text:
Published on 06.01.20 in Vol 5, No 1 (2020): Jan-Mar
Preprints (earlier versions) of this paper are available at http://preprints.jmir.org/preprint/15744, first published Aug 02, 2019.
Original Paper
Feasibility, Acceptability, and Impact of a Web-Based Structured Education Program for Type 2 Diabetes: Real-World Study
Shoba Poduval1, MRCGP, PhD ;
Louise Marston2, PhD ;
Fiona Hamilton1, MRCGP, PhD ;
Fiona Stevenson1, PhD ;
Elizabeth Murray1, FRCGP, PhD
1Research Department of Primary Care and Population Health, University College London, London, United Kingdom
2University College London, London, United Kingdom
Shoba Poduval, MRCGP, PhD
Research Department of Primary Care and Population Health
UCL Medical School (Royal Free Campus)
Rowland Hill Street
London, NW3 2PF
Phone: 44 (0) 20 7794 050 ext 36747
Email: s.poduval@ucl.ac.uk
Background: Structured education for people with type 2 diabetes improves outcomes, but uptake is low globally. In the United Kingdom in 2016, only 8.3% of people who were referred to education programs attended the program. We have developed a Web-based structured education program named Healthy Living for People with type 2 Diabetes (HeLP-Diabetes): Starting Out (HDSO), as an alternative to face-to-face courses. A Web-based program gives people more options for accessing structured education and may help improve overall uptake.
Objective: The aim was to explore the feasibility and acceptability of delivering a Web-based structured education program (named HeLP-Diabetes: Starting Out) in routine primary health care and its potential impact on self-efficacy and diabetes-related distress.
Methods: HDSO was delivered as part of routine diabetes services in primary health care in the United Kingdom, having been commissioned by local Clinical Commissioning Groups. Quantitative data were collected on uptake, use of the program, demographic characteristics, self-reported self-efficacy, and diabetes-related distress. A subsample of people with type 2 diabetes and health care professionals were interviewed about acceptability of the program.
Results: It was feasible to deliver the program, but completion rates were low: of 791 people with type 2 diabetes registered, only 74 (9.0%) completed it. Completers improved their self-efficacy (change in median score 2.5, P=.001) and diabetes-related distress (change in median score 6.0, P=.001). Interview data suggested that the course was acceptable, and that uptake and completion may be related to nonprioritization of structured education.
Conclusions: The study provides evidence of the feasibility and acceptability of a Web-based structured education. However, uptake and completion rates were low, limiting potential population impact. Further research is needed to improve completion rates, and to determine the relative effectiveness of Web-based versus face-to-face education.
JMIR Diabetes 2020;5(1):e15744
doi:10.2196/15744
diabetes mellitus, type 2;
self-management;
patient education;
internet;
digital divide;
social class;
health literacy;
Diabetes self-management education (DSME) aims to help people develop the knowledge and skills to manage their physical and emotional health [1]. There is evidence that DSME can improve glucose control [2,3] and prevent complications [4].
The National Diabetes Audit data in the United Kingdom indicates that only 8.3% of people who were referred to structured education attended in 2016 [5]. Established programs involve face-to-face group courses. Qualitative studies suggest that some people find the face-to-face courses difficult to attend because of timings of courses, lack of transport, work and family commitments, or they do not like taking part in groups [6]. Computer-based self-management interventions bypass some of the barriers to face-to-face education [7,8]. A 2013 Cochrane systematic review of computer-based diabetes self-management interventions found a small effect on glycemic control, which was larger in the mobile phone app subgroup [7]. A 2015 systematic review of internet-delivered DSME found significant improvements in glycemic control and clinic attendance compared with usual care [8]. Some studies in the review also found improvements in self-efficacy [9], diabetes knowledge [10-13], exercise behaviors [14,15], and self-care behaviors [14,16]. A 2017 systematic review of the reviews of technology-enabled diabetes self-management interventions found that 18 of 25 reviews reported a significant reduction in glycated hemoglobin; however, a meta-analysis was not conducted because of heterogeneity in interventions and study designs [17]. Reviews of Web-based diabetes self-management interventions are promising, but there are also challenges including low uptake and engagement, that can limit effectiveness and need further research [18].
In light of this, we developed a Web-based structured education program for people with type 2 diabetes mellitus (T2DM), called Healthy Living for People with type 2 Diabetes (HeLP-Diabetes): Starting Out (HDSO). The content and aims of the HDSO program were based on an earlier intervention named HeLP-Diabetes. The key difference between HeLP-Diabetes and HDSO was that HDSO was aimed at people who were newly diagnosed, and so it followed a structured written curriculum with specific aims and objectives, as recommended by the National Institute for Health and Care Excellence [19] and required for general practitioners (GPs) to receive quality and outcomes Framework remuneration for referral [20]. HeLP-Diabetes was developed for people at any stage of their illness, and contained information on 560 webpages, which people could dip in and out of without following a linear pathway. A randomized controlled trial (RCT) showed HeLP-Diabetes to be effective and cost-effective [21,22].
The HDSO program is discussed in this paper. HDSO was a Web-based intervention developed for use on desktop computers and tablets. The program development took an iterative user-driven approach informed by the human-computer interaction (HCI) design lifecycle [23,24] and the Medical Research Council (MRC) guidance on developing and evaluating complex interventions. The development process consisted of 3 phases: (1) initial design; (2) usability testing with volunteers; and (3) in the wild testing in the National Health Service (NHS) with people newly diagnosed with type 2 diabetes. The 3 stages of the development process are described in detail elsewhere [25].
In line with the MRC framework on the development and evaluation of complex interventions, and current advice on development and evaluation of digital health interventions [26,27], following the development process, we undertook a formative evaluation of the program to explore its feasibility, acceptability, and apparent impact on users. As this was a digital health intervention, it was appropriate to draw on methods more familiar to computer science and HCI researchers than biomedical ones, including an emphasis on real-world data, with participants using the intervention as they would in routine practice, rather than as part of an overt research project. Such real-world studies, also known as in the wild studies, provide a contextual backdrop for determining the strengths and weaknesses of the intervention accurately [28]. This allows digital health interventions to be tested by representative users attempting representative tasks in representative environments and makes any recommendations for further research user-led rather than researcher-led [29]. Studies in the wild can reveal complex and unexplained phenomena that can only emerge in the natural setting of the intervention [30]. They benefit from the strong external validity achieved by delivering the intervention as it will be used in routine practice, and not as part of an overt research project. In the wild studies are a necessary precursor to RCTs to determine effectiveness and cost-effectiveness as they allow for further refinement and optimization of the intervention, including the surrounding delivery package provided by health care professionals (HCPs), and a preliminary estimation of any associated changes in outcomes associated with the use of the intervention [27]. Such studies are not intended to, and cannot, determine any causal relationship between observed changes and the intervention tested.
In this study, we took advantage of the naturalistic, real-world setting and data provided by 5 Clinical Commissioning Groups (CCGs) commissioning HDSO in the NHS in the United Kingdom, as part of an overall menu of DSME offered to people with T2DM.
The overall aim of the study was to determine the feasibility, acceptability, and potential impact of delivering a Web-based structured education program (HDSO) in routine primary health care. Specific objectives were as follows:
Describe people's use of the program, including numbers (proportions) registering, starting, and completing the program.
Determine the demographic, clinical, and psychological factors associated with completion of the program.
Investigate the impact of the program on users' levels of diabetes-related distress and diabetes self-management self-efficacy (DSMSE).
Explore the views of people with T2DM and health professionals about the program, including reasons for engagement or nonengagement.
This was a mixed method study with a strong emphasis on real-world data and external validity. Quantitative data included the proportion of people starting and completing the program, and diabetes-related distress and diabetes self-management self-efficacy scale (DSMSES) questionnaire scores. Interviews with program users and HCPs provided further insights.
The study was conducted during implementation of the program in the NHS. People with T2DM in GP practices in 5 London CCGs registered for the program as an NHS service, rather than as research participants. This meant that we were unable to randomize participants to an intervention or control group, or collect clinical outcome data as we did not have access to their clinical records. However, this meant that the participants more accurately reflected the population of interest (people with type 2 diabetes treated in NHS primary health care) [31]. The total population of the 5 CCGs was 1,384,000. The population was diverse, with over 30% of the population from black and minority ethnic (BAME) groups [32]. All 5 CCGs were in the top quartile for deprivation in England [33]. RCTs are more limited in their external validity because of the characteristics of people who volunteer, and the inclusion and exclusion criteria in trial protocols [34,35].
