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JMIR Human Factors
Year: Select... 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023
Design and Usability of Websites for Special User Groups (77)
Published on 14.12.2017 in Vol 4 , No 4 (2017) :Oct-Dec
Deciding How to Stay Independent at Home in Later Years: Development and Acceptability Testing of an Informative Web-Based Module
Mirjam Marjolein Garvelink 1 ; C Allyson Jones 2 ; Patrick M Archambault 1, 3, 4, 5 ; Noémie Roy 1, 6 ; Louisa Blair 1 ; France Légaré 1, 5, 7
Original Paper
Mirjam Marjolein Garvelink1, MSc, PhD ;
C Allyson Jones2, PT, PhD ;
Patrick M Archambault1,3,4,5, MSc, MD, FRCPC ;
Noémie Roy1,6, MSc, MA ;
Louisa Blair1, PhD ;
France Légaré1,4,7, MD, PhD, CCMF, FCMF
1Centre de recherche sur les soins et les services de première ligne de l'Université Laval, Centre intégré universitaire de santé et services sociaux de la Capitale-Nationale, Québec City, QC, Canada
2Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, AB, Canada
3Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, QC, Canada
4Population Health and Optimal Health Practice Research Unit, Centre hospitalier universitaire de Québec, Université Laval, Québec City, QC, Canada
5Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, QC, Canada
6School of Architecture, Faculty of Planning, Architecture, Arts and Design, Université Laval, Québec City, QC, Canada
7Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Québec City, QC, Canada
France Légaré, MD, PhD, CCMF, FCMF
Centre de recherche sur les soins et les services de première ligne de l'Université Laval
Centre intégré universitaire de santé et services sociaux de la Capitale-Nationale
Pavillon Landry-Poulin, Bureau A-4574 Entrée A. 1-2
2525 Chemin de la Canardière
Québec City, QC, G1J 0A4
Fax:1 418 687 9694
Email: france.legare@fmed.ulaval.ca
Background: Seniors with loss of autonomy may face decisions about whether they should stay at home or move elsewhere. Most seniors would prefer to stay home and be independent for as long as possible, but most are unaware of options that would make this possible.
Objective: The study aimed to develop and test the acceptability of an interactive website for seniors, their caregivers, and health professionals with short interlinked videos presenting information about options for staying independent at home.
Methods: The approach for design and data collection varied, involving a multipronged, user-centered design of the development process, qualitative interviews, and end-user feedback to determine content (ie, needs assessment) in phase I; module development (in English and French) in phase II; and survey to test usability and acceptability with end users in phase III. Phase I participants were a convenience sample of end users, that is, seniors, caregivers, and professionals with expertise in modifiable factors (eg, day centers, home redesign, equipment, community activities, and finances), enabling seniors to stay independent at home for longer in Quebec and Alberta, Canada. Phase II participants were bilingual actors; phase III participants included phase I participants and new participants recruited through snowballing. Qualitative interviews were thematically analyzed in phase II to determine relevant topics for the video-scripts, which were user-checked by interview participants. In phase III, the results of a usability questionnaire were analyzed using descriptive statistics.
Results: In phase I, interviews with 29 stakeholders, including 4 seniors, 3 caregivers, and 22 professionals, showed a need for a one-stop information resource about options for staying independent at home. They raised issues relating to 6 categories: cognitive autonomy, psychological or mental well-being, functional autonomy, social autonomy, financial autonomy, and people involved. A script was developed and evaluated by participants. In phase II, after 4 days in a studio with 15 bilingual actors, 30 videos were made of various experts (eg, family doctor, home care nurse, and social worker) presenting options and guidance for the decision-making process. These were integrated into an interactive website, which included a comments tool for visitors to add information. In phase III (n=21), 8 seniors (7 women, mean age 75 years), 7 caregivers, and 6 professionals evaluated the acceptability of the module and suggested improvements. Clarity of the videos scored 3.6 out of 4, length was considered right by 17 (separate videos) and 13 participants (all videos together), and 18 participants considered the module acceptable. They suggested that information should be tailored more, and that seniors may need someone to help navigate it.
Conclusions: Our interactive website with interlinked videos presenting information about options for staying independent at home was deemed acceptable and potentially helpful by a diverse group of stakeholders.
JMIR Hum Factors 2017;4(4):e32
doi:10.2196/humanfactors.8387
decision making; shared; housing for the elderly; decision support techniques; instruction films and videos
Most seniors want to live at home and remain independent for as long as possible, a goal reflected in many government policies [1,2]. Independent living encompasses a holistic concept of autonomy that includes the social, psychological, functional, and health care needs of seniors related to active aging [3]. In 2011, 92% of all Canadian seniors aged 65 years and older lived autonomously in private households [4], of whom the majority were house owners [5]. Most still drove their cars, which was their main means of transportation; fewer than 6% used public transport; and fewer than 3% walked or cycled [4]. Similar patterns are seen abroad [6,7]. However, because of age-related decline in health and autonomy, many seniors receive informal or formal care at home (30.1% aged 75-84 years, and 54% over 85 years) [8]. Moreover, most seniors and their caregivers will ultimately face a decision about whether they can continue living at home, and if so, how to maintain their independence [8,9].
Although there are multiple options for seniors to remain at home [10-12], many seniors and their caregivers are unaware of them [13,14]. Before deciding to move elsewhere, it is important that seniors know their options about aging safely in situ and weigh these options alongside the option to relocate [15]. Moreover, active involvement in decision making is key to helping people self-manage their health.
According to the Ottawa Decision Support Framework, people cannot make preference-based shared decisions without accurate knowledge of the options, an understanding of what is most important to them, and effective support from others [15]. In the decision to stay at home or relocate, different kinds of knowledge (eg, medical, social, financial, and familial) are needed and supplied by different stakeholders. A senior may prefer to stay at home, for example, whereas others may know it is unsafe or untenable for their caregiver. Although the final decision is preferably the senior's, it is important that all the stakeholders [16-18] are involved in informing and discussing the decision. A recent ongoing study on the implementation of a shared decision-making (SDM) guide for seniors and caregivers about whether to stay at home or move indicates that the SDM guide helps stakeholders be more involved in the decision [18]. However, the guide does not provide detailed information on seniors' options for remaining at home [19]. In addition, it is paper-based and so presentation of options is limited. Some European countries have developed Web-based tools for seniors that offer more flexibility [20,21]. We therefore developed a Web-based interactive decision support module for seniors, caregivers, and health professionals in 2 Canadian provinces that would incorporate videos with discipline-specific information about diverse options for staying independent at home. As the module is interactive, people can watch only the videos relevant to their needs, and watch them again or watch others if their needs change.
