcher requested permission to voice record the interviews. The participants were informed that they would not receive monetary benefits for participating in the study. Extra precautions were taken to safeguard the participants with regard to anonymity and confidentiality. Their names were not mentioned and recorded during discussions. They were advised of the confidentiality and anonymity of the discussion and responses.
Themes that emerged from the data analysis are discussed below.
Lack of skills in managing mental healthcare users
The study revealed that PHC nurses who were managing patients at the clinic were not adequately competent to offer all the services that are offered in clinics where a one-stop-shop approach was used. This is supported by Lund et al. (2012:403) who reported that some mental health patients are treated by registered nurses who do not have qualifications in Psychiatric Nursing Science and that this practice may lead to mental health patients being misdiagnosed, leading to relapse of mental illness.
The following are some challenges expressed by interviewees:
'Not everyone who works in the clinic has Psychiatric Nursing Science qualification or has participated in the in-service training. A number of PHC nurses do not have a qualification in psychiatric nursing.' (PHC manager, Interview, P4)
'Currently, there is no trainer to assist staff in mental health training. Not every professional nurse is good in mental health care.' (Operational manager, Interview, P1)
'When it comes to human resources, there are not enough resources to deal with all these things, staff that is willing to implement the policy. Nurses must be trained, at the moment if one person has gone for training, that person needs to come back and cascade the information at PHC level.' (Operational manager, Interview, P2)
Primary healthcare–trained nurses, as evident from the above excerpts, felt neglected and concerned that they are not competent in mental healthcare as expected.
Unavailability of mental health policies for staff at the clinic
Unavailability of mental health policies for staff at the clinic was cited as a limiting factor in implementing the Policy on Integration of Mental Health Care into PHC, resulting in a lack of knowledge of the policy. At some of the clinics that the researcher visited, participants expressed concern that they had not seen the Policy on Integration of Mental Health Care into PHC and the Mental Health Act, although they had heard of these. The results of this study are consistent with the study conducted by Dube and Uys (2015:7) whose findings revealed that mental health guidelines, including the Mental Health Care Act (No. 17 of 2002), were not available in four of the study sites in South Africa. One can assume that participants expected managers to make policies accessible and they also needed to be educated on the policy and the act.
Participants responded as follows:
'We don't have access to policies. We have not seen the policy. I think not being aware of the policy, lack of access to information and policies is not good. I think managers should make sure that their staff have access to information.' (Professional nurse, FGD, P32)
'We don't have access to access to intranet. No one talks to us about policies for mental health. We have HIV policies instead.' (FGD, P7)
'We have no access to policies and Acts and most of us have not seen the policy and we don't understand contents of these policies you are talking about.' (Professional nurse, FGD, P30)
Inadequate resources
Inadequate resources emerged as a factor hindering the implementation of integration of mental healthcare into PHC. Participants from rural clinics reported shortage of space, consulting rooms and medication to treat mental illness. This was different from clinics in urban areas where there was enough space and consulting rooms. Lack of space results in lack of privacy which interferes with the ability of staff to counsel mental health patients.
All clinics cited shortage of staff, especially psychiatric nurses, specialist psychiatrists and advanced psychiatric nurses, as the main factor hindering the implementation of integration of mental healthcare into PHC. In some clinics, a psychiatrist only comes in once a week and a general practitioner sees all patients including mental healthcare users.
'We have shortage of staff, only two professional nurses in Out Patients Department, if one goes for lunch or sick, only one is left alone. Shortage of psychiatrists and no advanced psychiatric nurses.' (Operational manager, Interview, P3)
'There is inadequate space and consulting rooms suitable for counselling. We have inadequate staff and space in this clinic, no medication to give to mentally ill patients., (Professional nurse, FGD, P10)
Poor communication between management and staff
Poor communication between management and staff emerged as a factor hindering the implementation of the integration of mental healthcare into PHC. The participants said that there was a communication gap between managers and staff at grass roots level. In contradiction, managers expressed satisfaction with how managers and staff communicate. This is supported by Temane, Poggenpoel and Myburg (2014:7) who conducted a study with advanced psychiatric nurse practitioners on their ideas and needs for supervision in private practice in South Africa and found that supervisors lacked communication skills; they suggested that there is a need for supervisors to possess facilitative communication skills.
'Not being aware of the policy and lack of access to information. Management is not communicating with staff, not informing staff about new policies.' (Professional nurse, FGD, P4)
'Managers do not communicate with us staff members. No policies are communicated to us. It's the first time somebody has spoken to us.' (Professional nurse, FGD, P17)
'I feel managers should communicate with us, even if once a month. At this clinic, we only work. They only communicate with us when they give us work.' (Professional nurse, FGD, P6)
Lack of skills of managing mental healthcare users among primary healthcare nurses
Another factor hindering the implementation of the integration of mental healthcare into PHC was PHC nurses' lack of skills to manage mental health patients. It was found that PHC nurses' lack of skills in identifying signs of mental illness, misdiagnosing and giving wrong treatment or failure to treat mental health patients led to relapse of poor support, and lack of skills in identifying patients with signs of mental illness has been cited by Burns (2008:1) as an important factor undermining the implementation of integration of mental healthcare into PHC.
'Not every professional nurse knows how to nurse mental health care users. A number of professional nurses do not have skills and ability to diagnose and treat mentally ill patient.' (PHC manager, Interview, P1)
'Lack of skills in identifying mental health care users, misdiagnosing them and this leads to treating them with medication that will not relieve the symptoms.' (Professional nurse, FGD, P5)
Possible solutions that will allow integration of mental healthcare into primary healthcare to take place effectively
The participants cited conditions that need to be in place for the implementation of the Policy on Integration of Mental Health Care into PHC to be effective. These include adequate and appropriate space or consulting rooms for patients at the clinic, adequate supply of medication for all patients, protocol for the management and referral of mental healthcare users, qualification in Psychiatric Nursing Science and PHC for all nurses working at the clinic, and there should be more psychiatrists and advanced psychiatric nurses. Figure 1 summarises possible solutions for the integration of mental healthcare.
FIGURE 1: Possible solutions for the integration of mental healthcare into primary healthcare.
Adequate space or consulting rooms for patients at the clinic
Participants recommended that each PHC clinic must provide adequate space and consulting rooms for counselling and interviewing clients, which will allow effective integration of mental healthcare into PHC. Privacy allows confidentiality of information between the mental health patient and health worker to be achieved. Participants reported as follows:
'Environment should be conducive and safe for counselling and management of patients' space must be able to accommodate difficult patients and allows for management of agitated and aggressive patients in the clinic.' (Professional nurse, FGD, P11)
'We need more consulting rooms and bigger spaces especially because other members of the multi-disciplinary teams visit the clinic: we really need more space to accommodate everybody.' (Operational manager, Interview, P6)
Adequate medication for all patients
Participants suggested that in each PHC clinic, there should be adequate medication supplies for all patients. Adequate medication supplies allow PHC nurses to give quality treatment to mental health patients and prevent relapse and re-admission to mental institutions as noted in the excerpts below:
'There should be enough treatment available for all patients at the clinic. Enough medication needs to be stored in every consulting room even for night duty or weekends.' (PHC manager, Interview, P1)
'Shortage of medication and at times some of the drugs used by mental health care users is not in stock. Medication is important for managing mental health care users all the time.' (Operational manager, Interview, P1)
Protocol for management and referral of mental healthcare users
Protocol for management and referral of mental healthcare users is an important condition that needs to be in place before integration of mental healthcare can take place. In each clinic, there must be step-by-step procedures formulated by management for the management and referral of mental healthcare users and this must be communicated to all staff at the clinic. Engagement of community members and other stakeholders in the community, including police, on how to manage mental healthcare users, should be arranged so that all stakeholders support the policy.
'There should be step-by-step protocols on how to manage and refer mental health care users in each clinic, and there must be enough resources to implement the protocol.' (Professional nurse, FGD, P25)
'If the mental health care user cannot be treated, then the mental health care user needs to be referred and there must be a proper protocol in place to determine when the patient must be referred.' (Operational manager, Interview, P5)
'There should be protocols that are communicated throughout the department by management.' (Professional nurse, FGD, P14)
Qualification in Psychiatric Nursing Science and primary healthcare for all nurses working at the clinic
Qualification in Psychiatric Nursing Science for all nurses working at the PHC clinic was identified as an important condition for integration of mental healthcare into PHC to be effective. Participants recommended that PHC nurses should be trained to identify signs of mental illness as noted in the quotes below:
'PHC nurses must be trained in both Psychiatric Nursing Science and Primary Health Care to be able to understand and manage all patients including mental health care users.' (PHC manager, Interview, P2)
'Every professional nurse at the clinic must also have knowledge of mental illness and must be able to recognise signs of mental illness.' (Operational manager, Interview, P6)
'It is important to train nurses in psychiatric nursing so that they don't misdiagnose mental illness.' (Operational manager, Interview, P1)
The availability of advanced psychiatric nurses and psychiatrists at each clinic
Participants recommended that in each PHC clinic, there must be psychiatrists and advanced psychiatric nurses to provide support and mentoring of PHC staff who have basic qualifications in Psychiatric Nursing Science and PHC. According to Marais and Petersen (2015:15), there are insufficient specialist personnel to support professional nurses who have basic qualifications and those who do not have qualification in psychiatric nursing.
'I think that PHC nurses need support and mentoring from the psychiatrists or advanced psychiatric nurses. At the moment there is only one PHC nurse with advanced psychiatry.' (PHC manager, Interview, P1)
'The psychiatrist only comes only comes once a week and this is not enough. I think we are having problems to implement the policy because of lack of support from Psychiatrists.' (Professional nurse, FGD, P23)
'I think PHC nurses need specialist support for effective integration of mental health care into PHC.' (Operational manager, Interview, P3)
Integration of mental healthcare remains a critical issue in the healthcare system in KZN province despite many efforts by the National and Provincial Departments of Health. The study revealed that the phenomenon of integration of mental healthcare into PHC was seen by PHC-trained nurses as provision of comprehensive care that is either given through a supermarket approach or a one-stop-shop approach, depending on the availability of PHC nurses with a qualification in psychiatric nursing. The study also revealed that the majority of PHC nurses who were managing patients at the clinic were not adequately trained to offer all the services that were offered at a one-stop-shop. This is consistent with the findings of Lund et al. (2012:403) who reported that some mental healthcare users are seen by registered nurses who do not have a qualification in Psychiatric Nursing Science and further argue that this practice may lead to mental healthcare users being misdiagnosed, leading to a relapse of mental illness.