Ethical Approval and Consent to Participate
Ethical approval was granted by the Health Research Authority (HRA; reference number 159488). The program was offered to people as part of service delivery, so the use of the data on registrations, activities, and questionnaire scores generated through the Web-based program was permissible under the HRA clause that the secondary use of information collected in the course of normal care is generally excluded from the Research Ethics Committee review [36] and specific informed consent to participate in research is not required. However, everyone who volunteered to be interviewed provided full informed consent before being interviewed and was aware that the interviews were for research purposes.
Participants for the Intervention
The target population was adults with T2DM. Referral was not limited to people who were newly diagnosed, as many people only become ready for structured education after having come to terms with the diagnosis [37-39]. Referral therefore included people at any stage of diabetes to enhance uptake. As this was a service, there were no formal exclusion criteria, but we advised HCPs that people who could not use a computer because of severe mental or physical impairment, had insufficient mastery of English, or were currently participating in a trial of an alternative self-management program would not be suitable for referral. A sample size calculation, which would be used to determine a statistically significant treatment effect in RCTs, was not used as this was not appropriate for the study design.
Participants for Interviews
Everyone who registered for the program was invited to take part in interviews. We also invited HCPs working at practices who referred a high or low number of people with T2DM, and staff employed by the CCGs to support implementation of the program.
The program was offered to people with T2DM using referral packs sent by practices who identified eligible people from electronic medical records searches, text messages, flyers, or in consultations with doctors or nurses. In 1 CCG group, there was a dedicated Change Manager who visited practices to talk to staff and people with T2DM about the program. Data on the number of people who were offered the program and declined were not recorded by practices.
People with T2DM were asked to telephone or email the HDSO team, to be registered, and have baseline demographic and clinical data collected (see Outcome Measures). A username and password was emailed to users, along with contact information in case of problems. However, this process of telephone registration proved to be time consuming and caused delay in people being able to access the program. The registration process was therefore modified (see Multimedia Appendix 1) so that users had the option of Web-based self-registration. People with T2DM were given the registration webpage details at referral by HCPs and in referral packs, which they could access to enter their demographic details, and register a username and password to use to log into the program.
Consent Procedures
Quantitative Data (Collected as Part of Service Evaluation)
Users were informed that anonymized data on their use of the program and questionnaire scores were automatically collected by the website for service development. Users were asked to email the team if they did not wish their data to be used. Data were automatically pseudoanonymized and stored locally on a secure network drive. The data were password protected and were only made available to appropriate members of the research team, in keeping with University College London data protection regulations.
Qualitative Data
People with T2DM and HCPs who expressed interest in the interviews at registration were contacted by the lead researcher (SP) and given written information about the study and the opportunity to ask questions. After informed consent was received, audiorecorded interviews were undertaken via telephone or in person. Consent forms were stored securely and separately from questionnaire data and audio recordings.
The intervention was a Web-based structured self-management program for people newly diagnosed with T2DM. It is described in detail in Multimedia Appendix 1, using the Template for Intervention Description and Replication (TIDier) checklist [40], and summarized here.
The content was based on HeLP-Diabetes [41], an online self-management intervention for everyone with T2DM. The theoretical basis was the Corbin and Strauss theory that self-management involves 3 tasks: managing the disease process, managing the emotional consequences, and managing the changes that occur in daily life [42]. HDSO was a 4-session program, comprising 4 or 5 modules per session, and questionnaires measuring diabetes-related distress and diabetes self-management self-efficacy score (DSMSES) in weeks 1 and 4. Each module took about 15 to 20 min to complete (see Table 1). Information was presented using text, images, and videos (see Multimedia Appendix 2). Email reminders were sent to users if they had not logged on for 7 days or more.
Session title Module title
Week 1: Getting started
Module 1: An introduction to type 2 diabetes
 \
Module 2: Self-assessment
Module 3: Eating well for diabetes
Module 4: Becoming more active
Week 2: Self-management
Module 1: Taking control
Module 2: Protecting my body and mind
Module 3: Handling my feelings
Module 4: Making changes (including My goals and plans)
Week 3: Improving my health and well-being
Module 1: Making the most of the National Health Service
Module 2: Medication
Module 3: Reducing the risks of heart attacks and stroke
Module 4: Updating my goals and plans
Module 5: Understanding my moods
Week 4: Taking control of my diabetes
Module 1: My diabetes review
Module 2: Looking after my feet
Module 3: Reviewing my goals and plans
Module 5: Moving on—the beginning of the end
Table 1. Healthy Living for People with type 2 Diabetes: Starting Out program sessions and modules.
View this table
Users were provided with their scores from the diabetes-related distress and DSMSES questionnaires, and individualized feedback developed by GPs and Diabetes Specialist Nurses (DSNs). The feedback in week 1 helped users identify gaps in knowledge or skills, and signposted to sessions of the program that could help them improve. The feedback in week 4 focused on improvements made and directed users to the HeLP-Diabetes website for ongoing support. Users were asked to set specific, measurable, achievable, realistic, time-bounded goals [43], and they were given opportunities to review their goals.
The data collected reflect the objectives of the study (see Table 2).
The server side of the website automatically collected anonymized data on user ID, date and time of login, and pages visited. These were used to determine how many people registered for and completed the program.
Data on personal characteristics included the following: (1) age; (2) gender; (3) ethnicity; (4) highest educational attainment; (5) internet access (home or public); (6) information technology skill level (basic, intermediate, or advanced; (7) duration of diabetes; (8) previously offered face-to-face education (yes or no); (9) previously attended face-to-face education (yes or no); and (10) diabetes management (lifestyle alone, or tablets and/or insulin). Education level was categorized using UK and US qualifications, and the International Standard Classification of Education [44].
Data on change in diabetes-related distress and self-efficacy in self-management were collected using the Problem Areas in Diabetes (PAID) [45] and DSMSES [46] questionnaires.
Objective Measure How and when collected
People's use of the program, including numbers (proportions) registering, starting, and completing the program
Number of people with T2DMa who registered with the program, started the program, and completed it
Data collected on the server side of the website throughout the study and analyzed at the end of the study
Characteristics of people with T2DM registering for the program
Highest educational attainment
Information technology skill level (basic, intermediate, or advanced)
Duration of diabetes (<1 year/>1year)
Offered face-to-face education (yes or no)
Attended face-to-face education (yes or no)
Diabetes management (lifestyle alone or tablets and/or insulin)
Collected over the telephone by the HeLP program team, or using a Web-based questionnaire at registration
Effect of the program on diabetes-related distress and DSMSESb
Change in Problem Areas in Diabetes and DSMSES questionnaire scores
Questionnaires completed online by users at baseline (week 1 of the program) and follow-up (week 4 of the program)
View of people with T2DM and health professionals about the program, including factors affecting acceptability of the program
Qualitative interview data from interviews with people with T2DM and HCPsc
Interviews conducted after quantitative data collected
aT2DM: type 2 diabetes mellitus.
bDSMSES: diabetes self-management self-efficacy scale.
cHCP: health care professional.
Table 2. Outcome measures.
Problem Areas in Diabetes
Diabetes-related distress was chosen as an outcome measure as there is a strong correlation between diabetes-related distress and diabetes self-care behaviors, and strong predictive validity for glycemic control [47]. Furthermore, at least 4 in 10 people with diabetes experience diabetes-related emotional distress [48], and addressing emotional distress should be part of comprehensive care for everyone with T2DM [49]. PAID has 20 items on areas that can cause difficulty including social situations and social support [50]. Scores range from 0 to 100, with higher scores indicating more distress. A score of more than 40 is clinically significant [45]. The PAID questionnaire has been shown to have high reliability and validity [51].
Diabetes Self-Management Self-Efficacy
Perceived self-efficacy is an individual's perception of their ability to undertake a task [52]. Diabetes requires a high level of self-efficacy because of the high number of self-management tasks required to prevent complications [46]. Perceived self-efficacy is a reliable predictor of initiation of healthy lifestyle behaviors [53,54]. The 20-item DSMSES questionnaire measures the individual's expectations of being able to engage in self-management activities such as keeping to a healthy eating plan when away from home [46]. A self-efficacy score of 0 indicates no self-efficacy and a score of 150 indicates very high self-efficacy. The DSMSES questionnaire has strong face validity, and it is a reliable scale for measuring self-efficacy in diabetes research [46].
A total of 13 interviews were carried out by SP (a female academic GP) and 4 interviews were conducted by RB (a male HCI specialist). The interviews lasted between 30 and 60 min. Both interviewers used a topic guide containing questions addressing the aim of the study, including the experience of diagnosis and information seeking; registering for the program; factors that may have affected engagement with the program such as problems using the website; barriers to starting or working through the program; and features or content of the program they liked or disliked. The topic guide for HCPs was tailored for the different roles the staff had in promoting and referring to the program, for example, GPs and nurses were asked about their experiences of discussing HDSO during clinical encounters with people with T2DM, while professionals in nonclinical roles were asked about how they supported clinicians with referring people to the program. Despite using the same topic guide, the different professional roles and interviewing techniques of the 2 interviewers may have led to different responses from the people who were interviewed.