Study Design and Context
We used a 3-phase, multiprong, user-centered design [22] involving a needs assessment with qualitative interviews (phase I), module development (including script, videos, and textual information; phase II), and acceptability and usability testing (phase III). The study was approved by the CSSS Alphonse-Desjardins (Lévis) Ethics Committee and University of Alberta Health Research Ethics Board (Pro00055678).
Because health care in Canada is delivered under provincial and territorial rather than federal health insurance plans, we focused on 2 Canadian provinces: Quebec, a largely French-speaking province in eastern Canada with over 8 million inhabitants including 1.5 million seniors, and Alberta, an English-speaking province in western Canada with over 4 million inhabitants and almost 500,000 seniors. English and French versions of the module were developed simultaneously.
We were guided by a multidisciplinary steering committee of experts in SDM (MG, FL), primary care (FL), rehabilitation (AJ), architecture (NR), intensive care (PA), and a caregiver (LB), who met during each phase of the research and were responsible for data collection and analysis, determining the content of the module, and designing it. Video development, structure, and content were informed by the Interprofessional Shared Decision Making (IP-SDM) model [23,24], one of the few SDM models to acknowledge the contribution of multiple stakeholders, including multidisciplinary health teams and caregivers, in informing individuals' health-related decisions [25-29]. It has already proven useful in multiple contexts, including in decisions about where frail seniors will reside [18,25,26,29-31]. We added architects and urban planners, who reflected on the importance of neighborly relations and familiarity with one's surroundings in decisions about keeping seniors independent in their communities [18,26,29,32-37] (personal communication from Roy et al, 2017).
We recruited convenience samples of potential end users of the module (seniors, caregivers, and health care professionals) from Quebec and Alberta. Participants were identified using snowballing [38], based on our steering committees' social and professional networks.
Seniors were included if they were 65+ years and had struggled with how to remain independent at home. Caregivers (eg, son, daughter, or spouse) were included if they cared for a senior who had faced decisions about maintaining independence at home. Participants were excluded if they were cognitively impaired or not able or willing to sign informed consent. Professionals could be any professional with clinical experience in maintaining seniors at home, as well as built environment experts [39]. Teams caring for seniors could include caregiver representatives, home support workers, family doctors, home care nurses, nutritionists, social workers, pharmacists, physiotherapists, or occupational therapists.
Phase I: Needs Assessment
Inspired by other needs assessments [13], we conducted single, semistructured interviews to assess information needs for decision making about housing options (from lay and professional perspectives) among seniors, caregivers, and health professionals (see Textbox 1 for the interview guide). Interviews were conducted by 2 trained female research assistants with expertise in health care research. No prior relationship was established with participants other than a call or email contact to set a date for the interview. Field notes were taken. According to participants' preferences, interviews were conducted by phone or face-to-face in a place convenient for them. Interviews were conducted in French or English. Written informed consent was obtained. Participating seniors and caregivers received C$15 to cover expenses.
Interviews were audio-recorded and transcribed verbatim. They were descriptively content coded by a researcher using a deductive approach (coding emerged from the data), and then checked by the research assistants who had conducted the interviews. We listed and then produced an overview of the most important information needs (factors most mentioned) for decision making about housing options, that is, options that could best support staying independent at home, barriers or facilitators, costs, and relevant sources of information. In collaboration with team members, these information needs were organized into 6 categories: cognitive autonomy, psychological or mental well-being, functional autonomy, social autonomy, financial autonomy, and people involved. The categories emerged from the data and were congruent with literature on stated reasons for institutionalization [40-47] and on the concept of positive health [48]. Most factors (codes) were mentioned by multiple respondents (saturation). No software was used, as we planned no analysis other than listing the needs (factors considered important for maintaining independent at home) to ensure that they were all present in the module.
Phase II: Development of the Module
We linked information needs to solutions (options) and labeled them according to the IP-SDM model (focusing on identifying the decision and people involved, definition of their role, and providing information about options, including benefits, risks, and consequences) to ensure that they were addressed in the videos [49]. Video scripts were drafted and finalized by our steering committee. Participants from phase I were asked to provide feedback.
Interactive videos presented the options that best responded to the decision-making needs identified by end users. In the videos, the 15 stakeholders relate personal anecdotes, but include balanced, evidence-based information [50]. Videos can facilitate thinking and problem solving using verbal, nonverbal, and visual communication techniques [51,52] and can contribute to (shared) decision making [50]. They have proven appropriate for less literate populations [53] and people with vision or hearing disabilities. As the module is interactive, people can watch only the videos relevant to their needs, and watch them again or watch others if their needs change. Concrete (local) options as per province are further explained in a separate section of the website with links to more information sources. Users are invited to update and comment on this information using a comments tool. A webmaster approves all posts before publication and updates information.
Web-Based Decision Support
Although some evidence supports the use of the Internet by seniors [54-56], there are also concerns [57,58]. However, seniors will be increasingly computer literate as time passes [54-56], and the speed at which new options become available makes offline information provision (eg, paper brochures) inefficient. This Web-based module is accessible on computers, tablets, or mobile phones on demand (any time or place). It can easily be updated and host different media. Housing decisions need constant reevaluation as seniors' physical or mental health deteriorates [40], and Web-based decision support allows visitors to select the information relevant for their decisional stage, their personal or situational context, and their physical and mental functioning.
Phase III: Usability Testing
Participants were seniors, caregivers, and professionals who participated in phase I, and new participants recruited by snowballing and networking of team members. Participants were invited by personal email or by phone, and with an advertisement on the Arthritis Society of Canada website (Joint Health Express). The survey was also available on the interactive website itself (but not mandatory for visitors). A completed questionnaire was considered informed consent. No incentives were offered.
Participants were sent a Web-based questionnaire with instructions to view the interactive website at their own pace and convenience, and then answer 14 questions about its acceptability and usability (Textbox 2) [15].