This study reported challenges affecting the Policy on Integration of Mental Health Care into PHC as perceived by PHC-trained nurses in selected health districts in KZN province. Challenges identified included lack of training in mental healthcare services for staff working at PHC, unavailability of mental healthcare policies for staff at the clinic, inadequate resources, poor communication between management and staff as well as lack of skills among PHC nurses in identifying signs of mental illness. The findings of this study are consistent with the study conducted by Dube and Uys (2015:8), which explored practices used by PHC nurses in the management of mental healthcare users at selected PHC clinics in uThungulu District in KZN. Their study revealed that there was no evidence of thorough assessment of mental healthcare users and argued that this could be attributed to PHC nurses lacking knowledge and skills in managing mental healthcare users. Xaba, Peu and Phiri (2012:11) and Marais and Petersen (2015:6) highlighted the lack of training and support of staff in providing comprehensive care and recommended that healthcare workers should be appropriately trained and supported to render services that are otherwise beyond their level of training.
Inadequate resources emerged as hindering the implementation of integration of mental healthcare into PHC. Participants from rural clinics reported shortage of space, consulting rooms and medication to treat mental illness. This was different from participants from clinics in urban areas who reported having enough space and consulting rooms to maintain privacy. Lack of space results in lack of privacy, which interferes with the ability of staff to counsel mental healthcare users.
All clinics cited shortage of staff (especially psychiatric nurses, specialist psychiatrists and advanced psychiatric nurses) as the main factor hindering the implementation of integration of mental healthcare into PHC. In some clinics, a psychiatrist comes once a week only and a general practitioner sees all patients including mental health patients. Shihundla, Lebese and Maputle (2016:7) maintain that the Department of Health should have strategies to retain their staff to prevent shortages of staff and increased workload. This is supported by Igumbor et al. (2016:7) who state that innovative strategies are necessary to combat the shortage of healthcare professionals and improve the healthcare system in South Africa.
Lack of communication between management and staff was a factor hindering the implementation of the integration of mental healthcare into PHC. The participants were of the view that there was a communication gap between managers and staff at the grass roots level. The results of this study are consistent with the study conducted by Mmamma, Mothiba and Nancy (2015:4), which revealed that professional nurses experienced a lack of support from top management during the execution of nursing duties at the hospital. These authors further suggest that top management should support staff members rather than intimidating them. Similarly, Sojane, Klopper and Coetzee (2016:1) found that nurses felt unsupported and undervalued and suggested that nurse managers can improve job satisfaction by giving praise and recognition at work. Lack of communication about the policy on integration of mental healthcare into PHC at district level has been reported by Marais and Petersen (2015:14), who suggested that this can be improved by including strategic planners in development plans that have the capacity to translate policies into plans at provincial and district levels.
Primary healthcare nurses' lack of skills in identifying signs of mental illness, misdiagnosing and giving wrong treatment, or failure to treat leading to relapse of the mental healthcare users, emerged as a factor hindering the effective integration of mental healthcare into PHC. Currid et al. (2011:21) reported that PHC nurses in London have poor skills in detecting and treating people with mental disorders. Xaba et al. (2012:6) found that in Tshwane (Gauteng), there is a shortage of PHC nurses, psychologists and psychiatrists at clinics and newly qualified nurses are left on their own without support and mentoring. Al-Khatham et al. (2013:204) argued that if mental illness is not detected, it can lead to difficulties in managing it.
Adequate medication supplies for all patients were viewed as an important condition that needs to be in place before integration of mental healthcare can take place. The participants stated that enough medication supplies allow PHC nurses to give treatment to mental healthcare users and prevent relapse and re-admission to mental institutions. Marais and Petersen (2015:10) state that there are major challenges with regard to medicines and technologies related to the supply of psychotropic medicines at district level. In most instances, this is attributed to a breakdown in communication between the hospitals, clinics and pharmacies. These authors further state that lack of medication supplies leads to mental healthcare users defaulting which may lead to relapse.
One of the limitations of this study is that it did not include mental healthcare users and their families as they are the custodians of integration of mental healthcare into PHC. It would be of great interest to see how mental healthcare users perceive and understand integration of mental health into PHC. It would also be informative if general patients who are receiving treatment at PHC clinics together with mental healthcare were included to find out their perceptions of this policy.
Another limitation is that, of the 11 districts in KZN province, this study only looked at two rural districts and two urban districts; therefore, the study results cannot be generalised to other settings.
Despite the limitations that might impact the generalisability of the results, the following are some recommendations based on the findings of the study.
Based on the findings of this study, there is evidence that a lack of communication between management and operation staff exists. Despite the benefits of the Policy on Integration of Mental Health Care into PHC, a lack of communication regarding policies and provisions of the Mental Health Act may have a serious effect on the implementation of the policy. Therefore, KZN needs to have protocols, guidelines and communication strategies on how to implement the policy. Managers need to be capacitated with requisite skills to provide leadership in this matter.
Lack of supervision by specialists can also hamper the provision of quality mental healthcare at PHC.
Therefore, it is recommended that there should be more resident psychiatrists and advanced psychiatric nurses who can supervise and mentor PHC nurses in providing quality mental healthcare.
Lack of resources, space, equipment, lack of political will and increased workloads were identified as major factors hindering the implementation of the policy. It is recommended that PHC facilities should receive increased budgets to provide adequate and additional services at PHC clinics.
The growing population in South Africa together with the increasing burden of disease requires additional services that need to be provided by PHC nurses. This situation often creates increased workloads, where there are shortages of staff, especially trained staff. The training of more nurses with adequate skills is critical. On the basis of the findings of this study, it is recommended that the PHC curriculum should be re-examined so that new PHC graduates understand the integration of mental healthcare into PHC, their roles in this regard and how to function in such an environment.
This study has revealed that there are challenges affecting the implementation of the Policy on Integration of Mental Health Care into PHC. The researcher recommends that future research should be conducted on the effect of the implementation of the Policy on Integration of Mental Health Care into PHC on mental healthcare users and their families.
This study attempted to analyse the challenges that affect the implementation of the Policy on Integration of Mental Health Care into PHC with the aim of suggesting solutions that will enhance the implementation of the policy in KZN, South Africa. Considering the challenges pertaining to PHC nurses' abilities and skills to implement the Policy on Integration of Mental Health Care into PHC, PHC-trained nurses should engage in lifelong learning and be encouraged to develop their knowledge, skills and competence throughout their professional lives.
The authors acknowledge Durban University of Technology, KZN Department of Health and District Managers for granting them permission to conduct the study.
E.N.H. was the principal investigator and M.N.S. was the supervisor and also assisted with conceptual design of the study.
Funding for this study was sponsored by Durban University of Technology in South Africa.
Data availability statement
Data sharing is not applicable to this article as no new data were created or analysed in this study.
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.
African National Congress (ANC), 1994, National health plan for South Africa, Umanyano Publications, Johannesburg.
Al-Khathami, A.D., Al-Harbi, L.S., AlSalehi, S.M., Al-Turki, K.A., AliZahrani, M.A., Alotaibi, N.A. et al., 2013, 'A primary mental health programme in Eastern Province, Saudi Arabia', Mental Health in Family Medicine 10, 203–210.
Awenva, A.D., Read, U.M., Otori-Attah, A., Doku, V.C.K., Akpalu, B. & Osei, A., 2012, 'From mental health policy development in Ghana to implementation: What are the barriers?', African Journal of Psychiatry 13, 184–191.
Brink, H., Van der Walt, C. & Van Rensburg, G., 2012, Fundamentals of research methodology for health care professionals, 3rd edn., Juta, Cape Town.
Burns, J.K., 2008, 'Implementation of the Mental Health Care Act 2002 at district hospitals in South Africa: Translating principles into practice', South African Medical Journal 98(1), 46–49.
Creswell, J.W., 2012, Qualitative inquiry and research design: Choosing among the approaches, 3rd edn., Sage, Thousand Oaks, CA.
Currid, T.J., Turner, A., Bellefontaine, N. & Spada, M.M., 2011, 'Mental health issues in primary health care: Implementing policies in practice', British Journal of Community Nursing 17(1), 21–25. https://doi.org/10.12968/bjcn.2012.17.1.21
Department of Health (of South Africa), 2002, Mental Health Care Act, No.17, Government Gazette, Government Printers, Pretoria.
Department of Health (of South Africa), 2006, National guidelines for the management of mental health care user in South Africa, Government Printers, Pretoria.
Department of Health (of South Africa), 2010, Re-engineering primary health care in South Africa: Discussion document, Government Printers, Pretoria.
Department of Health (of South Africa), 2013, National mental health policy framework and strategic plan 2013–2020, Government Printers, Pretoria.
Dube, F.N. & Uys, L.R., 2015, 'Primary health care nurse's management practices of common mental health conditions in KwaZulu-Natal, South Africa', Curationis 38(1), 1–10. https://doi.org/10.4102/curationis.v38i1.1168
Grove, S.N., Burns, N. & Gray, J.R., 2013, The practice of nursing research appraisal, synthesis and generation of evidence, 7th edn., Saunders, St. Louis, MO.
Igumbor, J., Davids, A., Nieuwoudt, C., Lee, L. & Roomaney, R., 2016, 'Assessment of activities performed by clinical nurse practitioners and implications for staffing and patient care at primary health care level in South Africa', Curationis 39(1), 1–8. https://doi.org/10.4102/curationis.v39i1.1479
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The Muslim Student Association (MSA) is hosting regular gatherings called Bandaids for the Soul at the U of M Fort Garry campus.
The program is aimed at ending the stigma attached to mental illness in the campus' Muslim community, and more broadly within the city of Winnipeg.
MSA president Yazan Hammad said the group has hosted three sessions since the inception of the program in November.
Hammad said the sessions were not aimed at solving problems, but to help people come up with their own solutions having listened to the lived experiences of their peers.
Rashedeh Naseri, MSA marketing director and photographer, said the sessions aim at promoting psychological well-being among students and community members through an open discussion forum.
Rahma Shahin, a volunteer with the MSA, said she felt that "within the Muslim community, there's huge stigma [attached to] mental health," which makes people less likely to speak about it.
UMSU's annual Mental Health and Wellness Week will run Jan. 29 to Feb. 2.
Kilgour said the stigma surrounding mental health makes people less likely to seek help. As such, Mental Health Awareness Week was designed keeping this in mind.
She said the weeklong event will bring together different groups from "on and off campus tabling and sharing resources" with regard to mental health including many planned activities and games.
She noted that students are a population of individuals struggling with mental illness due to stress and other reasons associated with being a student.
"With potential tuition increases, the cost of living and the current job market, as well as the stress of classes and everyday life, many of our students are in need of more mental health support," said Kilgour.
Kilgour noted that UMSU had decided to prioritize mental health by constantly seeking new ways in which students could be provided support.
UMSU made sure to include mental health services within its Health & Dental Plan and introduced Empower Me, a free, 24-hour counselling services to all students enrolled in the plan.
Kilgour added that during the wellness week, UMSU will launch a new program called "Speak Up U of M" – a program intended to spark conversations around mental illness on campus.
However, she noted that "access to proper supports is lacking all across Manitoba" and UMSU continues to advocate for changes from the university as well as the provincial government.
Mental Health and Wellness week is held simultaneously with "Bell Let's Talk Day" Jan. 31, an initiative which also aims to promote discussions on mental illness.
Kilgour said "Bell Let's Talk has been an incredible success" in encouraging these discussions.
"We wanted to include this day in our programming and involve the entire campus community to remind everyone that this is an issue that affects all of us, and that it's up to all of us to change the culture and how we think and talk about mental health," she said.
Zia also stressed the importance of creating awareness surrounding mental illness as a way of addressing the matter.