Data on the number of people registered for the program and the pages they visited were used to calculate the proportions of people registered for the program who started and completed it. Web-based questionnaire scores were analyzed, and as they were not normally distributed, median and lower and upper quartiles of the scores were calculated. Nonparametric Wilcoxon signed-rank tests were used to determine whether there were any significant differences between the start (week 1) and end (week 4) of the program.
Characteristics of completers and noncompleters of the program were compared using Chi-square tests (or Fisher exact tests where appropriate) to see if there were any factors associated with completion. Mean baseline questionnaire scores of completers and noncompleters were compared using t tests. Statistical analyses were carried out using SPSS Statistics version 22 (IBM).
Interviews were recorded on a digital audiorecorder and transcribed verbatim by a professional transcription company. Transcripts were anonymized and checked for accuracy by the lead author (SP). Interview findings were analyzed thematically to explore the perspectives of people with T2DM and HCPs, with a particular focus on exploring similarities and differences between perspectives of professionals and people with T2DM [55,56].
Data were analyzed using the following steps: (1) The transcripts were read and re-read by the lead author to allow familiarization with the overall content; (2) the lead author then re-read the transcripts line by line looking for initial codes (text which was relevant to the research question). Codes were highlighted in MS Word; (3) once the lead author was confident that all the data relevant to the research question had been coded, these initial codes were copied and pasted into a separate document. Codes were compared with look for similarities and differences. Similar codes were grouped into potential themes; (4) to maximize rigor, transcripts, codes, and themes were also read by and discussed with FS, EM, and qualitative researchers attending 2 data clinics. The data clinics comprised exploration of the interpretations of the data, and consideration of refinements to existing themes and generation of new themes with 6 qualitative researchers from a range of disciplines (including health services research, sociology, and psychology). After these discussions with colleagues, the transcripts were re-read by the lead author (SP) who refined the themes and then discussed them with FS and EM until consensus was reached.
Applying Concepts of Normalization Process Theory to the Data
Once the themes were agreed upon, it became clear that some of the themes related closely to the constructs from Normalization Process Theory (NPT). NPT is concerned with making new interventions routine practices in health care (embedding) and sustaining embedded practices (integration) [57]. The theory operationalizes the work of implementation as 4 constructs: (1) coherence (sense making of the intervention); (2) cognitive participation (commitment of the participant); (3) collective action (the work participants do to make the intervention function); and (4) reflexive monitoring (how participants appraise the intervention). We used knowledge of the NPT constructs, the intervention, and the intervention setting to define intervention-specific meanings for each construct. We then mapped these constructs to the appropriate themes from the interviews. This 2-stage process of analysis has been used in other qualitative studies of complex interventions in primary health care [58] and provides a deeper analysis, by allowing researchers to embed the findings in existing theoretical concepts and in this way provide a theoretically informed interpretation in relation to implementation.
Use of the Program
A total of 791 people registered for the program, 188 started it (completed at least the first module of the first session), and 74 completed all 4 sessions (see Multimedia Appendix 3).
Characteristics of Participants
Data on the characteristics of people with T2DM is given in Table 3. A total of 791 people with T2DM registered to use the program. Demographic data were self-reported at registration (by either telephone or Web-based questionnaire), and there is a large amount of missing data because of nondisclosure, particularly on previous offer and attendance at structured education and diabetes management. The average age of people with T2DM registering to use the program was 57.6 years, over half (316/586, 53.9%) were male, over half (310/605, 51.2%) were from BAME backgrounds, and nearly one-third (181/602, 30.1%) had no qualifications beyond high school leaving age (Table 3). Just over one-quarter (170/589, 28.9%) had had their diabetes <1 year, and while half (193/394, 49.0%) recalled being offered face-to-face education, only 9.4% (37/394) had attended it.
Characteristics of Completers
The only factors associated with completion were duration of diabetes (P=.04), and having been offered (P=.001) and having previously attended (P=.002) face-to-face education. Having advanced information technology skills was not associated with completing the program (see Table 3).
Variable Registered people with T2DM Completers Noncompleters P value
Mean (SD) or n (%) N Mean (SD) or n (%) N Mean (SD) or n (%) N
Age (years) 57.6 (12.9)a 749 56.7 (13)a 749 56.8 (20.9)a 749 .63
Sex (male) 316 (53.9) 586 36 (51) 71 280 (54.4) 515 .50
White 287 (47.4) 605 37 (51) 72 250 (46.9) 533 .53
Black 206 (34.0) 605 24 (33) 72 182 (34.1) 533 N/Ab
Asian 67 (11.1) 605 8 (11) 72 59(11.1) 533 N/A
Mixed 20 (3.3) 605 2 (3) 72 18 (3.4) 533 N/A
Other 17 (2.8) 605 0 (0) 72 17 (3.2) 533 N/A
Prefer not to say 8 (1.3) 605 1 (1.4) 72 7 (1.3) 533 N/A
GCSEc/high school diploma 181 (30.1) 602 19 (28.4) 67 162 (32.9) 492 .45
Basic or intermediate information technology skills 406 (71.5) 568 46 (71) 65 360 (71.6) 503 .89
Diabetes duration <1 year 170 (28.9) 589 32 (45.1) 71 138 (28.5) 485 .04
Offered face-to-face education 193 (49.0) 394 42 (69) 61 151 (45.3) 333 .001
Attended face-to-face diabetes education 37 (9.4) 394 11 (18) 62 26 (7.8) 333 .002
Lifestyle alone (ie, diet and physical activity) 111 (28.2) 394 19 (31) 62 92 (27.7) 332 .22
Tablets and/or insulin 283 (71.8) 394 43 (69) 62 240 (72.3) 332 N/A
aRefers to mean (SD).
bN/A: not applicable.
cGCSE: general certificate of secondary education.
Table 3. Characteristics of registered people with type 2 diabetes mellitus (T2DM), completers, and noncompleters.
Impact of Completing the Program
Median DSMSES (self-efficacy) scores were significantly higher (better) in week 4 compared with week 1. Median PAID (distress) scores were significantly lower (better) in week 4 than week 1 (see Table 4).
Questionnaire Week 1 median (LQa,UQb) Week 4 median (LQ, UQ) P value
PAIDc 7.50 (4.00, 11.25) 5.00 (2.00, 9.00) .001
DSMSESd 101.50 (78.00, 119.25) 107.50 (95.50, 130.50) .001
aLQ: lower quartile.
bUQ: upper quartile.
cPAID: problem areas in diabetes.
dDSMSES: diabetes self-management self-efficacy scale.
Table 4. Baseline and follow-up questionnaire scores.
Views of People With T2DM and Health Professionals About the Program
Interviews were conducted with 17 participants (10 people with T2DM and 7 HCPs). Of the 10 people with T2DM, 7 had completed the program and 3 had registered for the program, but not completed it. Other characteristics are listed in Multimedia Appendix 4. Of the HCPs, 3 were DSNs, 2 were GPs, 1 was a HeLP-Diabetes Change Manager (employed by the local CCG to liaise with the GP Practices and promote the HDSO program) and 1 was a CCG Project Officer (providing support to senior CCG project managers). The data from people with T2DM and HCPs are combined in the results, as many of the subthemes are shared. Where a subtheme is unique to a particular group, this is stated in its description and illustrated with a quote.
Four major themes emerged from the analysis of the interview data, each with a number of subthemes (see Table 5). We mapped 2 of the major themes to NPT constructs. NPT explains whether and how complex interventions become embedded in health care practice. Hence, the themes that mapped to the constructs were those that related to health care system factors (the value of discussion between HCPs and people with T2DM about DSME at the time of referral; and improving uptake of the HDSO program) rather than factors that related to people with T2DM or the program. The NPT constructs and the HDSO-specific meanings we defined for each construct are listed in Table 6. The themes and subthemes we mapped to the constructs are listed in Table 7.
Major theme Subthemes
Lack of discussion between HCPsa and people with T2DMb about DSMEc at the time of referral
Poor understanding of structured education by professionals
Lack of time to discuss structured education
Factors affecting people's motivation toward DSME
Not being ready for information
Perceived lack of relevance
Perceived lack of need
User experience and advantages of a Web-based education program
Improving uptake of the HDSOd program
Supporting HCPs with referrals
Changes to the program
aHCP: health care professional.
bT2DM: type 2 diabetes mellitus.
cDSME: diabetes self-management education.
dHDSO: Healthy Living for People with type 2 Diabetes: Starting Out.