Interview guide.
Seniors/caregivers
What is your/your loved one's year of birth?
What is your/your loved one's living situation?
Do you/your loved one currently receive home care? (If so, which?)
Which resources have you/your loved one added to your home to keep living there?
Which community resources are available to you/your loved one and which do you/your loved one use?
Can you tell me briefly what you think about your/your loved one's situation and whether you have ever thought about moving or trying to stay as long as possible at home, and how?
(For caregivers only) What is your relationship with the senior?
Can you tell me about the extent to which you are involved in the care of your loved one, and decision making about social and medical decisions?
As you/your loved one have grown older, what are the important factors to keep mobile (independent) in your/your loved one's home and your community? (ie, who/what helps you stay mobile/independent?)
What do you think are the most important issues associated with staying independent at home (issues that should be addressed in our videos)?
Do you know anything about your options, and the cost of each, in terms of staying at home or moving? Where did you/your loved one get information about these things?
Did anybody ever bring up the question whether or not to stay at home or move with you/your loved one?
What is your profession?
Home or acute care?
What is the percentage of older people in your clientele?
How many years have you worked in this profession?
Can you give me a short example of what the job is about (something you would tell a senior when they come to see you and do not know what you do)?
From your (professional) point of view, what factors or issues are important when considering mobility/independence in the home or community for older adults?
What options are most often available for seniors for remaining mobile and independent at home, from your (professional) point of view?
What do you think are the most important issues (issues that should be addressed in our videos)?
Can you give an estimate of costs of the options that you mentioned?
How do people get reimbursed for this?
Textbox 1. Interview guide.
Usability test.
Please rate each section of the module by circling one of the following to show what you think about the clarity of the information: 4—Everything clear, 3—Most things clear, 2—Some things unclear, and 1—Many things unclear.
The length of each separate video was: Too short/Just right/Too long.
The total time needed to watch all the videos was: Too short/Just right/Too long.
The amount of information was: Too little /Just right /Too much.
I found the presentation: Slanted toward staying at home/Balanced/Slanted toward moving elsewhere.
Do you think the module would be helpful for people making this decision? Yes/No
Do you think the module would be acceptable to use with people making this decision? Yes/No
Did the full module (including the videos) meet your expectations?
Would you like to use (or keep using) the module?
What did you like about the module?
What did you dislike about the module? (concerns)
At what point would it be useful for seniors to see this module? When they are still able to function at home without help/When they are beginning to lose autonomy /When they can no longer function on their own at home/Other, please specify.
Textbox 2. Usability test.
All questions were posted on the same page, and answers could be reviewed and changed until submission of the questionnaire. One reminder was sent after 4 weeks.
We performed a descriptive analysis of the data, and calculated mean, median, and range when relevant. Summary statistics were performed using Microsoft Excel.
Between March 20 and September 28, 2015, we interviewed 29 stakeholders: 15 in Alberta and 14 in Quebec. Participants included 4 seniors, 3 caregivers, and 22 health care and other professionals (see Table 1). None of those contacted refused to participate. One interview was conducted simultaneously with both members of a senior couple. The mean interview time was 31.45 min (range 11.42-69.47).
Important Factors Influencing Decision Making About Staying Independent at Home
Cognitive Autonomy
Respondents mentioned the need for seniors to think about future housing options before there is cognitive decline or an emergency (eg, a fall). Seniors also should be encouraged to consider their changing needs over time to avoid having to frequently reevaluate them. This way, when the time comes to relocate, they may avoid long waiting lists for assisted living facilities and adjust more easily to the new environment. At the same time, seniors may be well aware of risks, and what to do about them should be in their hands.
Psychological or Mental Well-Being
Depression among seniors was frequently mentioned. It may be associated with isolation, as well as with the general effects of aging and loss of autonomy. Depression medication is associated with reduced mobility and risk of falls, whereas social or exercise programs (eg, walking or gardening) may improve both mental and physical health. It was mentioned that all who are involved in decision making should encourage seniors to participate in activities that they enjoy. Participants also mentioned the importance of seniors being happy and feeling safe where they are, but that they must accept that their needs are changing before they decide to make adjustments (eg, use a walker). Having a positive attitude toward the options for staying at home and being involved in the decisions about them were considered important decisional needs. Attitudes often change once people have tried the equipment and seen the benefits for themselves.
Functional or Physical Autonomy
Functional autonomy encompasses physical ability (muscle mass, strength, and balance), the environment, and prevention and support. If seniors are less able to perform certain tasks or activities, instead of doing the task for them, it is important to teach them a new way to perform the task themselves. Autonomy also depends on their home environment. Environmental barriers indoors (furniture, carpets, clutter, and distance to the toilet in case of incontinence) and outdoors (curbs and stairs) should be assessed in terms of safety. In suggesting equipment such as walkers or grab bars, it is important to discuss with seniors what is important for them and what limits them from being active. Specialized architects and occupational therapists can suggest how to redesign the living environment, such as moving the bedroom and toilet downstairs. Urban planners, who are more concerned with the external environment, pay attention to curbs and other walkability features of cities and public spaces. However, it should be recognized that whatever adaptations one makes to the home and environment, choosing to stay independent at home may one day no longer be realistic, safe, or affordable.
Table 1. Sociodemographic characteristics of participants in phase I (N=29).
Characteristics Quebec Alberta Total
Seniors 2 2 4
Age, range 87-88 82-84 82-88
Sex (female), n (%) 1 (50) 1 (50) 2 (50)
Marital status, n
Married 2 1 2
Widowed - 1 1
Living situation, n
House or suburban or urban area 2 1 2
Apartment style condo or urban - 1 1
Caregivers 1 2 3
Mean age, range 67 (N/A)a 69 (56-82) 68.3 (56-82)
Sex (female), n (%) 1 (100) 2 (100) 3 (100)
Relation with senior, n
Spouse - 1 1
Child 1 1 2
House with senior or urban 1 1 2
Bungalow with senior or urban - 1 1
(Health) professionals 11 11 22
Type of professional, n
Dietitian 1 1 2
Physiotherapist 2 2 4
Occupational therapist 2 1 3
Social worker 1 1 2
Family physician 1 - 1
Transition nurse in geriatrics 1 - 1
Geriatrician 1 1 2
Architect 1 1 2
Human resources consultant (community activities) 1 - 1
Pharmacist - 1 1
Recreational therapist - 1 1
Nurse or case manager in homecare - 1 1
Coordinator at community organization that helps the elderly - 1 1
Sex (female), n (%) 10 (91) 10 (91) 20 (91)
Years of experience, range 15.2 (5-33) 16 (5-31) 15.6 (5-33)
Percentage of elderly clients, range 82.3 (40-100) 77 (30-100) 79.5 (30-100)
aN/A: not applicable.