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Other Nano Resources
Other Nanotechnology User Facilities
NNCI is not the only federally-supported resource for nanotechnology users from academia and industry. The list below includes additional organizations that supplement and complement the NNCI user facilities. Each resource has its own application process, modes of operation, fee structure, and technical scope. These facilities are all operated independently of NNCI and are listed here as a helpful reference.
NIST Center for Nanoscale Science and Technology
Operated by the National Institute of Standards and Technology (NIST), a component of the Department of Commerce, the Center for Nanoscale Science and Technology (CNST) supports the U.S. nanotechnology enterprise from discovery to production by providing industry, academia, NIST, and other government agencies with access to world-class nanoscale measurement and fabrication methods and technology. The CNST is the only national nanocenter with a focus on commerce. CNST includes a shared-use NanoFab available to external users, as well as in-house nanotechnology research programs.
The Network for Computational Nanoscience (NCN) at Purdue University
Supported by the National Science Foundation, NCN provides an infrastructure and research network for computational nanoscience. Extensive resources in support of research and education are delivered through its portal at nanohub.org.
Department of Energy Nanotechnology User Facilities
The U.S. Department of Energy operates five Nanoscale Science Research Centers (NSRCs) which are open to the research community on a peer-reviewed basis. Each NSRC is located at a DOE National Laboratory, providing users with access to many other facilities and additional opportunities for collaboration.
The Center for Nanoscale Materials (CNM) at Argonne National Laboratory is a premier user facility, providing expertise, instruments, and infrastructure for interdisciplinary nanoscience and nanotechnology research. Academic, industrial, and international researchers can access the center through its user program for both nonproprietary and proprietary research.
The Center for Nanophase Materials Sciences (CNMS) at Oak Ridge National Laboratory (ORNL) integrates nanoscale science with neutron science; synthesis science; and theory, modeling, and simulation. Operating as a national user facility, the CNMS supports a multidisciplinary environment for research to understand nanoscale materials and phenomena.
The Molecular Foundry (Lawrence Berkeley National Laboratory) is a Department of Energy-funded program providing support to researchers from around the world whose work can benefit from or contribute to nanoscience. Through unparalleled access to state-of-the-art instruments, materials, technical expertise and training, the Foundry provides researchers with the tools to enhance the development and understanding of the synthesis, characterization and theory of nanoscale materials.
The Center for Functional Nanomaterials (CFN) at Brookhaven National Laboratory provides state-of-the-art capabilities for the fabrication and study of nanoscale materials, with an emphasis on atomic-level tailoring to achieve desired properties and functions. The CFN is a science-based user facility, simultaneously developing strong scientific programs while offering broad access to its capabilities and collaboration through an active user program. The overarching scientific theme of the CFN is the development and understanding of nanoscale materials that address the Nations' challenges in energy security, consistent with the Department of Energy mission.
The Center for Integrated Nanotechnologies (CINT) is a Department of Energy, Basic Energy Sciences Nanoscale Science Research Center jointly operated by Los Alamos National Laboratory and Sandia National Laboratories. CINT's objective is to foster scientific discovery enabling the integration of nanoscience concepts and structures into the micro and macro worlds. As a National user facility, CINT provides access to its staff and capabilities for nanoscale science research at no fee to approved users for non-proprietary research. Proprietary research may be conducted under a full-cost recovery agreement.
NIH Nanotechnology Characterization Laboratory
The NIH National Cancer Institute's Nanotechnology Characterization Laboratory (NCL) provides knowledge and services to help researchers transition nanomaterials-based cancer treatments from the laboratory into FDA-approved clinical trials. NCI, a component of the National Institutes of Health, established the Nanotechnology Characterization Laboratory to perform pre-clinical efficacy and toxicity testing of nanoparticles intended for cancer therapeutics or diagnostics. Information on participating in the NCL program is available on the NCI Website.
The mission of the NNN (supported by the NSF) is to serve as a catalyst for progress in nanomanufacturing in the U.S., through the facilitation and promotion of nanomanufacturing workshops, road mapping, inter-institutional collaborations, technology transition, test beds, and information exchange services. The NNN operates as an open-access network of centers, leaders, experts, and stakeholders from the nanomanufacturing research, development, and education community. It is a partnership between academia, industry and government that is built to foster and serve nanomanufacturing communities of practice. Information on nanomanufacturing processes is distributed through its interNano website.
Other University Cleanroom Facilities
Brigham Young University maintains a list of academic cleanrooms in the United States. This list is not complete, and not all of these facilities are open to external users.
NNI Research and Development Centers and Networks
In addition to the network of federally-supported user facilities, there has also been significant investment by NNI-participating agencies in the creation of multidisciplinary research and education centers devoted to nanoscale science and engineering. Centers and networks provide opportunities and support for multidisciplinary research among investigators from a variety of disciplines and from different research sectors, including academia, industry and government laboratories.
Full listing of NNI R&D Centers and Networks
Department of Defense (DoD)
Institute for Nanoscience (Naval Research Laboratory)
Institute for Soldier Nanotechnologies (Massachusetts Institute of Technology)
National Institutes of Health National Cancer Institute (NCI)
Alliance for Nanotechnology in Cancer
Centers of Cancer Nanotechnology Excellence (CCNE)
Innovative Research in Cancer Nanotechnology (IRCN)
Cancer Nanotechnology Training Centers (CNTC)
National Institute for Occupational Safety and Health (NIOSH)
Nanotechnology Research Center, Robert A. Taft Lab
Environmental Protection Agency (EPA)/National Science Foundation (NSF)
Center for the Environmental Implications of Nanotechnology (CEINT, Duke University)
University of California Center for Environmental Implications of Nanotechnology (CEIN) at University of California – Los Angeles and University of California – Santa Barbara
US Department of Agriculture (USDA) - Forest Service
Cellulose Nanomaterials Pilot Facilities - Process Development Center/ University of Maine School of Forest Resources and the Advance Structures and Composites Center (Maine)
Forest Service Forest Products Laboratory (Wisconsin)
Nanoscale Science and Engineering Centers (NSEC)
Nanosystems Engineering Research Centers (NERC)
Science and Technology Centers (STC)
Materials Research Science and Engineering Centers (MRSEC)
Centers of Chemical Innovation (CCI)