Table 5. Major themes and subthemes from the qualitative data.
Constructs HDSOa-specific meaning of the constructs
1. Coherence (sense-making of the intervention; anchoring in experience) How well HCPsb understood the HDSO program and how it was different to face-to-face courses. Whether HCPs valued the projected benefits of the HDSO program to people with T2DMc and the primary care team, and whether they developed a shared sense of benefit of the program.
2. Cognitive participation (engagement and commitment of the participant) The engagement of HCPs in the HDSO program, whether they thought it was a good idea, and whether they were willing to invest time, energy, and work into it.
3. Collective action (the work participants do to make the intervention function) The additional work for practices of promoting the program (including sending recruitment packs or text messages, and printing and displaying flyers in waiting areas). The work for HCPs of fitting discussions about DSME and referrals to the HDSO program into time-limited consultations. Any additional training needed to be able to explain and demonstrate the program, and send referrals.
4. Reflexive monitoring (how participants reflect on or appraise the intervention) Whether HCPs perceived the worth of the HDSO program, and its impact on their other tasks.
aHDSO: Healthy Living for People with type 2 Diabetes: Starting Out.
bHCP: health care professional.
cT2DM: type 2 diabetes mellitus.
Table 6. Normalization process theory constructs and Healthy Living for People with type 2 Diabetes: Starting Out–specific meanings of the constructs.
Major theme and subtheme NPTa construct
Major theme 1: Lack of discussion between HCPsb and people with T2DMc about DSMEd at the time of referral
Poor understanding of structured education by professionals Coherence
Lack of time to discuss structured education Collective action
Major theme 4: Improving uptake of the HDSOe program
Familiarizing professionals with the program Collective action; reflexive monitoring
Health assistant or administrative assistant-led referral Collective action
aNPT: normalization process theory.
dDSME: diabetes self-management education.
eHDSO: Healthy Living for People with type 2 Diabetes: Starting Out.
Table 7. Mapping of themes onto normalization process theory constructs.
Lack of Discussion Between Health Care Professionals and People with Type 2 Diabetes Mellitus About Diabetes Self-Management Education at the Time of Referral
HCPs and people with T2DM both expressed a sense of dissatisfaction about the way structured education was discussed at the time of referral. When people with T2DM described how they were informed about structured educations they explained that they received written confirmation of referral to an education program, but no discussion with HCPs about what the education program involves or the benefits of attending.
How much information did you get from your GP and your practice nurse about the diabetes when you first got it?
[Interviewer]
I don't remember getting that much, just referrals. I got it in a letter. She didn't call me and say, you have diabetes, so you have tipped over and we are now referring you.
[Participant 4, 63-year-old female noncompleter, duration of illness 1-5 years]
People with T2DM did not express views on why discussions about DSME with HCPs were limited, but HCPs identified contributing factors as being lack of time in consultations (collective action) and poor HCP understanding of the nature and benefits of structured education (cognitive participation):
The mode of referral played a part in how effectively people took up structured education programs. And a lot of this is due to, I think there are two main facts. One, lack of knowledge about what structured education is amongst health care professionals, and also the time and type of engagement that people have when engaging with patients who have been newly diagnosed with diabetes.
[Participant 14, GP, and Clinical Director]
All the HCPs who were interviewed agreed that there is no opportunity for significant discussion of DSME, as there is not enough time in the consultation to explain or (in the case of the HDSO program) demonstrate the program, as well as manage the person's other problems:
I think you're asking the impossible. GPs have a few minutes, the practice nurses probably have 20 minutes, at best...
[Participant 17, Diabetes Specialist Nurse]
Factors Affecting People's Motivation Toward Diabetes Self-Management Education
We asked both HCPs and people with T2DM about factors which may have contributed to whether people who registered for the program used it or not. We were particularly interested in why people registered for the program but did not complete it. All 10 of the people with T2DM who were interviewed registered for the program. Then, 3 started the program but did not complete it, and 7 started the program and did complete it. Both completers and non-completers described how competing priorities got in the way of having time to work through the program. HCPs and people with T2DM questioned whether people at an earlier stage of their illness might not feel ready for the information in the program or perceive the information as lacking relevance to them.
People described having other priorities competing for their time when they were working through the program, which meant stopping and starting and having long periods of not using the program at all. Competing priorities included work, as most people with T2DM who were interviewed were working age, and family responsibilities.
And yes, from time to time I got phone calls which were helpful and it just, again, just sort of urge you to get on to the program if you'd had a long gap from going on to doing it, yes.
[Participant 5, 64-year-old female completer, duration of illness 1-5 years]
So was that something that you found difficult? Because what we try and get people to do, is to do a session a week or a session every two weeks so that it kind of proceeds at a good pace. Did you find that difficult?
No that wasn't difficult. I think it was again just due to work. It may have fallen over periods where I'm so busy at work that I just didn't have time to do it.
HCPs expressed their concern that people with T2DM at an earlier stage of the illness do not feel the need to take self-management seriously yet. They described how people with T2DM without complications may feel well and have no symptoms, and so are not ready or willing to take on information about changing their lifestyle through self-management.
If we're talking about complications it's too far away for them to think about, if we're talking about behaviour change they think... It's a disease with no symptoms, largely, and I think that that's the massive issue, I think that people take it seriously when things start to go wrong.
Some people with T2DM saw themselves as newly diagnosed even if they had diabetes for more than a year, because they were not yet taking medication to manage the illness. These people talked about how they perceived much of the information in the program as being more relevant to people taking medication and less relevant to them:
A lot of the online (program) also I think targeted people who are on medication so how much as a, sort of a newly diagnosed I don't know how helpful it was to be honest with you. Because some of it I just felt didn't apply to me.
Some people expressed that they did not feel the need for more information about diabetes self-management, because they believed they already knew what they needed to know, particularly about diet changes:
They probably could give me further hints but at the same time, I just feel I really do know what to do—don't eat any carbs or sugars or anything and you'll keep it under control.
Despite the low completion rate, people with T2DM reported enjoying being able to work through the program at their own pace, as opposed to being given a lot of information at one time on a 1-day face-to-face course. People also talked positively about the way information was presented in the program using text, graphics, and videos (particularly videos of others living with the illness). This is crucial in understanding the importance of giving people with T2DM a Web-based option for DSME.
People with T2DM described a preference for taking their time to work through the large amount of information contained in a self-management education course, as opposed to processing information given in a 1-day face-to-face course:
I think that was the other thing which was really good about this site, is that with the DESMOND [Diabetes Education and Self-Management for Ongoing and Newly Diagnosed], it's all there in one day, like packed into a day. And... I mean, yes, they... you go away with nice little booklets and that, but I don't... I swear to God; I haven't really even looked at it. Whereas this, it's, sort of, like, telling you that you can make tiny little changes.
People with T2DM described enjoying the variety of formats in which the information was presented, including text, graphics, and videos. In particular, people with a preference for learning using visual information appreciated the videos accompanying the text:
The videos explain things... some things really, really well. I think everybody is different, aren't they? Some people work well with visual stuff, and other people work well with written stuff. I'd always think if you read and look, you know, it gets into the brain. You know, I think those things were really, really good.
[Participant 8, 60-year-old female completer, duration of illness less than 1 year]
Some people with T2DM found the support provided by the program with managing the emotional side of the illness useful, particularly watching the videos of others talking about living with the illness. This emphasizes the need for structured education programs to acknowledge the emotional challenges of diabetes self-management and the need to include emotional support in courses:
I thought it concentrated a lot about your emotional side. And listening to some of the other people, and I thought, oh, it's not just me who was annoyed. I know a lot of people got upset, and, I mean, I didn't get upset, I was just annoyed. And so I felt that there were similar experiences, you know, other people probably, it's not just me who was feeling that way. The other people reacted probably similar when they found out that they were diabetic.
Improving the Uptake of Healthy Living for People With Type 2 Diabetes: Starting Out Program
The HCPs who were interviewed had a number of suggestions for improving the uptake of the HDSO program. These included supporting professionals to improve the discussion at the time of referral by encouraging them to familiarize themselves with the program before discussion with people with T2DM (collective action and reflexive monitoring); and delegating some of the workload by allowing health care assistants or administrative assistants to refer people to the program (collective action). Other suggestions were made by people with T2DM about changes to the program to provide more personalized information, and making the program available to access on smartphones.
Supporting Health Care Professionals With Referrals
As discussed above, all the HCPs expressed that there is not enough time in a clinical consultation to discuss and demonstrate the program to people with T2DM at the time of referral. Suggestions were therefore made about supporting HCPs with referral, including allowing health care assistants and administrative staff to refer people to the program before or after their clinical consultation with a doctor or nurse, when there is more time for discussion:
Ideally, if there were a health care assistant or an admin person who could catch the patient separately either before or after the appointment to show them the website and sign them up, I think that would work really well.