It is also important to assess people's mode of transportation to access services in the community. People who drive their own cars are often more active, but at some point, this may no longer be safe. Many special seniors' transport options exist such as buses for people with disabilities, taxis, as well as special seniors' services that offer drivers to accompany seniors to their medical appointments.
Social Autonomy
When people age, their contemporaries start to die, leaving some people feeling isolated. Being socially active was mentioned several times. Although not everyone minds being alone, many benefit from having company and participating in activities with others. Social participation and having a social network are safer (somebody to call for help) and can be an information source about options. Many seniors are reluctant to ask for help, which means admitting to themselves and others that they are no longer autonomous. This reluctance can also make caring for them more difficult.
Financial Autonomy
To receive the help they need at home, seniors in many jurisdictions have to be willing and able to pay for services. Although some services are provided or reimbursed through government programs or tax credits, other services require direct payment from the senior. To be reimbursed, the senior must have the mental agility and patience to fill out difficult forms or have somebody to help him or her. With the Internet, it is increasingly possible to order and pay for things online and have them delivered (groceries, medication, or clothes) to the home, but many seniors are not able to do this, whether from lack of a computer, knowledge, or confidence.
Seniors, caregivers, and health professionals need to understand each other's limits and communicate about their difficulties. As informal caregivers are often key to keeping seniors independent at home, they should be kept informed of everything regarding the senior's health care needs and options that help them stay at home. Without a single care coordinator, it is often the informal caregiver who manages the patient's file. Their needs should be taken into account too, as the burden can become too much for them and threaten their own health. Caregivers can be informed of caregiver associations and helped to gain access to services such as respite care.
Table 2 provides the quotes from participants, and Table 3 provides an overview of the factors.
On the basis of the factors identified in phase I, we developed scripts for 15 stakeholders in decisions about seniors' housing options: a decision coach, a senior, 3 types of caregivers (son, daughter, or spouse), a caregiver representative, a home support worker, a family doctor, a home care nurse, a nutritionist, a social worker, a pharmacist, a physiotherapist, an architect, and an occupational therapist. The decision coach explained how a decision should be made and introduced the rest of the videos, and the architect added information about community, the built environment, and home adaptation. We kept the scripts as general as possible so that the information would not quickly become outdated and that it could be used in several contexts. Information that frequently changes, such as costs and resources, was presented on the resource page.
In total, 4 stakeholders commented on the script (caregiver, pharmacist, architect, and physiotherapist). Overall, they were positive about it. On the basis of their expert opinion, we made some editorial changes to the script and the list of resources, and a senior (female, 85 years old, living independently at home with her daughter) evaluated the final scripts. She was positive about them and the initiative as a whole, and she thought the information was complete and relevant.
The Final Module
The final product is an interactive website with video links and additional text-based resources for seniors, caregivers, and professionals, called SupPortIng seNiors And Caregivers to stay mobile at Home (SPINACH). It consists of 3 Web pages as discussed below.
Visitors select English or French, and then choose whether to see the videos, consult the resources, or comment on or add to the resource page.
A team of 15 members sitting around a table shows visitors the range of stakeholders involved in making decisions with seniors who wish to stay independent at home (Multimedia Appendix 1). A mouse scroll-over function presents a short description of what each team member will discuss in his or her 1- to 3.5-min video. After selecting a team member, a popup appears with the videos (Multimedia Appendix 2). The selected stakeholder talks about his or her decision-making experiences with staying at home or moving, provides information on decisions related to staying at home, and/or gives specific information on options or guidance in the decision-making process.
The resource page provides with background information on options for staying independent at home (eg, local resources, equipment, and links to informative websites). Visitors can add comments or additional information about local services. A webmaster evaluates them and controls publication.
Table 2. Quotes illustrating the main categories from phase I.
Theme Quotes
Cognitive autonomy And if people want to live with a degree of risk, that\'s fine from my stand point. As long as they understand that [the risk and consequences]. I mean we can\'t wrap people up, you know in lots and lots of bubble wrap to totally protect them. [A13, Geriatrician]
Yes and it's, as I say, if you make the choice yourself it makes it easier for everybody. When you get to that point in life where you have to, and you don't have a choice and you have to go where you are sent, I think a lot of people have trouble adjusting. [A7 and A8, Seniors]
Psychological or mental well being
So what factors do you think are important to consider when trying to keep them mobile, I guess, in the community? [Interviewer]
Finding things they like to do. Like if they love animals, like walking the dog. If they like, you know, the river valley, take them to the river valley. Finding things to engage them so that they want to do it, not so they have to do it… [Participant]
You know, for us we say as long as it\'s something active, it can be anything. You know, we can go for a walk and they love doing crossword puzzles, maybe we stop at a park, do some crossword puzzles. [A14, Coordinator in a home care company]
[…] when you go to a walker, you are giving up your dignity. […] You are no longer totally independent. Here I am, I am handicapped now, I cannot just stride off into the sunset. I need help. It's hard for people to understand the lack of enthusiasm for suddenly having to start using a cane and a walker. [A5, Senior]
Many seniors don\'t want to look like seniors. They don\'t want to look old. You know, even though it might improve their ability to be mobile. [A13, Geriatrician]
I would say the bigger challenge is when someone is adamant that they will lose independence because of the walking aid and once they've tried it you can often convince people that actually when they use the walker, you can actually walk further because you can sit down when you are tired, you do not have to look for a bench to sit on. […] but it can be difficult to persuade people that they need to give it a try because a lot of people just cannot get past the stigma of seeing themselves as someone who is using a walker. [A2, Physiotherapist]
Physical functioning … if you don't use it you lose it! I get so tired of that phrase, but it's so true. And there is the social aspect [of exercise programs] as well, which is maybe almost as important as the mobility factor. [A5, Senior]
Environment You want to age in your current location, you are attached to it, have memories but you have difficulties in moving around, using stairs, or you are anxious […]. My role is to see how we can modify this environment, do renovations, to make sure that you can be autonomous, that you feel safe and good in your home. It is possible that if there is nothing that can be done at the regulatory level, in terms of financial resources or support in your environment (family, neighbours) then the best option may be to move. But we know how hard it is to leave your house so we are here to help you. [R5, Architect specialized in housing for the elderly]
Transport Can she (the senior) go out, take the bus, walking, what are the distances to walk in the suburbs to do the grocery shopping and bring back bags with groceries? Is there adapted transportation? And the time you have to wait before it comes to your house? Is there a taxi? Maybe it is less expensive to take a taxi than to move to a residence with services. [R5, Architect specialized in housing for the elderly]
Social autonomy Like let's start doing this, you know, while you're healthy, while you\'re well, because then, you know once they've got that social network then that just opens up so many more doors. [A11, Occupational therapist in home care]
It's through social contacts really that you know about things. It's important that you know people, and they tell you about these things. [A5, Senior]
A lot of it, you know like so many seniors, they say oh my kids are so busy, they can\'t do this, and they've got a very important job and all of that kind of stuff. But we need to actually kinda break it down, you know, the family members are the ones that...they certainly would do something if they knew what to do. Or if they knew that things would be a little better for their loved ones. [A11, Occupational therapist in home care]
People involved Some families are great and some are not but you need to be able to see that your supports are there and that they are functioning and healthy and that it is not taking its toll on one single person. But it often does. [A6, Social worker]
Table 3. Overview of the categories and factors mentioned in the interviews (phase I).