redpajama_set_name: RedPajamaCommonCrawl


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Luno II Oil Field, North Sea
Offshore field
North Sea, Norway
Estimated reserves
Between 40Mboe and 100Mboe
Lundin Norway (50%), OMV (20%), Statoil (15%) and Wintershall (15%)
Lundin Norway
Luno II discovery well was successfully appraised by the COSL Innovator drilling rig in March 2018. Credit: Lundin Petroleum.
Luno II is expected to be tied-back to the Edvard Grieg platform. Credit: Lundin Petroleum.
Three concept studies are being carried out for the development of the Luno II field. Credit: Lundin Norway.
Luno II lies 15km south of the Edvard Grieg field. Credit: Norwegian Petroleum Directorate.
The Luno II oilfield is located in the production licence PL359 within the Utsira High area of the North Sea, Norway.
The PL359 licence is jointly owned by Lundin Petroleum subsidiary Lundin Norway (50%), OMV (20%), Statoil (15%) and Wintershall (15%).
Lundin Norway is serving as the operator for the licence.
The partners are currently carrying out concept studies for the development of the Luno II.
The plan for the field's development and operation is expected to be submitted by the end of 2018.
Luno II field discovery details
Luno II was originally discovered by the 16/4-6 S well, which was drilled in 101m of water on the south-western flank of the Utsira High, approximately 15km south of the Edvard Grieg field.
The well was drilled to a total depth of 2,233m by the Bredford Dolphin drilling rig between March 2013 and April 2013.
The well encountered a 40m oil column in sandstones of the Middle Jurassic age.
A drill stem test was conducted on the well, which flowed at the rate of 271m³ of oil and 53,900m³ of gas per day.
Geology and reserves of Luno II
The Luno II reservoir contains oil-bearing sandstones of the Triassic age.
The field is estimated to contain reserves of 40 million barrels of oil equivalent (Mboe) to 100Mboe.
Appraisal on Luno II
Luno II was appraised by three appraisal wells, with the first well 16/4-8 S being drilled in August 2014, approximately 4km south-east of the discovery well.
It primarily targeted the Central South segment of the field.
The well was also drilled using the same Bredford Dolphin rig and encountered a 30m oil column in the Jurassic / Triassic sandstones.
The well was production-tested and flowed at the rate of 450 barrels per day.
A second appraisal well, 16/4-9 S, was drilled on the Utsira High in the Luno II North prospect, north-west of the Luno II discovery and south-west of the Johan Sverdrup field.
The well was drilled to a depth of 2,305m by the Bredford Dolphin from June 2015 to August 2015.
It encountered a 23m gross oil column in the Jurassic / Triassic sandstones.
Pressure data from the well showed that the properties of hydrocarbons in the Luno II North prospect were different from those of the Luno II discovery.
Another appraisal well, 16/4-11, was drilled using the semi-submersible drilling rig COSL Innovator in March 2018, approximately 2.5km south of the discovery well in order to prove additional resources within the field.
The well encountered a 20m oil column in the Triassic sandstones with very good reservoir quality.
Luno II field development plan
A total of three concept development solutions are currently being studied for the development of the field as a subsea tie-back to the Edvard Grieg platform.
The concept studies are anticipated to assess the stand-alone development of Luno II, as well as development of the Luno II North prospect.
The first two studies will assess various subsea production solutions for the field, while the third study will assess the feasibility of developing the field using an unmanned wellhead platform.
Each of the concept studies is expected to take approximately four months to complete.
Contractors involved
FORSYS Subsea and Xodus were contracted to carry out two concept studies for the field's subsea production system.
The scope of the contracts includes the provision of solutions for the laying of cables, pipelines and risers to be tied-back to the Edvard Grieg platform.
Heerema Fabrication Group is set to conduct the concept study for the development of the field using an unmanned wellhead platform.
GE Oil and Gas, along with Emas Chiyoda Subsea, will serve as partners to FORSYS Subsea, Heerema and Xodus.
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The Strait of Hormuz: a long disputed chokepoint
The importance of water bath heaters in the oil and gas industry
UK forces detain tanker suspected of carrying oil to Syria
Police search Sembcorp Marine's Brazil shipyard
Taylor Energy oil spill may be considerably worse than first thought


text:
Caratteristiche tecniche
Guardia dinamica con un'altezza da ala piccola (1,96 m), è in grado di risultare determinante sia nelle azioni offensive sia a rimbalzo. Dispone inoltre di un'ottima visione di gioco che si palesa nella buona media di assist per i compagni.