Some people with T2DM expressed the need for more personalized information, particularly specific diet information on what they should and should not be eating. People mentioned that they would like to be able to use the program on their mobile phones, for convenience, and that they were unable to do so with the current format:
I, sort of, get on it and go through it, because I'm in that mood. Then go through two of the modules, let's say, from part four. I've done part four and part five today. But when I wanted to [unclear] on my mobile phone, when I was [unclear], I thought: right, no I'll sit down on the phone, you know. I jumped on my phone to do the modules. I found it, kind of, difficult. I find I had to restart the modules on my mobile phone. It wasn't... it wasn't, sort of... it didn't jump out at me and I found it quite frustrating.
[Participant 7, 47-year-old male completer, duration of illness <1 year]
Principal Findings
This study found that it is feasible to deliver Web-based structured education in the NHS; a wide demographic can use it; and it may improve self-efficacy and diabetes-related distress. The quantitative data showed that there were problems with uptake and completion, with completion positively associated with duration of diabetes <1 year, and self-report of having been offered and/or attended structured education previously. The qualitative data helped us to explore the low uptake more fully. Findings from interviews with people with T2DM and health professionals suggested that professional factors, personal factors for people with T2DM, and program factors affected program acceptability and attrition. More research is needed on improving uptake and determining the relative effectiveness and cost-effectiveness of Web-based and group-based structured education.
The strengths of this study include the strong external validity, with our data drawn from real-world experience of implementation and delivery of the service within routine primary health care. Other strengths include the use of a mixed method, with quantitative data on uptake, usage, and outcomes, and qualitative data to explore the underlying reasons for these observed data, and the use of theory (NPT) in the data analysis. Using NPT allowed us to make a theoretically informed interpretation of the qualitative data in regard to implementation. The design was appropriate for the study objectives, namely, to determine acceptability, feasibility, and apparent impact of the program. Acceptability and feasibility related not only to patients but also to health professional factors, which NPT allowed to explore more deeply.
It is important to state clearly that this design cannot be used to determine effectiveness of the intervention, nor can any causal links be inferred. Determining effectiveness and ascribing a causal impact of an intervention requires an RCT design, with an appropriate comparator, and a sample size calculation. In light of the multiple tests undertaken, it is possible that the observed associations between likelihood of completion and duration of diabetes, and self-reported offer or attendance at structured education are because of chance. A specific weakness of our study was the lack of clinical outcome data and our reliance on proximal outcomes collected through self-reported outcome measures. This was a direct result of our emphasis on external validity and real-world data, so that people with T2DM used the program as part of their routine NHS care, and not as part of a research study. Hence, we could not obtain formal informed consent, except from those who participated in interviews, and as such, it would not have been ethical to have access to clinical data. A further limitation was our inability to invite people who were offered the program but did not register to use it to take part in interviews because of the ethical limitations. Interviewing these people would have helped us to understand why some people do not want to use Web-based structured education.
Comparison With Previous Work
The percentage of completers was low (9.4%) but compares favorably with attendance at face-to-face education (8.3%) [5] and adherence to other digital self-care interventions [8,59-63]. The interviews helped explore attrition from the program, and NPT improved interpretation and transferability of the themes. Reasons for low engagement were similar to findings from a 2016 systematic review of diabetes education programs [6] and suggest that personal factors for people with T2DM and HCP factors, including nonprioritization, lack of enthusiasm from HCPs for education, and people feeling that they would benefit or that knew enough already, contributed to poor uptake and completion [6].
The study included people with any duration of diabetes, but one of the factors associated with completion was duration of diabetes of less than a year (P=.04). The rationale for including people with any duration of diabetes was that the literature suggests that many people only become ready for structured education after having come to terms with the diagnosis [37-39], and we did not want to limit uptake by only including people who were newly diagnosed. Our previous research had shown that uptake was lower when people with diabetes of duration greater than a year were excluded [25]. Overall, our findings therefore suggest that while offering structured education to people with diabetes of any duration does help improve uptake, overall uptake is still low, and it is the newly diagnosed group who are more likely to complete the course. This is consistent with a 2014 study by Roelofson et al, which found low overall participation in a Web-based patient platform for T2DM containing health data and educational information (110 people used the intervention out of 974 who were registered, 11.3%), but interest was higher in people with shorter duration of illness [64]. This suggests that DSME should be offered to everyone with T2DM, but people who are newly diagnosed are a group who should continue to be targeted and offered referral in the first year following diagnosis.
Having been offered face-to-face education (P=.001) and having attended face-to-face education (P=.002) also seemed to be associated with completion. The association between likelihood of completion and having been previously offered, or attended, structured education has not been reported previously in the literature. This association could reflect intrinsic characteristics, whereby people with more interest in and commitment to structured education are more likely to remember the offer and attend whatever education they are offered, or could reflect an effect of structured education, in that it makes people aware of how much there is to learn, and hence promotes engagement with subsequent offers. Further research is needed on whether people are more likely to take up structured education if they are offered it more than once, or whether more incentives are needed to increase intrinsic motivation and interest and commitment to complete a course.
If Web-based structured education can be found to be effective and cost-effective and have acceptable reach, this could give people with T2DM more options for learning about self-management and help improve structured education uptake.
Funding for a percentage of staff time, travel to practices, printing and postage of registration packs, posters about the program for practices, website development, and a percentage of hosting and maintenance of the website was provided by the National Institute for Health Research (NIHR) School for Primary health care Research (project reference 280). The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The authors thank the people with T2DM and staff who took part in the research, particularly those who gave their time to be interviewed and the staff who identified eligible participants and sent out registration packs. The authors also thank the HeLP-Diabetes: Starting Out team (Kingshuk Pal, Orla O'Donnell, Helen Gibson, and Rebecca Owen).
SP, FH, and EM contributed to the research proposal. EM and SP are coprincipal investigators. SP collected and analyzed the data and drafted the manuscript. EM and FS examined and discussed the qualitative data. LM and FH examined and discussed the quantitative data. All authors read and approved the final manuscript.
EM is Managing Director of HeLP-Digital Community Interest Company, a not-for-profit social enterprise established to roll out HeLP-Diabetes. She is not remunerated for this role, and there is no financial gain from the publication of this paper.
Multimedia Appendix 1
Description of Healthy Living for People with type 2 Diabetes: Starting Out according to the Template for Intervention Description and Replication checklist.
DOCX File , 22 KB
Screenshot of Healthy Living for People with type 2 Diabetes: Starting Out.
PPTX File , 491 KB
Flowchart showing numbers of people with type 2 diabetes mellitus registering, starting, and completing the program.
PDF File (Adobe PDF File), 117 KB
Characteristics of people who participated in interviews.
XLSX File (Microsoft Excel File), 13 KB
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BAME: black and minority ethnic
CCG: Clinical Commissioning Group
DSME: diabetes self-management education
DSMSES: diabetes self-management self-efficacy scale
DSN: diabetes specialist nurse
GP: general practitioner
HCI: human-computer interaction
HCP: health care professional
HDSO: HeLP-Diabetes: Starting Out
HeLP-Diabetes: Healthy Living for people with type 2 Diabetes
HRA: Health Research Authority
MRC: Medical Research Council
NHS: National Health Service
NIHR: National Institute for Health Research
NPT: normalization process theory
PAID: Problem Areas in Diabetes
RCT: randomized controlled trial
T2DM: type 2 diabetes mellitus
TIDier: Template for Intervention Description and Replication
Edited by G Eysenbach; submitted 02.08.19; peer-reviewed by R Forde, I Katsikavelas, M Renfrew; comments to author 10.09.19; revised version received 04.10.19; accepted 22.10.19; published 06.01.20
©Shoba Poduval, Louise Marston, Fiona Hamilton, Fiona Stevenson, Elizabeth Murray. Originally published in JMIR Diabetes (http://diabetes.jmir.org), 06.01.2020.
This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Diabetes, is properly cited. The complete bibliographic information, a link to the original publication on http://diabetes.jmir.org/, as well as this copyright and license information must be included.


thumb|right|300px|Kaiba's conviction that he's alone.The main characters of Kisara and the Beast.
"No pain could be deeper!
No life could be cheaper!
If I can't love her!" - Kaiba after Kisara runs away.
Prince Seto Kaiba - After his parents death, Kaiba was spoiled by the castle's servants. One night, during Christmas, Kaiba refused to let in a beggar, but she turned out to be a powerful enchantress named Ishizu. She cursed Kaiba, and turned him into a mammalian monster. Embarrassed of his monstrous form, Kaiba has concealed himself in his castle. When Kisara arrives, Kaiba realizes that she could be his best hope of breaking Ishizu's spell, but what beautiful, self-respecting girl would ever love a beast like him?