Category, factor (code), and examples (subcodes) Solutions Barriers to implementation
Good judgment regarding risks
Estimate risks, being self-critical Avoid risks Attachment to belongings
Good judgment and decision making
Incompetent Power of attorney, personal directive Needs to be put in place before cognitive decline
Competent: making decisions yourself makes adapting easier Incorporate everyone's values and preferences
Remember to eat, take meds, and turn off oven Caregiver, calendar, box for pills, and microwave instead of oven Isolation, confusion
Thinking ahead People do not know what their needs will be in 5-10 years
Happy at home Stay at home Functional incapacity, isolation
Feeling safe, fears
Stays in because is afraid to walk outside Motivation, support people Attitude—not willing to use aids or ask for help
Due to isolation, general effects of aging, loss of autonomy Medication, exercise programs, and caregiver Medication can affect mobility; lack of awareness about benefits of participation for mental and physical health
Functional autonomy
Managing the basic needs
Medication Community and social care services, check with pharmacist Medication interactions with comorbidity
Hygiene Grab bars in bathroom, care services offered by public health care system Adaptability of homes, attitude of seniors
Food preparation and access (quantity and quality) Meal services, vitamin D supplements and calcium Attitude—willingness or ability to cook
Cost of meal services or ready cooked meals
Good muscle mass, cardiorespiratory Exercise program, services at home Lack of motivation, accessible programs, awareness, education, or confidence; fear of falling; focus on disability, pain versus on ability
Getting around (internal and external)
Design of the environment Remove architectural barriers (internal: furniture, carpets; external: sidewalks, stairs) Attitude: do not want change, want to design own house
Costs of home renovations
Transport Bus or taxi for seniors or caregiver transport Access to information, costs
Mobility Walkers, canes Attitude: "those are for old people," giving up dignity and independence
Pay attention to environment Height of curb, height and number of stairs, and rugs Awareness of need to change habits (people already use the walls and counters for balance or support), muscles that have not been used for a long time, current habits not safe
Of falls, eating problems Programs, equipment, awareness; learning new things that they can still do themselves instead of taking it out of their hands
No isolation, well-being
Hobbies, activities Day centers, friends People have habits and do not like to change. Try to find intrinsic motivation, but decision is up to them
Have people around you
Friends, family, neighbors Social worker or caregiver Not everybody wants to meet other people and do things together
Ask for help (formal and informal)
Emergency system, lifeline Bracelet, call someone Attitude: children are too busy
Ability to pay and manage finances
Pension, reimbursement, subsidies Financial support, tax benefits, and health insurance Income: not enough to pay for services
Attitude: unwillingness to pay, inability to complete forms for reimbursement, mental capacity, online payments versus cash
People involved in caring for senior
Good collaboration
Caregiver and health care professionals understand each other's limits, communicate
Do not get on with social worker
Caregiver needs
Decrease the burden Respite care
Access to care when caregiver is not around Access to information, capacity to advocate, family member differences regarding how they view the senior
Phase III: Acceptability of the Module
A total of 21 people completed the acceptability survey: 8 seniors, 7 caregivers, and 6 professionals. Respondents were mostly female (15/21). Mean age of seniors was 76 years (range 66-91), whereas the mean age of caregivers was 69 years (range 36-70; Table 4). Most seniors and caregivers had higher education (college or university; 12/15). Caregivers were mostly adult children of a senior parent. Seniors had either no caregivers (n=3), an adult child (n=2), a partner (n=2), or other (n=1). Professionals were a nurse, an urbanist, an architect, a social worker, and a community care worker. In addition, 3 other professionals gave feedback by email to the researcher.
Comprehensibility
With a mean overall rating of 3.6 out of 4, participants thought the videos were very clear (Table 4), although one senior suggested that content should better reflect differences across Canada.
Length and Amount of Information
Most participants were positive about the length of each video (17/21; 81%) and the amount of information (17/21; 81%), but fewer people liked the length of the videos altogether (13/21; 62%). Some thought the module was too long (n=7) or had too much information (n=2), whereas others wanted more information (n=2). Others indicated that the module could be better tailored to specific characteristics of the senior (n=4).
Table 4. Acceptability test results for seniors, caregivers, and professionals (N=21).