Carriera
Formatosi cestisticamente all'Università di Harvard, non viene scelto da nessuna squadra NBA. Dopo diverse stagioni in D-League, decide di continuare oltreoceano.

2017-18: l'approdo in Europa
Nella stagione 2017-18 approda in Europa nella Korisliiga finlandese, ingaggiato dal Kataja, con cui si distingue con 15,4 punti, 7,5 rimbalzi e 2,6 assist in 37 gare di campionato e con 11,8 punti in 12 gare di Fiba Europe Cup.

2018-19: l'arrivo a Cremona
Il 26 luglio 2018 la Vanoli Cremona annuncia la firma del giocatore. L'esordio in campionato avviene il 6 ottobre 2018 al PalaTrento. Saunders, alla prima con Cremona, mette a referto la sua migliore prestazione italiana , con 29 punti in 40 minuti, 8 rimbalzi, 4 palle recuperate, 2 assist e 10 falli subiti, contribuendo, con una prestazione a tutto campo, alla vittoria della Vanoli dopo un supplementare. Nell'ultima gara d'andata, vinta contro Reggio Emilia, mette a referto una doppia doppia da 15 punti e 15 rimbalzi: chiude il girone con una media di 7,7 rimbalzi a partita, al decimo posto della classifica della LBA in questa specialità, al primo se si escludono i centri e le ali forti. Riesce a confermarsi anche al ritorno come il migliore rimbalzista tra i piccoli. Chiude la stagione regolare con la media di 10,9 punti, 6,7 rimbalzi e 3,3 assist. Migliora in parte questi valori nei play-off, che chiude con 13,9 punti, 6,1 rimbalzi e 3,2 assist a partita.

Coppa Italia 2019
Il 14 febbraio 2019 esordisce nella manifestazione realizzando 20 punti e 7 rimbalzi nei quarti contro Varese. Due giorni dopo, in semifinale contro la Virtus Bologna, ne mette a referto altri 15 assieme a 5 rimbalzi. Conquistata la finale contro Brindisi, contribuisce alla prima vittoria della coppa da parte di Cremona con 18 punti e 9 rimbalzi. Nelle tre partite in cui è stato impiegato ottiene una valutazione complessiva di 80 (28+26+26), la seconda migliore di sempre nelle Final 8 (il record di 81 fu ottenuto nel 2013 da Mike Green).

2019-20: il secondo anno a Cremona
Il 10 giugno 2019 la società lombarda annuncia il rinnovo di Saunders fino al 30 giugno 2020.

2020-2021: Monaco e Fortitudo Bologna

Dopo aver iniziato la stagione tra le fila del Monaco, nel campionato francese, a inizio novembre rescinde il contratto con i francesi, e si accasa alla Fortitudo Bologna, ritrovando così coach Romeo Sacchetti, suo mentore nelle stagioni di Cremona.

Palmarès

Cremona: 2019

Note

Collegamenti esterni

redpajama_set_name: RedPajamaWikipedia


Emerson said that these edge facilities, or neighbourhood data centres, will support the larger data centres providing low-latency content and applications to users or data processing and logic for IoT networks.
Reams of data will pour into data centres as IoT becomes more widely adopted, but data will not be the only changing factor impacting the industry.
To answer this, data centres will need to find a common language in which devices can interact.
According to Emerson, cloud could get more complex as data centre servers are still running below their optimum capacity.
The company said the solution will enable new levels of visibility, control and automation by creating interconnectivity across data centre systems.
Why Open Source Software Is Taking Over You don't have to look far to see evidence of open source software's impact on IT as a whole.
You don't have to look far to see evidence of open source software's impact on IT as a whole.
But no one is making real money from open source.
Over the past decade we have seen the migration from physical servers to virtual machines and now to public cloud, private cloud and hybrid cloud.


Given a list of numbers, write a Python program to remove multiple elements from a list based on the given condition.
Multiple elements can be deleted from a list in Python, based on the knowledge we have about the data. Like, we just know the values to be deleted or also know the indexes of those values. Let's see different examples based on different scenario.
Example #1: Let's say we want to delete each element in the list which is divisible by 2 or all the even numbers.
Removing all even elements in a list is as good as only including all the elements which are not even( i.e. odd elements).
Below Python code remove values from index 1 to 4.
Let's say the elements to be deleted is known, instead of the indexes of those elements. In this case, we can directly eliminate those elements without caring about indexes which we will see in next example.
Example #5: When index of elements is known.
Though indexes of elements in known, deleting the elements randomly will change the values of indexes. Hence, it is always recommended to delete the largest indices first. Using this strategy, index of smaller values will not be changed. We can sort the list in reverse order and delete the elements of list in descending order.


Standing next to the Mercedes-Benz Fashion Week Swim sign at the Raleigh Hotel.
As you know I had a chance to travel to Miami to cover Mercedes-Benz Fashion Swim for the first time a few weeks ago.
My flight was first delayed and then canceled which left me stranded at the airport over night. To add insult to injury the airport lost track of my luggage and wasn't sure if it was already shipped to Miami or not. How's that for a fashion nightmare?
It took about 4 hours of crying and begging for me to finally get a flight out that day. My luggage was still missing so I took a big chance when I got on the plane. Luckily, it was a chance that paid off as I finally found my luggage in Miami.
Although I missed the first official day I was just happy that I finally made it (with luggage) to Miami. I still had 4 more days at Mercedes-Benz Fashion Week Swim and it was everything I dreamed of and more. The picture above is of me beaming with excitement before seeing my first show in Miami. I can't wait to tell you about the exciting shows, events and people I've met during my trip.


What is an Acquired Brain Injury ? An Acquired Brain Injury (ABI) is any sudden damage to the brain received during a person's lifetime and not as a result of birth trauma.
can vary widely according to the extent and location of the damage to brain tissue.
Acquired brain injury is referred to as the hidden disability because its long term problems are often in the areas of thinking and behaviour and are not as easy to see and recognise as many physical disabilities.
further 7,000 being diagnosed with a stroke.
Additionally, we estimate that there are up to 30,000 people in living in Ireland between the ages of 16-65 with long term problems following brain injury. Brain injury is the foremost cause of death and disability in young people. Those that are between 15-29 years of age are three times more likely to sustain a brain injury than any other group.
There are two types of brain injury traumatic and non-traumatic.
These injuries usually damage relatively localised areas of the brain resulting in specific damage.
collision, and may involve a brief loss of consciousness of less than 15 minutes, or no loss of consciousness at all.
usually defined as a condition where the patient has been in a coma for 6 hours or more, or has PTA of over 24 hours and may require a long period of intensive care or neurosurgery.
progresses. Often a person with an injury to the brain can fall unconscious for a period of time.
shortly after an injury which will vary depending on the severity.