Kisara - Raised by Solomon after her mother died in a carriage crash, Kisara is a lover of books, and she sticks out in her town like a sore thumb. When Solomon was captured and imprisoned by Kaiba, Kisara asked to take her step-father's place. Kaiba agrees.
Joey - When Ishizu cursed the castle, Joey was turned into Flame Swordsman. He's a very well known ladies man. His girlfriend Mai is often furious with his flirtatious style. He's also very kind and caring.
Tristan - Tristan was left in charge of the household when Kaiba's father died, and he takes his job very seriously. When Ishizu cursed the castle, Tristan was turned into Cyber Commander.
Isis - The sister of Ishizu. Isis was turned into Spiria. She's also the adoptive mother of two young children named Yugi and Mana. She is a big fan of tea, and she's very maternal to everyone, including Kaiba.
Mana - Left on the doors of Kaiba's castle as a baby, Kaiba reluctantly let Isis adopt her. When Ishizu placed the curse on the castle, Mana was turned into Dark Magician Girl. She's very energetic and willing to make friends in an instant.
Yugi - While wandering into the castle grounds during Christmas, Isis adopted Yugi as Kaiba only found out a few moments before the curse was activated. When he was cursed, he became the Dark Magician. He's much more soft spoken than Mana, but he's still willing to make friends.
"So Kisara, what'll it be? Is it yes, or is it... OH, YESSSS!!"
"I... I just don't deserve you!"
"Who does? Oh I know... MEEEEEEE!" - Bakura's failed proposal to Kisara.
Bakura - Bakura's the most popular guy in the village. He's determined to make Kisara his wife as she's the only woman who's as beautiful as himself. When she refuses and Solomon comes in raving about a beast, he comes up with the perfect plan to force Kisara to marry him.


Talking to your kids about death can be difficult. But if you think that's tough, try talking to them about Weslaco, TX cremations. Most kids really struggle to wrap their minds around what cremation is and how exactly it works. Far too often, they allow their imaginations to run wild and end up thinking the worst when they hear that their loved one is going to be cremated.
Cremation shouldn't be something that scares your children. Instead, it should be something that they fully understand and even embrace once you talk to them about it. As long as you do a good job of explaining cremation to your kids, they should be able to come to terms with a loved one being cremated and see the value in it. Here is a guide that will help you to talk to your kids about cremations.
Begin by asking your kids what they know about cremation.
Before you start trying to explain what cremation is to your kids, begin by having your kids tell you what they know about cremation. This will give you a good idea of how much explaining you're going to need to do to them. It'll also help you get a better grasp of how your kids feel about their loved one being cremated in Weslaco, TX. You'll be able to address everything they tell you once you take the floor.
Clear up any misconceptions your kids might have by explaining cremation in simple terms.
After you've listened to your kids talk about cremation, it'll be your turn to speak. Remain calm and talk softly as you work your way through a full explanation of cremation. Try not to use any words or phrases that might touch a nerve in your kids. Instead, stay as matter-of-fact as possible while you walk through what a cremation is and how it's carried out.
Talk to your kids about how their loved one chose cremation and tell them why they did it.
Some kids are under the impression that their loved one was cremated as some act of punishment. But this obviously couldn't be further from the truth. Many people preplan their cremations and actively choose them over traditional burials. Tell your kids why their loved one chose to be cremated, if you know the reason, and explain to them that cremation is what their loved one really wanted.
Encourage your kids to ask questions about cremations if they have any.
No matter how good of a job you do while explaining cremations, your kids are going to have a million and one questions for you. Field each and every one of them and do your best to provide adequate answers. You don't want to get too far into the details surrounding the actual cremation process, especially if your kids are on the younger side. But if your kids have questions for you, provide them with some kind of answer, even if you have to hold back a little for their sake.
McCaleb Funeral Home performs cremations regularly. We can provide you with more tips for talking to your kids about cremation if you would like. We can also set you up with the cremation services in Weslaco, TX that you need to give your loved one a proper sendoff. Call us at (956) 968-7533 today to speak with a funeral director or schedule a meeting with us at 900 W 4th St., Weslaco, TX 78596.


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ALJF 〉
Chris Marker * 1921 in Paris, lives in Paris
http://chrismarker.org/
Chris Marker (1921-2012) was one of the most influential and important filmmakers to emerge in the post-war era. Marker appeared on the Paris cultural landscape as a writer and editor and also became identified for his uniquely expressive non-fiction films. Marker began garnering international recognition in 1962 with the science-fiction short film La Jeté. In the seventies Marker created documentaries both on the history of the left (Le Fond de l'air est rouge, 1977) [...]
Chris Marker (1921-2012) was one of the most influential and important filmmakers to emerge in the post-war era. Marker appeared on the Paris cultural landscape as a writer and editor and also became identified for his uniquely expressive non-fiction films. Marker began garnering international recognition in 1962 with the science-fiction short film La Jeté. In the seventies Marker created documentaries both on the history of the left (Le Fond de l'air est rouge, 1977) and travel and memory (Sans Soleil, 1982). Marker has also produced acclaimed media installations, including Owls at Noon Prelude: The Hollow Men, shown at New York's Museum of Modern Art in 2005 and presented by Peter Blum at Art Basel Unlimited in 2006, and Silent Movie, commissioned by the Wexner Center for the Arts in 1995 and which subsequently traveled internationally. Additionally, he has been included in exhibitions at the Walker Art Center, Minneapolis; MoMA PS1 Contemporary Art Center, New York; The Centre Georges Pompidou, Paris; The Jeu de Paume, Paris; The Douglas Hyde Gallery, Dublin, and Fundació Antoni Tàpies in Barcelona.
Événement Conférence / table ronde
COLLOQUE CHRIS MARKER

redpajama_set_name: RedPajamaCommonCrawl


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Achievements, challenges and recommendations
conference-summary.pdf
Summary of outcomes of the GP 10 Conference: 16 - 17 October 2008, Oslo
The Oslo conference reaffirmed the Guiding Principles as an important framework for upholding the rights of IDPs and was encouraged by reports from a number of states that the Principles had been incorporated into national laws and policies and that a variety of actors have found them useful in promoting IDP rights.
However, the conference emphasised that increased political and financial commitment is needed to ensure the full protection of IDPs. States are encouraged to develop or strengthen their policies to include: (1) preventive measures to avert displacement, (2) crisis mitigation procedures, to be activated once displacement has occurred, and (3) durable solution frameworks.
There is an urgent need for humanitarian and development actors, governments and financial institutions to work together to ensure durable solutions to displacement. Joint approaches are also required to address the challenges resulting from the increasing scale and complexity of forced displacement, and to ensure that the standards set by the Guiding Principles are met.
Participants in the conference emphasised that the Guiding Principles have become a key point of reference for the development of normative frameworks for the protection of IDPs in domestic laws and policies. For example, in Turkey, the government has incorporated the Guiding Principles in its Strategy document and used them as a basis for its Compensation Law. With the help of the UN, the model used to develop the Van Province Plan of action for IDPs is now being expanded to cover other provinces. Examples from Mozambique and The Maldives were also given, confirming the relevance of incorporating the Guiding Principles into national legislation in situations of displacement resulting from natural disasters.[1]
At the regional level, the Organization of American States and the Council of Europe[2] have recommended the adoption of the Guiding Principles through national legislation to their Member States. In Africa, the Great Lakes Protocol on the Protection and Assistance to Internally Displaced Persons includes a legal obligation for signatories to incorporate the Guiding Principles into domestic law.
The essential role of the judicial system and civil society organisations in promoting the Guiding Principles and monitoring commitments and obligations of national authorities was highlighted in the context of Colombia.
During the discussion, it became apparent that the Guiding Principles are operationally valuable for actors engaged in providing protection and assistance to IDPs. From the point of view of humanitarian agencies, the Guiding Principles have shaped humanitarian and protection operations. They also provide the primary reference from which humanitarian and protection standards and practices are developed.[3]
With respect to displacement resulting from natural disasters, the conference affirmed that the Guiding Principles provide a useful framework for disaster risk reduction, the mitigation of displacement and ending displacement after disasters. In situations of disaster-induced displacement, protection risks are often under-estimated. In disaster-prone countries, the Guiding Principles should be used to build closer partnerships between governments, aid providers and civil society, as part of the disaster prevention framework. At the onset of a disaster, IOM noted the role of the Guiding Principles in serving as a checklist to develop a response strategy which ensures that all proper planning and response are carried out.