Acceptability test question Seniors (n=8) Caregivers (n=7) Professionals (n=6) Total group (N=21)
Comprehensibility of videos (mean rating out of 4)a,b
Video: decision coach 3.7 3.8 3.5 3.7
Video: senior 1 3.9 4 3.7 3.8
Video: caregiver 1 3.4 3.8 3.7 3.6
Video: caregiver representative 3.3 3.7 3.7 3.5
Video: home support worker 3.6 3.8 3.7 3.7
Video: family physician 4 3.8 3.3 3.7
Video: nurse in homecare 3.7 3.8 3.3 3.6
Video: dietitian 3.8 4 3.7 3.8
Video: social worker 3.8 3.7 3.2 3.5
Video: pharmacist 3.7 4 3.7 3.7
Video: physiotherapist 3.9 4 3.7 3.8
Video: architect 3.6 4 2.8 3.4
Video: occupational therapist 3.6 4 3.2 3.6
Length of single videos, n (%)
Too short - - 1 (17) 1 (5)
Just right 7 (78) 5 (83) 5 (83) 17 (81)
Too long 2 (22) 1b (17) - 3 (14)
Time needed to watch all videos, n (%)
Too long 5 (56) 12 (17) 1(17) 7 (33)
Amount of information, n (%)
Not enough 1 (11) - 1(17) 2 (9)
Too much 1 (11) 1b (17) - 2 (9)
Presentation was balanced, yes 6 (67) 5 (83) 6 (100) 17 (81)
Helpful? yes 6 (67) 5 (83) 5 (83) 16 (77)
Acceptable to use for people in this situation? yes 8 (89) 5 (83) 5 (83) 18 (86)
Did module meet your expectations? yes 6 (67) 5 (83) 5 (83) 16 (77)
Would you like to use/keep using the module? yes 3 (34) 3 (50) 6 (100) 12 (58)
At what point would it be useful for seniors to see this module?, n (%)
When they start losing their autonomy 3 (34) 2 (33) 3 (50) 8 (38)
When they are still able to function at home without help 6 (66) 4 (67) 3 (50) 13 (62)
a4—Everything clear; 3—most things clear; 2—some things unclear; 1—many things unclear.
bOne caregiver did not watch any videos, and rated all as Not applicable.
Most respondents thought the module was helpful (16/21; 77%). In total, 4 people did not agree because of navigation difficulties (1 senior), inadequate detail, 1 professional), lack of specificity or tailoring (1 senior), or design (1 caregiver). Of the participants, 1 senior was not prepared to accept her need to make any adaptations, so the information was of no interest to her.
Acceptability
Most respondents thought the module was acceptable (18/21; 86%), but 3 people did not because of a lack of information (1 professional), too idealistic presentation of options (1 caregiver), and navigation difficulties (1 caregiver). All professionals were eager to start using the module with their clients when finalized (6/6; 100%), as were most caregivers (3/7; 43%). Seniors were less willing to continue using the module (5/8; 66%) because of navigation difficulties or because it needed changes (n=2), or their preference for information face-to-face or in a brochure (n=2). A senior said she would return to the module when it becomes more relevant to her situation.
What People Liked About the Module
Participants liked the interprofessional character of the module, the diversity of information, the concrete and practical examples, and the information about available services. They also liked the positive tone (focus on what can be done instead of what cannot).
Concerns About the Module
The concern most often mentioned by seniors was its overall length. A senior and a caregiver mentioned that it did not portray the reality (eg, long wait times or services that are not available). A caregiver was negative about the whole module, saying he did not like watching videos. Some professionals wanted more details on the role of health professionals (eg, health evaluations by nurses). Others mentioned the challenge of using the module with people with dementia.
Principal Findings
Using a 3-phase, user-centered design, we developed and tested the acceptability of an interactive Web-based module for seniors, their caregivers, and health professionals with videos presenting information about options for staying independent at home. A needs assessment (phase I) uncovered numerous decisional needs, including the need to start thinking about this decision early on, safety issues inside and outside the home, and the importance of social supports and psychological or mental well-being. In the production phase (phase II), we developed scripts that addressed these decisional needs, which were positively evaluated by end users and used to create 15 bilingual videos. These were integrated into an interactive Web-based module. In usability testing (phase III), this was found to be clear, comprehensible, and providing enough information, but users found that it took too long to watch all of the videos and that seniors might need assistance navigating the module. In total, 3 concluding reflections were derived from these findings.
First, research has shown that good levels of knowledge about services and support, as well as good housing, are associated with the likelihood of continuing to live in the community [59]. In accordance with our needs assessment, the content of the module focused primarily on the first steps in SDM models: identifying the decision and people involved and providing information about options, including benefits, risks, and consequences [13,27]. Decisions made in the absence of knowledge about available options are less likely to be accepted (phase I) and may result in feelings of uncertainty and conflict in the caregiver or conflict between the caregiver and the senior [9]. For a full SDM process, an interactive (face-to-face) discussion with all those involved in decision making is required to weigh all relevant information in light of personal and professional opinions and reach agreement about the best option [31,60]. As the Internet has been found to be one of the most commonly used and trusted information sources for health information among the elderly [56], this Web-based module can prepare people for this discussion. As decisional needs and Internet use vary with personal and sociodemographic characteristics [15,61], our videos present a variety of senior and caregiver profiles, and the viewer can select which ones to watch. However, acceptability test results led us to conclude that much shorter videos tailored to different characteristics could provide people with information even more closely matched to their needs, increase understanding, and decrease viewing time [20]. Future plans with this module are to tailor the information and videos to characteristics and situations, such as early symptoms of dementia, physical problems, and presence and type of caregiver. In line with concerns of participants who were uncertain about whether (other) seniors would be able to go through the module alone [58,62], we suggest that seniors go through the module with a caregiver. This would also facilitate personal dialogue between the senior and the caregiver and improve the process of SDM.
Second, staying active and being socially engaged were mentioned to be linked with staying healthy in both the needs assessment and the acceptability test. The concept of positive health refers to the capacity to live autonomously with physical, emotional, and social challenges [48]. This relates to the principles of self-management and use it or lose it mentioned by our participants (phase I), reflected in the videos (phase II), and positively evaluated in the acceptability test (phase III) [63]. This module helps seniors to self-manage and stay independent by helping them think about what they can and cannot do by themselves. Although seniors in our study showed less concern for social support, many professionals in our study mentioned its importance for well-being and autonomy, and other research supports this [64]. Social support may be a crucial and overlooked element of the inside and outside built environment and of community care options for seniors. The Internet may be another way to access social support [55].