text:
THE PROGRESSIVE ERA BODY PROJEC...
THE PROGRESSIVE ERA BODY PROJECT: CALORIE-COUNTING AND "DISCIPLINING THE STOMACH" IN 1920S AMERICA
Chin Jou (a1)
DOI: https://doi.org/10.1017/S1537781418000348
Published online by Cambridge University Press: 09 October 2018
Although the scientific origins of the calorie date back to the 1820s, calorie counting for weight loss only became popular in the late 1910s and 1920s. Placing this development in the broader context of the Progressive Era, this article considers how calorie counting and the reconstitution of food as calories reflected the period's fixation with science, rationalization, and quantification. This article also situates calorie counting within shifting bodily ideals among white women in the 1920s, and the ways in which class and race informed the promotion of the slender body as the feminine ideal. The second half of this article focuses on exchanges between Lulu Hunt Peters, a syndicated newspaper columnist and the author of a best-selling calorie-counting guide, and advice-seeking readers of her column. While Peters presented calorie counting as empowering for dieters and a way for them to seize control over their weight, her calorie-restriction program facilitated a new form of bodily discipline and self-regulation during a period that saw enhanced forms of surveillance in other areas of life.
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COPYRIGHT: © Society for Historians of the Gilded Age and Progressive Era 2018
email: chin.jou@sydney.edu.au
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The title of this article derives from historian Joan Jacobs Brumberg's 1997 book, The Body Project: An Intimate History of American Girls (New York: Random House, 1997).
2 Peters, Lulu Hunt, Diet and Health with Key to the Calories (Chicago: The Reilly and Lee Company, 1918), reader entry in "Weekly Weight Chart," unpaginated. This particular copy of Diet and Health was obtained from the Northwestern University library system in 2006. Adelaide Hoag bequeathed her copy of Diet and Health to the Archibald Church Library of Northwestern University in Nov. 1930. An inscription on the back cover of the book read, Merry Christmas, Adelaide, Junius. (Junius was Hoag's husband.)
3 Peters outlined her "rule to find ideal weight": "Multiply number of inches over 5 ft. in height by 5 ½; add 110." Hoag, however, calculated her ideal weight incorrectly. She yielded 20.5 rather than 22 when multiplying 4 x 5½. See Peters, Diet and Health, 11.
4 Ibid.
5 Peters, Diet and Health (Northwestern copy). Weight chart is unpaginated.
6 Schwartz, Hillel, Never Satisfied: A Cultural History of Diets, Fantasies, and Fat (New York: Free Press, 1986), 175; Jou, Chin, "Counting Calories," Chemical Heritage 29:1 (Spring 2011), http://www.chemheritage.org/discover/media/magazine/articles/29-1-counting-calories.aspx?page=1 (accessed Jan. 20, 2016); "Los Angeles Physician Writes 'Best-Seller,'" Los Angeles Times, June 11, 1922, II3; Carole Sugarman, "The History of Thinking Thin," Washington Post, June 16, 1987, A1; Peters, Lulu Hunt, Diet and Health with Key to the Calories (Chicago: Reilly and Lee Co., 1929), inside cover. This book may have sold particularly well for the following reasons: (1) it contained a very comprehensive list of the caloric values of specified amounts of commonly consumed foods (127 foods from every food group); (2) it instructed readers how many calories they should consume based on gender and level of physical activity; (3) it provided tables for readers to keep track of their weight loss.
7 "Dietary Discoveries Better Human Health," New York Times, Mar. 10, 1929, 158.
8 Roberts, Lydia J., Nutrition Work with Children (Chicago: University of Chicago Press, 1927), 55; Jou, "Counting Calories."
9 Peters, Lulu Hunt, Diet for Children (and Adults) and The Kalorie Kids (New York: Dodd, Mead and Company, 1924), 177. "Dorothy" did not indicate her height, so it is not known whether her weight did indeed exceed Peters's weight-height strictures.
11 Peters, "Diet and Health," Los Angeles Times, June 24, 1922, II7. Although "B.N." did not report her height, she noted to Peters that "[b]y your way of figuring I should be 135," which meant that she was approximately 5 feet 4 ½ inches.
12 Ibid. "B.N." wrote that she "tr[ied] to keep to 1000 Cs. a day."
13 Peters did, however, instruct readers to try to maintain a balanced diet replete with fruit and vegetables, carbohydrates, protein, and even fat, but only after they achieved their goal weight. Even so, those with a propensity to gain weight would have to count calories for the remainder of their lives. See Peters, Diet and Health, 38–39, 94; Peters, Diet for Children (and Adults) and the Kalorie Kids, chap. 8.
14 "Reducing" is in quotations because the term was a synonym for "dieting" during this period.
15 McCollum, E. V. (Elmer Verner), A History of Nutrition: The Sequence of Ideas in Nutrition Investigations (Boston: Houghton Mifflin, 1957), 127–28, 150; Atwater, W. O. (Wilbur Olin), "The Potential Energy of Food," The Century 34:3 (July 1887): 401.
16 McCollum, A History of Nutrition, 204. For more on Pettenkofer and Voit's studies, see also Widdowson, Elise M., "The First Fifty Years," Nutrition in the 20th Century, ed. Winick, Myron (New York: John Wiley and Sons, 1984).
17 Jou, "Counting Calories."
18 Ibid.; Cullather, Nick, "The Foreign Policy of the Calorie," The American Historical Review 112:2 (Apr. 2007): 346.
19 Atwater, W. O., Principles of Nutrition and Nutritive Value of Food, United States Department of Agriculture Farmer's Bulletin (Washington, DC: Government Printing Office, 1902), 44.
20 W. O. Atwater, "The Inadequately Nourished," undated paper, film 4, reel 8, Wilbur Olin Atwater Papers, 1872–1914 ("Additional Papers, 1869–1914"), Van Pelt Library, University of Pennsylvania, Philadelphia (reproduced as microfilm from Wilbur Olin Atwater Papers, Wesleyan University, Middletown, CT).
21 Cullather, "The Foreign Policy of the Calorie," 338.
22 Ibid., 348; Jou, "Counting Calories."
23 "Food and Nutrition in the Depression Period," Journal of the American Medical Association (Jan. 2, 1932): 50; A. Hendee (artist), "Eat Less, and Let Us Be Thankful That We Have Enough to Share with Those Who Fight for Freedom (Chicago: A. Hendee Edwards & Deutsch Litho. Co., 1918), photograph, retrieved from the Library of Congress, https://www.loc.gov/item/2002711984/ (accessed Sept. 4, 2017)."
24 Cullather, 348; Jou, "Counting Calories."
25 Veit, Helen Zoe, Modern Food, Moral Food: Self-Control, Science, and the Rise of Modern American Eating in the Early Twentieth Century (Chapel Hill: University of North Carolina Press, 2013).
26 For more on the history of home economists, see Goldstein, Carolyn, Creating Consumers: Home Economists in Twentieth-Century America (Chapel Hill: University of North Carolina Press, 2012); Rethinking Home Economics: Women and the History of a Profession, eds. Stage, Sarah and Vincenti, Virginia B. (Ithaca, NY: Cornell University Press, 1997); Shapiro, Laura, Perfection Salad: Women and Cooking at the Turn of the Century (New York: Farrar, Strauss and Giroux, 1986); Veit, Modern Food, Moral Food; Biltekoff, , Eating Right in America: The Cultural Politics of Food and Health (Durham, NC: Duke University Press, 2013).
27 Jou, Chin, "Make America's (Foodways) Great Again: Nostalgia, Early Twentieth Century Dietary Critiques, and the Specter of Obesity in Contemporary Food Commentary," Gastronomica: The Journal of Critical Food Studies 17:1 (2017): 23.
28 Lowe maintains that African American students at Spelman College, for example, were more focused on skin care and hair-grooming rituals rather than preoccupied with weight loss. Lowe also notes that "nineteenth-century connections between robust bodies, fat, health, and prosperity that had faded for middle-class white Americans by the 1920s remained potent symbols for African Americans still on the economic margin." Lowe, Margaret A., Looking Good: College Women and Body Image, 1875–1930 (Baltimore: Johns Hopkins University Press, 2003), 150–51.
29 See Lowe, Looking Good; Brumberg, The Body Project; Seid, Robert, Never Too Thin: Why Women Are at War with Their Bodies (New York: Prentice Hall Press, 1989); Fass, Paula S., The Damned and the Beautiful: American Youth in the 1920's (New York: Oxford University Press, 1977); Levenstein, Harvey A., Revolution at the Table: The Transformation of the American Diet (New York: Oxford University Press, 1988), 166. A creation of the prominent artist Charles Dana Gibson, the image of the Gibson Girl appeared in advertisements and books, and even on ashtrays, matchboxes, teacups, saucers, tiles, wallpapers, pillow covers, and numerous other household items. For more on the cultural significance of the Gibson Girl, see Clarke, Michael Tavel, These Days of Large Things: The Culture of Size in America, 1865–1930 (Ann Arbor: University of Michigan Press, 2007), 184.