Challenges ahead
Despite considerable achievements, some of which are outlined above, major challenges to the realisation of rights of IDPs remain. The number of people who have been forcibly displaced from their homes is estimated at 1% of the world's population. Moreover, the number of IDPs continues to increase, primarily as a result of the growth in disaster-induced displacement related to climate change but also because of protracted situations of displacement. Protracted displacement usually occurs as a result of unresolved conflicts and lack of political will amongst national governments, as well as insufficient support by international actors. In many countries, significant gaps between policies and practice are observed, especially in relation to durable solutions.
The conference noted that a majority of states affected by internal displacement remain unable or unwilling to take on their responsibilities for protecting IDPs. In the worse cases, the humanitarian space required to prevent displacement or to provide protection to IDPs is limited as a result of obstruction by governments or non-state actors. In reality, the Responsibility to Protect concept has been of limited value in the protection of human rights of IDPs, as a number of states remain more committed to the doctrine of national sovereignty when it comes to dealing with internal displacement.[4]
It was felt that the current legal and normative protection framework needs to be re-examined in the light of the new categories of forced migrants as a result of climate change-related disasters or long-term environmental degradation.
With an increasing number of IDPs residing in urban areas, states and protection agencies must seek new and appropriate means of providing them with adequate protection and assistance, as their requirements are different from those of people in camp settings or in rural areas. The appropriate durable solutions also need to be considered, as urbanisation affects choices and opportunities. For example, after IDPs have adapted to urban livelihoods, return to rural homes is often no longer an option.
With respect to international protection, humanitarian reform has contributed to better predictability in humanitarian responses. The fact that UNHCR now takes the lead for protecting IDPs in situations of armed conflict has significantly improved leadership of coordination of protection. Nevertheless, as stressed by the Emergency Relief Coordinator, humanitarian actors risk having their credibility undermined if greater care is not given to ensure equality of attention to different IDP populations in protracted crises.
In situations of disaster-induced displacement, protection leadership remains inadequate at the institutional level, as the responsibility for international coordination is divided between UNHCR, UNICEF and OHCHR, all of which have concerns about their capacity to take on this additional responsibility.
Incorporation into national legislation
The Guiding Principles should be incorporated into national legislation so as to promote their implementation and to improve accountability for the protection of IDPs. The publication of the Manual for Law and Policymakers on Protecting Internally Displaced Persons[5] will be a useful resource for governments as it provides a guide for policymakers on how to bring relevant domestic laws in line with the Guiding Principles in a practical way. National authorities have a responsibility not only to develop legislative frameworks but also to ensure that laws and policies are implemented.
Effective partnerships are necessary in order to meet the twin challenges of preventing displacement and of ending displacement. These partnerships should be developed amongst states; between states and civil society; between states and financial institutions; between states, civil society and international protection and assistance agencies; and between international humanitarian agencies and development agencies.
Preventing and ending displacement
More efforts need to be made to prevent displacement, through effective disaster risk reduction and emergency preparedness, and through conflict prevention. In parallel, sustained efforts need to be made to end displacement. Both areas of action should be accompanied by coordinated political commitment of all influential actors, as well as adequate and predictable resourcing.
Durable solutions
Planning for durable solutions must start soon after displacement occurs so as to facilitate the transition from humanitarian assistance to development through effective early recovery strategies. Following the ongoing field testing of the framework for durable solutions, the focus should be on implementing the framework from an early stage in the humanitarian response.
Political dialogue, including peace negotiations, needs to ensure that IDPs' voices are represented and heard on all issues which affect them. Experience shows that early and sustained dialogue on issues relating to access to land, housing and property is essential to the identification of durable solutions.
In disaster-prone countries, the Guiding Principles should be used to build closer partnerships between governments, aid providers and civil society, as part of the disaster prevention framework. At the onset of a disaster, the Guiding Principles should be used as a checklist to develop a response strategy to ensure proper planning and response.
Urban IDPs
With an increasing number of IDPs residing in urban centres, states and protection agencies must seek new and appropriate means of providing them with adequate protection and assistance, as their requirements are different from those of people in camp settings or in rural areas.
Participation of IDPs
Finally, it is important to develop mechanisms to ensure the participation of IDPs in political processes, in decisions affecting their lives during displacement, and in developing and implementing solutions to bring an end to their displacement. Their participation is a precondition to the implementation of the Guiding Principles.
This is a shortened version of the Chair's Summary, prepared by NRC/IDMC, the Brookings-Bern Project on Internal Displacement and the Norwegian Ministry of Foreign Affair,which is online on the GP10 Conference website at
http://www.internal-displacement.org/gp10
[1] For more examples, see article on Uganda on p… and Georgia on p...
[2] See article on p…
[3] See statements by António Guterres, John Holmes and Angelo Gnaedinger on p… In addition, OHCHR noted that the Guiding Principles had proven to be useful in a variety of situations and that they had been shared with all its offices.
[5] See p..
Enlaces transversales de libro para Achievements, challenges and recommendations
‹ The genesis and the challenges
Developments in the legal protection of IDPs ›


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Home > Uncategorized > Netflix's Flower Fight, TVNZ's Flack: Great shows to stream this week
Netflix's Flower Fight, TVNZ's Flack: Great shows to stream this week
daniltalks360 May 31, 2020 Uncategorized No Comments
THE BIG FLOWER FIGHT (NETFLIX)
This new reality series attempts to transplant the successful British Bake Off format to the world of floral design. Ten teams of two from around the globe have been gathered together in a giant dome in the English countryside for some serious "avant gardening".
Vic Reeves and Natasia Demetriou host, while sole regular judge, florist-to-the-stars Kristen Griffith-VanderYacht, hogs the limelight.
EVIL (LIGHTBOX)
Luke Cage's Mike Colter plays a former journalist studying to be a Catholic Priest in this new series from the creators of The Good Wife. His character teams up with a skeptical forensic psychologist (Westworld's Katja Herbers) to investigate supposed supernatural incidents.
"Offering thoughtful debates about religion and more, Evil could be a new kind of TV animal: the philosophical procedural," wrote Entertainment Weekly's Kristen Baldwin.
Snwowpiercer, Flack and I Know This Much is True are among the series well worth checking out this week.
* The Great: Why Elle Fanning's period romp is likely to become your new Favourite
* Netflix's White Lines to Amazon's Little Fires: Shows to stream this weekend
* The TV you need to see in May 2020
Former Luke Cage star Mike Colter headlines Evil.
FLACK (TVNZ ONDEMAND)
New Zealand's own Anna Paquin returns to headline the second season of this darkly dramedy about a sharp and witty PR agent who's an expert at her craft, but a complete self-saboteur when it comes to her personal life. Joining the cast this season are Lost's Daniel Dae-Kim and Paquin's co-star from The Piano, Sam Neill.
"It rises above most drama-comedies by the means of the occasional, carefully rationed, impassioned monologue. The best underhyped thing on the box, wrote The Guardian's Euan Ferguson. Debuts here at midday on June 1.
THE GREAT (NEON)
Elle Fanning and Nicholas Hoult star in a look at the reigns of Russia's Peter and Catherine the Great that's a very different pot of borscht to last year's serio-political Helen Mirren drama. This is a black comedic romp, very much in the same vein as writer Tony McNamara's Bafta-winning The Favourite.
Yes, not only does it share a similar 18th-century setting, rabbit-loving monarch and bedroom antics, but it also possesses the same sharp wit and bawdy humour that made McNamara and Deborah Davis' look at Queen Anne's court such a hit with audiences.
Anna Paquin is back with more Flack – on TVNZ OnDemand from June 1.
HOMECOMING (AMAZON PRIME VIDEO)
Janelle Monae replaces Julia Roberts as the focal point for this second season of this psychological thriller based on the hit podcast of the same name. Her character wakes in a rowboat adrift a lake, with no memory of how she got there – or even who she is. The series also stars Chris Cooper and Joan Cusack.
"Builds to a shocking and satisfying finale that you're not likely ever to forget," wrote TV Insider's Matt Roush.
I KNOW THIS MUCH IS TRUE (NEON)
Star of Spotlight, Dark Waters and Thor: Ragnarok, Mark Ruffalo pulls double duty to tremendous effect in the haunting, harrowing six-part adaptation of Wally Lamb's much loved 1998 novel. It's the story of twin brothers Dominic and Thomas Birdsey, who were born both six minutes and a decade apart.
The latter makes headlines again 40 years later, when he lops off a limb as a sacrifice at the Three River Public Library. Troubled by events in Kuwait – and his own paranoid schizophrenia – he's decided it's the only way to prevent a global crisis.
Natasia Demetriou and Vic Reeves are the hosts of Netflix's The Big Flower Fight.