Third, the module emphasizes the importance of involving seniors and caregivers and professionals in decision making, implying that they all need to know and understand the best available evidence regarding the risks and benefits of all options for staying independent at home [17,60,65]. This interdisciplinary aspect of our module, which was specifically appreciated by participants and is considered key in IP-SDM [16-18], was possible because of the interdisciplinary and user-centered design used throughout the development of the module. Although future research should assess what types of end users should be involved in updating the module and to what extent, we will continue to involve end users in updating the module by inviting them to add regional information or propose adaptations using the comment function. This function will facilitate ongoing and sustainable patient and professional engagement in our process [66,67]. The Web-based and end user–adaptable nature of the module will also facilitate implementing and scaling up the intervention [68].
Although people were initially enthusiastic about participating in several developmental rounds, the decreasing response per round indicated that more was needed to successfully create ownership and that participants were losing interest because of the lengthy process.
Data collection and identification of local resources took place in Quebec and Alberta only. Thus, although the videos are bilingual, generic, and in principle applicable to any context, local options are currently available only for Quebec and Alberta. Future studies could adapt the module to other Canadian contexts. Finally, the modest number of participants in this project was adequate for a user-centered development process, but future phases of this project should use different study designs (eg, pre-post or randomized trial designs) and larger samples of participants to achieve generalizable results, for example, with regard to the effectiveness of the module or its implementation.
We adopted a user-centered design to develop a Web-based decision support module for seniors, caregivers, and health professionals that incorporates discipline-specific information about options for staying independent at home. The module was deemed acceptable and potentially helpful.
Seniors are often anxious and fearful when the first signs of loss of autonomy appear, and confused about what they can do about it. These are first steps toward providing them with the information they and their caregivers need to make decisions about how to stay independent at home. We plan to adapt the module to better target the most important user (the senior), and to continue its development and evaluation, as well as develop implementation strategies. In the meantime, the module is available on the Web as the information on the module is already of use for many seniors.
The authors would like to thank all participants for their input in developing this module. The authors are also grateful to Cheryl Koehn, president of Arthritis Consumer Experts, for promoting the acceptability test among the members.
Multimedia Appendix 1
Screenshot of stakeholders whose videos can be chosen using mouse scroll-over.
PNG File, 166KB
Screenshot of a stakeholder (architect).
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IP-SDM: Interprofessional Shared Decision Making
SDM: shared decision making
Edited by G Eysenbach; submitted 10.07.17; peer-reviewed by T Kool, E Melnick; comments to author 25.08.17; revised version received 18.10.17; accepted 29.10.17; published 14.12.17
©Mirjam Marjolein Garvelink, C Allyson Jones, Patrick M Archambault, Noémie Roy, Louisa Blair, France Légaré. Originally published in JMIR Human Factors (http://humanfactors.jmir.org), 14.12.2017.
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 Human Factors, is properly cited. The complete bibliographic information, a link to the original publication on http://humanfactors.jmir.org, as well as this copyright and license information must be included.
Garvelink MM, Jones CA, Archambault PM, Roy N, Blair L, Légaré F
doi: 10.2196/humanfactors.8387 PMID: 29242178 PMCID: 5746619
JMIR Human Factors ISSN 2292-9495


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I have commanded my holy ones; I have summoned my warriors to carry out my wrath--those who rejoice in my triumph.
They come from faraway lands, from the ends of the heavens--the LORD and the weapons of his wrath--to destroy the whole country.
See, the day of the LORD is coming--a cruel day, with wrath and fierce anger--to make the land desolate and destroy the sinners within it.


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My Egyptian Discovery On My Chosen Retreat My Egyptian Discovery On My Chosen Retreat To be lying wide awake at twenty to three At present is not unusual to me To be lying awake with a bum going numb I can say is not an unusual one Numb from leaning, back to the wall But this time a change, ...
SFI July 2013
The Positives are coming to the USA! In August and September 2013, in Dallas and Baltimore respectivley, Silvia will be holding an array of Trainings, including Positive EFT, Positive EMO, the Energy EFT Master Practitioner, and the brand new Trainer Training.
This special SFI has full details...
Just bought the plane tickets for my forthcoming trip to the US.
In the spring, I travelled around the United Kingdom and Ireland, met lots of energists and many civilians and learned a lot.
The result of this was Positive EFT, amongst many other things.
My fact finding mission was primarily about how to get modern energy techniques into the mainstream.
By mainstream, I mean how to make it so that every hospital offers it, every local health centre, and that what we have learned is available to use for real people - the guy who works the checkout at the gas station, the old gentleman on the park bench with his dog, the busy CEO of a company or a stressed manager, the window cleaner, the soldier, the housewife.
Talking with people who are not therapists, it becomes very apparent that normal people are not interested in therapy, and "personal development" is the last thing on their minds, as they are busy and stressed with work and family. Trying to make a living, trying to make their way in the world.
Normal people are, however, very interested in making their lives easier and having a better time of it.
They do not want to think about their worst moments, work on their childhood trauma (!!!) or start to psycho-analyse themselves.
We - who have been doing this stuff for decades in some cases - are so used to looking for roots and negatives and digging for trauma, it has become second nature.
By spending a lot more time with civilians, I began to see the problems we've always had with "spreading the word" about EFT. It asks people to turn their minds towards their problems, when it is natural and normal to want to turn AWAY from problems.
Indeed, it can be argued that for normal people that's the right thing to do.
To try and find SOLUTIONS to their problems NOW so there will be a better future NEXT, rather than digging up the past.
The thing is that EFT can offer that. There are two wings on the SUE scale, and it's the positive wing with the high energy states where the magic starts to happen.
So how about offering people the power of the positives instead of asking them to start thinking about their problems and formulating problem statements?
And really - OMG.
Going with what normal people naturally want makes the introduction of EFT so much easier.
It starts the relationship with EFT on a GOOD experience.
It makes people keen and interested to learn more, to feel even better.
And to me, that's the key to mainstreaming EFT.
When someone has experienced how EFT can make them feel better with the positives first, they are inordinately more likely to try EFT for other things as well.
Some might never want to do that at all, and that's OK as well.
Getting powerful positive energy experiences through EFT is not be sniffed at, and definitely not second best to becoming your own psychoanalyst.
So that's exciting news and a real breakthrough for all who are like us out there, trying to get more people to try EFT.