30 Annie Dewey, "Methods of Organization and Control in Institutional Departments. Menu and Meal Systems: A New Plan," Journal of Home Economics (Nov. 1910): 521, American Association of Family and Consumer Sciences Collection, No. 6578, Box 508, Division of Rare and Manuscript Collections, Carl A. Kroch Library, Cornell University, Ithaca, NY. One could argue, of course, that waiters did not enjoy serving women for other reasons, and that women patrons allegedly tipped less than men because they had lower incomes or depended on allowances from men in their households.
31 Pirtle, T. R., History of the Dairy Industry (Chicago: Mojonnier Bros. Company, 1926), 133. Pirtle reports that some Boston employers sought to prevent fatigue and fainting spells from starvation by encouraging their employees to drink milk during mid-day. Implementing this practice apparently "reduce[d] the time lost through employee sickness."
32 For more on American workers feigning fatigue or illness in order to evade work, see Kelley, Robin D. G., Race Rebels: Culture, Politics, and the Black Working Class (New York: Free Press, 1996).
33 "'Boyish Figure' Aim Brings Health Test," New York Times, Feb. 22, 1926, 3.
34 Roberts, Nutrition Work with Children, 291.
35 Lowe, Looking Good, 144. Lowe points out that a decline in food costs could have also contributed to the reduced food expenditures, but that the Smith College campus warden suspected students' dieting to be a significant factor. It should also be noted that while Smith students eschewed potatoes in favor of low-calorie vegetables, they did not always abide by their food restriction programs. Lowe is careful to point out that they (and their counterparts at Cornell University, another one of Lowe's case studies) occasionally "stuffed themselves at campus spreads and in downtown restaurants; they skipped meals and snacked between them; and they indulged in cakes, fudge, and other sweets." See Lowe, Looking Good, 140. But when they did violate their diets, Smith students were racked with guilt, primarily because food indulgences could result in weight gain and make them appear weak willed.
36 Ibid., 143. The letter to the editor, titled, "To Diet or Not to Die Yet?" was published in the Oct. 29, 1924, issue of the Smith College Weekly. The authors did not sign their names, only their class graduation years.
37 For more on the history of scales, see Gilman, Sander L., Fat Boys: A Slim Book (Lincoln: University of Nebraska Press, 2004), 89; Czerniawski, Amanda M., "From Average to Ideal: The Evolution of the Height and Weight Table in the United States, 1836–1943," Social Science History 31:2 (Summer 2007): 273; Kercher, John, "Obesity," Illinois Medical Journal 40 (July 1921): 19; Berge, Ann F. La, "How the Ideology of Low Fat Conquered America," Journal of the History of Medicine and Allied Sciences 63:2 (Apr. 2008): 141.
38 "Fat Women Busy Reducing; Thin Ones Adding Weight," New York Times, July 16, 1925, X10.
40 See Lowe, Margaret A., "From Robust Appetites to Calorie Counting: The Emergence of Dieting Among Smith College Students in the 1920s," Women and Health in America, ed. Leavitt, Judith Walzer (Madison: University of Wisconsin Press, 1999), 175; Czerniawski, 280. For more on the history of height and weight tables, see Weigley, Emma Seifrit, "Average? Ideal? Desirable? A Brief Overview of Height-Weight Tables in the United States," Journal of the American Dietetic Association 84:4 (1984): 417–23.
41 Cummings, Richard Osborn, The American and His Food (New York: Arno Press, 1970), 161. It was not that middle-aged and older women refrained from dieting; they frequently did. A 1925 New York Times article quoted a dance instructor as saying, "I'm just swamped with middle-aged classes. They'll go through anything to reduce and call for more." See Fat Women Busy Reducing; Thin Ones Adding Weight," X10. But despite their weight-loss efforts, older women were generally heavier than their younger counterparts, according to surveys commissioned by life insurance companies.
42 See "Women Cut Weight to Suit Fashions," New York Times, May 25, 1915, 6; Steele, Valerie, Fashion and Eroticism: Ideals of Feminine Beauty from the Victorian Era to the Jazz Age (New York: Oxford University Press, 1985), 241.
43 Brumberg, Joan Jacobs, Fasting Girls: The History of Anorexia Nervosa (New York: Vintage, 2000), 182.
45 Søland, Birgitte, Becoming Modern: Young Women and the Reconstruction of Womanhood in the 1920s (Princeton, NJ: Princeton University Press, 2000), 51.
46 Lucrezia Bori, "How You May Reduce Your Hips by a Few Simple Daily Exercises," Washington Post, Aug. 26, 1921, 4.
47 Soland, 55.
48 Ibid., 51, 55.
49 "This Too Solid Flesh," New York Times, Feb. 25, 1926, 22.
50 See Segrave, Kerry, Obesity in America, 1850–1939: A History of Social Attitudes and Treatment (Jefferson, NC: McFarland and Company, 2008), 117; "Fat Women Hopeless, Says Poiret," Ogden (UT) Standard Examiner, Jan. 13, 1923, 6.
51 See, for example, Ewen, Stuart and Ewen, Elizabeth, Channels of Desire: Mass Images and the Shaping of American Consciousness (New York: McGraw-Hill, 1982), 117.
52 Jou, "Counting Calories." For more on how "slendernesss symbolizes the freedom from want," see Cassidy, Claire, "The Good Body: When Big Is Better," Medical Anthropology 13:3 (1991), 203. For more on the transformation in food production during this period, see Jou, "Make America's (Foodways) Great Again: Nostalgia, Early Twentieth-Century Dietary Critiques, and the Specter of Obesity in Contemporary Food Commentary," 22.
53 In his discussion of "civilized restraints," Stearns cites the German sociologist Norbert Elias's The Civilizing Process (1939). See Stearns, Peter N., Fat History: Bodies and Beauty in the Modern West (New York: New York University Press, 1997), 249.
55 Bynum, Caroline Walker, Holy Feast and Holy Fast: The Religious Significance of Food to Medieval Women (Berkeley: University of California Press, 1987); Griffith, R. Marie, Born Again Bodies: Flesh and Spirit in American Christianity (Berkeley: University of California Press, 2004).
56 Veit, Modern Food, Moral Food, 159, 4.
57 Faludi, Susan, Backlash The Undeclared War Against Women (New York: Crown, 1991).
58 Wolf, Naomi, The Beauty Myth: How Images of Beauty Are Used Against Women (New York: Chatto and Windus, 1990).
59 Frost, Liz, Young Women and the Body: A Feminist Sociology (Basingstoke, UK: Palgrave Macmillan, 2001), 176.
61 Belasco, Warren, Food: The Key Concepts (Oxford, UK: Berg, 2008), 2.
62 Adelaide Hoag was married to Dr. Junius Clarkson Hoag. The couple's address can be found on page 126 of a directory of the Chicago Woman's Club, 1917–1918. See Chicago Woman's Club (no publication information), https://books.google.com/books?id=_XsqAAAAYAAJ&lpg=PA126&ots=qYHiBc7Vah&dq=junius%20adelaide%20hoag&pg=PP1#v=onepage&q=junius%20adelaide%20hoag&f=false (accessed Sept. 4, 2017). Junius Hoag's tenure as president of the Chicago Medical Society can be found here: "Current and Past Presidents of the Chicago Medical Society, 1850–Present," Chicago Medical Society, http://www.cmsdocs.org/about-us/history/current-and-past-presidents-of-the-chicago-medical-society-1850-present (accessed Sept. 4, 2017).
63 See, for example, Peters, Los Angeles Times, Apr. 7, 1923, II9; Aug. 19, 1922, II7.
64 For an example of how historians have explained the "crisis of masculinity," see Messner, Michael A., Out of Play: Critical Essays on Gender and Sport (Albany: State University of New York Press, 2007), 35.
66 Refer to Veit, Modern Food, Moral Food, and Biltkeoff, Eating Right in America, for more context on progressive food reformers.
67 Peters, Diet for Children (and Adults) and The Kalorie Kids, 57.
69 Peters, "Diet and Health," Los Angeles Times, Mar. 31, 1923, 11; Peters, Diet and Health, 88. Peters did not initially caution readers that weight loss would vary depending on dieters' initial weight, or that their weight loss might eventually plateau. By the 1920s, however, she would note the latter phenomenon in her syndicated column.
70 Ibid., 28–29.
71 Lusk, Graham, Food in War Time (Philadelphia: W. B. Saunders Company, 1918), 39. Added emphasis.
72 Lowe, "From Robust Appetites to Calorie Counting: The Emergence of Dieting among Smith College Students in the 1920s," 183.