SNOWPIERCER (NETFLIX)
Hot on the heels of Bong-Joon Ho's Oscar haul for Parasite comes this small-screen adaptation of one of his earlier movies. Jennifer Connelly and Daveed Diggs headline this 10-part show which focuses on the inhabitants of a gigantic, perpetually moving train that circles the frozen wasteland that is all that remains of our world.
"A soapy, ambitious sci-fi season that takes big swings and follows through, engaging with not just class struggle but also leadership, loyalty, compromise, and coalition," wrote Vanity Fair's Sonia Saraiya.
TRIAL BY MEDIA (NETFLIX)
Six-part documentary series which looks at some of the most dramatic and memorable real-life courtroom dramas in recent history. It aims to explore the many ways in which the press have contributed to reshaping public perception about guilt or innocence before, during or after a trial.
"It's a heartbreaker, with a genuine sense of uncovering and pointing to a terrible wrong," wrote The Globe and Mail's John Doyle.
String of murder-suicides in north west England 'could be serial killer on the loose' A coroner suspicious of a string of apparent murder-suicides involving elderly couples across England's has raised fears they could actually be the work of a serial killer : TrueCrime
Questions about Ontario's stay-at-home order answered
In Melbourne's interminable lockdown, my daily walks have gone from a chore to a delight | Amanda Dunn | Opinion
Biden's climate plan is missing a crucial element
Christmas in Montreal will be warm, windy and wet, warns Environment Canada
Kiwis splash out $12b more in house buying frenzy this year
Bluey's Big Play review – magical adaptation brings unbridled joy to kids (and parents) | Australian Broadcasting Corporation
City of Ottawa declares overnight parking ban to clear snow
Pandemic cripples learners' futures – The Mail & Guardian
Coca Cola repays subsidies after better-than-expected full-year profit
Covid-19: Expat upskills to launch new business in Northern Ireland lockdown
Get ready for weekend shutdown of Highway 20 West


A new composite image of Chandra and Spitzer data shows G54.1+0.3, the dusty remains of a collapsed star.
X-rays from Chandra reveal a wind of high-energy particles from the pulsar at the center of the image.
The Spitzer data shows an infrared shell around the pulsar that is made of gas and dust that condensed from the supernova.
A new image from NASA's Chandra X-ray Observatory and Spitzer Space Telescope shows the dusty remains of a collapsed star. The dust is flying past and engulfing a nearby family of stars. Scientists think the stars in the image are part of a stellar cluster in which the a supernova exploded. The material ejected in the explosion is now blowing past these stars at high velocities.
The composite image of G54.1+0.3 shows X-rays from Chandra in blue, and data from Spitzer in green (shorter wavelength infrared) and red-yellow (longer wavelength infrared). The white source near the center of the image is a dense, rapidly rotating neutron star, or "pulsar," left behind after a core-collapse supernova explosion. The pulsar generates a wind of high-energy particles -- seen in the Chandra data -- that expands into the surrounding environment, illuminating the material ejected in the supernova explosion.
The infrared shell that surrounds the pulsar wind is made up of gas and dust that condensed out of debris from the supernova. As the cold dust expands into the surroundings, it is heated and lit up by the stars in the cluster so that it is observable in the infrared. The dust closest to the stars is the hottest and is seen to glow in yellow in the image. Some of the dust is also being heated by the expanding pulsar wind as it overtakes the material in the shell.
The unique environment into which this supernova exploded makes it possible for astronomers to observe the condensed dust from the supernova that is usually too cold to emit in the infrared. Without the presence of the stellar cluster, it would not be possible to observe this dust until it becomes energized and heated by a shock wave from the supernova. However, the very action of such shock heating would destroy many of the smaller dust particles. In G54.1+0.3, astronomers are observing pristine dust before any such destruction.
Scale Image is 3 arcmin across (about 17 light years across).
This is breathtaking. This should be made available to students in elementary school.
Amazing how mankind can go that far with their instruments hope someday we can go in person.
Is it possible that black hole creation is almost at a halt? Since most of the first generation gargantuan stars are now black holes, this leaves pulsars and heavy amounts of stellar debris without orientation. Which might create gigantic heavy dust fields that might in turn create gargantuan stars again repeating the cycle. Thanks, awesome work.
How beautiful is the universe we live in. I have the greatest admiration for such explorers like you.
The dusty remains of a collapsed star.
About 20,000 light years from Earth.
X-rays from Chandra were overlaid on infrared data from Spitzer.
About 17 light years across.
X-rays are blue, shorter wavelength infrared are green and longer wavelength infrared are red-yellow.
In the constellation Sagitta (the "arrow") visible in the Northern Hemisphere.


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Harlow's and All Things Comedy Present
All Things Comedy Presents "Tin Foil Hat Comedy" Live
with Sam Tripoli, and Eddie Bravo
"Tin Foil Hat Comedy" Live
Sam Tripoli, the host of one of America's most popular conspiracy themed podcasts "Tin Foil Hat", is bringing his provocative world view to the stage in a special night of stand up comedy and far out theories.
Joined for this limited engagement by fellow status quo provocateur & Joe Rogan podcast regular Eddie Bravo, the dissenting duo will turn conventional thinking & historically accepted accounts on its' collective ear.
You're under the impression that man really walked on the moon? You've assumed all these years that the world was round? Sam and Eddie have a collection of entertaining observations on those widely held positions (and many others like them) that will start you laughing but leave you thinking.
Boasting a stand up career that spans three decades, including appearances on Comedy Central, Showtime, and Netflix, Sam Tripoli enjoys ongoing success as a comedian, actor, and podcaster. In addition to hosting weekly episodes of the wildly popular Tin Foil Hat and Punch Drunk Sports podcasts, Tripoli recently starred alongside the biggest names in comedy in the feature film "Dying Laughing."
Perhaps best known for founding the 10th Planet Jiu-Jitsu martial arts system, as well as his many appearances on the "Joe Rogan Experience", Eddie Bravo is the definition of a Renaissance man. Known as an accomplished martial artist, musician, commentator, and viral philosopher, Bravo is a counter cultural dynamo who wows any crowd that gathers within the sound of his voice. His disciples and devotees travel long distances to listen to Bravo hold court on all things unbelievably yet undeniably curious.
Hear your favorite conspiracy theorists Sam Tripoli and Eddie Bravo (and friends) tackle your favorite conspiracy theories at "Tin Foil Hat Comedy" Live
with Sam Tripoli
and Eddie Bravo


" The stock market crash in '29 and the Dust Bowl left us with nothing, out on the streets, our youth our only asset. We were to reduced to wandering from place to place- no work, no future. What we were yet to realize, was that our only hope of saving our skins would be to risk our lives."
Une version en anglais à l'occasion des célébrations du Débarquement.


Tori Amos (born Myra Ellen Amos; August 22, 1963) is an American pianist and singer-songwriter. She was at the forefront of a number of female singer-songwriters in the early 1990s and was noteworthy early in her career as one of the few alternative rock performers to use a piano as her primary instrument. Some of her charting singles include "Crucify", "Silent All These Years", "God", "Cornflake Girl", "Caught a Lite Sneeze", "Professional Widow", "Spark", "1000 Oceans", and "A Sorta Fairytale", her most commercially successful single in the U.S. to date.


The efficacy of bright light therapy to treat seasonal affective disorder (SAD) is firmly established, and researchers have expanded their investigations into further applications of this approach. Studies in the area of chronotherapeutics have found evidence that additional methods of manipulating circadian rhythms may help treat depression, while providing more support for the use of bright light therapy (BLT).
BLT "can be an important and effective treatment of depression, with more rapid onset than anti-depressant medication and minimal side effects," Richard S. Schwartz, MD, an associate professor of psychiatry at Harvard Medical School and co-founder of GoodLux Technology, told Psychiatry Advisor.
"It 'phase-advances' a patient's circadian rhythm — effectively making his or her biological day start earlier — by stimulating specialized receptors in the retina with links to the suprachiasmatic nuclei in brain," he added, which essentially comprise the master clock of our bodies. This results in reduced levels of melatonin and increased production of serotonin.
Research shows that BLT, also sometimes called phototherapy, is effective not only for SAD, but also for non-seasonal unipolar and bipolar depression.
In a randomized, double-blind, placebo- and sham-controlled trial2 reported online last month in JAMA Psychiatry, 122 adults with non-seasonal major depressive disorder (MDD) were randomly assigned to groups consisting of treatment with light therapy, fluoxetine, a combination of the two or placebo. At the end of the eight-week study period, the group showing the most improvement on the Montgomery-Asberg Rating Scale (MADRS) was the one treated with a combination of BLT and fluoxetine, followed by the BLT group.