73 Donnelly, Antoinette, How to Reduce, New Waistlines for Old (New York: D. Appelton, 1920), 28. Besides Donnelly, there were a number of other newspaper columnists who wrote on beauty. One of the better-known columnists was Lina Cavalieri, an Italian opera singer whose byline in the Washington Post read, "Mme. Lina Cavalieri, the most famous living beauty." See Segrave, Obesity in America, 1850–1939, 53.
74 This idea derives from Michel Foucault's theoretical perspectives on power and disciplinary regimes, as well as other scholars' interrogations on the making of the sex binary, gender, and sexual norms. See Foucault, Michel, Discipline and Punish: The Birth of the Prison, trans. Sheridan, Alan (New York: Pantheon, 1978); Laqueur, Thomas, Making Sex: Body and Gender from the Greeks to Freud (Cambridge, MA: Harvard University Press, 1992); Butler, Judith, Gender Trouble: Feminism and the Subversion of Identity (New York: Routledge, 1990); Foucault, Michel, The History of Sexuality, 3 vols., trans. Hurley, Robert (New York: Pantheon, 1978–86).
75 Peters, "Diet and Health," Los Angeles Times, Jan. 24, 1923, II8.
76 Peters, "Diet and Health," Los Angeles Times, Mar. 31, 1923, I11.
78 Peters, Diet for Children (and Adults) and The Kalorie Kids, 172.
79 For more on the history of diabetics weighing their food, see Schwartz, Never Satisfied, 172–73.
80 One could argue that in modern America, scientific discoveries that could not be seen by the naked eye (e.g., calories and bacteria) came to be accepted as real entities. For more on how the discovery of microbes changed American life, see Tomes, Nancy, Gospel of Germs: Men, Women, and the Microbe in American Life (Cambridge, MA: Harvard University Press, 1998).
81 See Porter, Theodore M., Trust in Numbers: The Pursuit of Objectivity in Science and Public Life (Princeton, NJ: Princeton University Press, 1995); Bouk, Dan, How Our Days Became Numbered: Risk and the Rise of the Statistical Individual (Chicago: University of Chicago Press, 2015).
82 Apple, Rima, Vitamins in American Culture (New Brunswick, NJ: Rutgers University Press, 1996).
83 Peters, Diet and Health, 24; Jou, "Counting Calories." Added emphasis.
84 See Brumberg, The Body Project.
85 Peters, "Diet and Health," Los Angeles Times, Nov. 29, 1922, II8.
86 Peters, "Diet and Health," Los Angeles Times, Mar. 23, 1923, II8.
87 According to Peters's calorie-counting gospel, if one were to indulge in high calorie foods on a special occasion, one would have to atone for such a dietary lapse by severely restricting caloric intake on subsequent days. Peters informed readers of her column that she was not going to deny herself a Thanksgiving buffet consisting of "turkey with chestnut dressing, rich gravy with the giblets minced in it, candied sweet potatoes and mashed Irish, a bunch of celery, a big dish of boiled onions with cream gravy, some baked squash, a dish of corn, some cranberry sauce, hot biscuits, salad, pumpkin and mince pie, and finally some nuts, raisins, candy and fruit." The day following her Thanksgiving profligacy, however, Peters intended to place herself on a virtual starvation diet: "Then tomorrow I shall go on a low calorie day, not over 600 calories of liquids or fruit—skimmed milk (1 glass, 80 C's)[,] consommé (fat free, 2 cups, 50 C's). And in this manner I shall free myself of the excess bird I put on today." See Peters, "Diet and Health," Los Angeles Times, Nov. 30, 1922, II8.
89 Peters, Diet and Health with Key to the Calories, 1918 ed., 84.
95 While Fletcherizing is characterized here as the chewing of food far beyond what would be adequate for digestion, Fletcher himself maintained that slow and prolific mastication was essential to "healthy" digestion. See Fletcher, Horace, The A. B.-Z. of Our Own Nutrition (New York: Frederick A. Stokes Company, 1903), 19–20.
98 Peters, "Diet and Health," Los Angeles Times, Apr. 12, 1923, II8.
100 Ibid., Mar. 8, 1923, II8.
101 For more on the resurgence of the Ku Klux Klan in the early twentieth century, see MacLean, Nancy, Behind the Mask of Chivalry: The Making of the Second Ku Klux Klan (New York: Oxford University Press, 1994).
102 See Seid, Never Too Thin, 91. Margaret A. Lowe similarly relates that, "when postwar depictions of working class, immigrant, or African American women surfaced in student literary magazines or the college newspaper, they were indeed described as having 'sturdy' or 'hearty' constitutions." See Lowe, Looking Good, 147. It should be pointed out, however, that this notion that labor marred the looks of working-class women from the "Old World," existed before the 1920s. In 1881, George Beard, the physician best known for his delineation of the "disease of civilization," neurasthenia, asserted: "Among the middle and lower orders of the old world, beauty is kept down by labor. A woman who works all day in the field is not likely to be very handsome, nor to be the mother of handsome daughters; for, while mental and intellectual activity in the middle age heightens beauty[,] muscular toil, out-doors or in-doors, destroys it." See Beard, George M., American Nervousness, Its Causes and Consequences; A Supplement to Nervous Exhaustion (Neurasthenia) (New York: G. P. Putnam's Sons, 1881), 67. For more on advertisements featuring representations of aristocratic femininity, see Marchand, Roland, Advertising the American Dream: Making the Way for Modernity, 1920–1940 (Berkeley: University of California Press, 1985), 181–84.
103 For more on Progressive Era conflations of food consumption habits with morality, see Veit, Modern Food, Moral Food, and Biltkoff, Eating Right in America.
104 See Jou, "Make America's (Foodways) Great Again."
105 Peters, "Diet and Health," Los Angeles Times, Jan. 13, 1923, II7.
106 Ibid.
107 See Levine, Deborah I., "The Curious History of the Calorie in U.S. Foreign Policy: A Tradition of Unfulfilled Promises," American Journal of Preventive Medicine 52:1 (2017): 125–29; Biltekoff, Eating Right in America; Veit, Modern Food, Moral Food.
108 Several years earlier, the U.S. Food Administration, of course, had discouraged Americans from eating candy because its primary ingredient—sugar—need to be conserved to feed soldiers.
109 See Morrison, W. F., "The Harmfulness of Over Eating," Providence Medical Journal 5 (1904): 174; Litchfield, Lawrence, "The Importance of Weight Control in the Maintenance of Health and in the Management of Disease," The Pennsylvania Medical Journal 25:10 (July 1922): 676; Russell Chittenden, "Physiological Economy in Nutrition" in Fletcher, The A. B.-Z. of Our Own Nutrition, 80; Butler, George F., "Overeating and Its Influence on Longevity," Medical Exam and Practice 16 (1906): 202.
110 Chittenden, "Physiological Economy in Nutrition," 80.
111 Morrison,178; Litchfield, 676; Owen, , "Food—What It Is, and What It Should Be," International Clinics 2 (1912): 61.
112 Webster, Ralph W., Metabolic Aspects of Overfeeding and of Underfeeding," American Medicine (New Series) 2:6 (June 1907): 354; see also Chittenden, Russell H., The Nutrition of Man (New York: Frederick A. Stokes Co., 1907), 158, for the articulation of a similar viewpoint.
113 See Veit, Modern Food, Moral Food, 4, for a characterization of Progressive Era nutrition authorities' predilection for "downplaying the pleasure of eating—and even renouncing pleasure altogether in some cases …"
114 Again, see Foucault, Discipline and Punish, for the theoretical basis of this claim. For more on how technology and scientific innovation failed to emancipate women from household tasks, see Cowan, Ruth Schwartz, More Work for Mother: The Ironies of Household Technology from the Open Hearth to the Microwave (New York: Basic Books, 1983).
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Alexander Nikolayevich Afanasyev (Afanasief, Afanasiev or Afanas'ev,Russian: Алекса́ндр Никола́евич Афана́сьев) (11 July 1826 – 23 October 1871) was a Russian Empire Slavist who published nearly 600 Russian folktales and fairytales—one of the largest folktale collections in the world. The first edition of his collection was published in eight fascicules from 1855–67, earning him the reputation of the Russian counterpart to the Brothers Grimm.
He was educated at a high school in Voronezh and studied law at the University of Moscow, in which he attended the lectures of Konstantin Kavelin and Timofey Granovsky. He brought out a series of articles about leading personalities of the 18th century. Being a progressive, he failed his final exams (because of the inspector (ревизор) Sergey Uvarov) and could not have a chair in the university of Moscow.
Luckily, he was appointed librarian in the Archives of Moscow in 1849 and stayed there for 13 years until 1862. In that year, he was dismissed because of the scandal provoked by his publishing of the Russian Popular Religious Legends, which were a ferocious satire of the Orthodox clergy.