Positive EFT makes it consumately easy to invite people to just have a go - and feel good.
But then there's also that other side.
What about all the trauma and therapy?
Well, using Positive EFT in therapy is a wonderful thing.
It is used in Energy EFT to start sessions, to de-stress clients, at any time when the client needs a boost, and of course, the last half of the session when we are after the healing event is all Positive EFT as well.
But it is a fact that all the therapy people don't know how to work with postiives, simply because they've never really done it.
It's not taught in universities, it's not taught in counselling courses, and people have little experience of working with the positives correctly.
Think about how many books there are on trauma clearance, and how many books there are out there on how to make a person feel better than good?
We're not done when a person is at zero, at rest.
That's barely the beginning.
Modern energy work allows us to do so much more for people, and most of all, create those high energy healing events which are what change lives.
Nothing else can.
So this is important to me and I look forward to the two Positive EFT days in particular. Trust me, tapping all day on positives is going to get you feeling things you've NEVER felt before. And learning things about yourself, other people and the world which will blow your mind.
I'm doing a Positive EFT training in Dallas and Washington DC, one day only, so if you're ready to get a taste of the high life, come and join us there.
In Dallas, I am also going to do a special Positives With EMO day. Patricia Dancing Elk, my dear sister in spirit, is in Dallas and she has been sharing the delight that is EMO for some years now. This is something for people who can really feel energy and love it; I am very excited about that because ... well, it's EMO :-)
We're going to be touring by car from Dallas to Washington DC for three weeks, meeting local people along the way and the tour ends with a full sweep of Positive EFT as the introduction, the Energy EFT Master Practitioner (three days) and the new AMT Trainer's Training, for those who want to teach this new stuff in the US of A.
It's going to be amazing :-) and I can't wait to get on the plane on August 21st. I'll be celebrating my 54th birthday in Dallas on the 23rd, and Positive EFT is on the 24th, so ... sounds good to me :-)
For our European friends, I'll be doing a Positive EFT in November at the AMT conference so you can pick it up there, and if you're an AMT Trainer, add it to your arsenal so you can teach it too.
Now back to work on the Positive EFT book, which is going to be our official first introduction to modern energy work from now on.
Working with positive energies is just a joy, and bringing joy and happiness to other people (who may have had too much misery and trauma in their lives by far!) is a wonderful and very precious thing to be doing.
The world needs more positive energy, that's for sure.
Indeed, one might say that positive energy is the absolute ANTIDOTE to energy stress and emotional suffering.
Love rules the universe. Not trauma.
And on that happy note - have a fantastic summer too!
Silvia :-)
PS: I have an EMO/Project Sanctuary based Positives generator on www.SilviaHartmann.com/star/
You can use it to find a Positive to tap EFT on, too.
PPS: Someone mailed me and asked if they could do two, instead of just one, positive, if that would be OK! Yes! Do as many as you want! Energy is free. JOY, BEAUTY, YOUTH, VITALITY, ENERGY, STRENGTH, DOMINION - all there for you and so much more. Tap a round and just find out how it makes you feel when you do! Positives rock!
Silvia Hartmann
www.SilviaHartmann.com
UK Healing Retreat Venue Sedgwick West Sussex We are blessed to be have the magnificant private stately home near Horsham in West Sussex for our UK detox and healing retreat dates in the UK. With all guest rooms finished with the utmost love and attention to detail and gardens whose beauty quite ...

redpajama_set_name: RedPajamaCommonCrawl


Made with fresh milk butter, beer, almonds, and covered with a dense cloud of fluffy powdered sugar… and do not forget the clove pins, that make the difference.
If you have a "traumatic" experience making Kourabiedes, maybe so hard that can break teeth or with a flat taste, try this recipe and will change your opinion about the "real" kourabiedes.
Kourabiedes began their sweet life in Persia in the seventh century, shortly after the use of sugar became relatively common in the region.
They are made with small variations, all around the Middle East, the Philippines, Spain, Mexico and the United States.
In some areas of Greece the Christmas Kourabiedes are decorated with a whole clove pin embedded in each piece.
Put the butter, melted but not hot, with a tablespoon of powdered sugar in the mixer bowl on the lowest speed, and let it beat the mix for 1 hour.
In the meantime bake the almonds in the oven grill for 5 minutes, and if you prefer, cut them in two or crush them into smaller pieces.
In an hour the butter will thicken and will become as white as cream.
…and beer. Continue with the mixer for ∼2'.
…alternating with the almonds until the flour is all over and you have a soft, pliable dough that will not stick to your hands.
We prefer the almonds whole but you can break them if you like.
In large, shallow baking pan, spread some baking paper.
Knead with your hands thick, oblong sticks and bend them slightly to get the shape of the crescent.
Put them to the pan and stick one or two clove pins.
Bake in preheated oven at 200°C/ 400°F/ Gas 6, with resistance above and below, at the second lowest rack for ~30'.
When they have browned lightly and cooked at the bottom too, remove from the oven and add a drop of rosewater, optional.
* Put the second pan in the oven.
As they are still hot, add them 2-3 together in powdered sugar.
Carefully turn them on all sides, to sprinkle well, and get lots of sugar.
Then put them on a large platter, with enough sugar in their midst.
Repeat the same with the next tray.
Sift additional powdered sugar on the platter, and let them cool.
You have now 50 thick, hearty, full of almond kourabiedes.


Order brought back to Credit Hold again after running Freight Update R4981 . Freight Update puts sales order on hold even if respective sales order entry processing option Credit hold flag is BLANK. Order Hold code has been set C1 in Customer Master F03012. If the freight update sales order version does not check credit hold, shouldn't the End Doc (in Freight Update Program R4981) ignore the the hold code in customer Master validation?


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HealthTech Forum
Innovate Israel 2019
Start-up Company Finder
Trading with Israel
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TechCrunch: Gett raises $80m led by VW
Gett raises $80M led by VW at a $1.4B valuation, says it will be profitable by Q1 of next year
While Uber is growing its business with a net loss on its balance sheet, a smaller rival has confirmed a round of funding, and projects that it will be profitable by Q1 of next year. Gett, the transportation-on-demand startup that competes with the likes of Uber but also traditional taxi cabs, has raised $80 million led by existing investor VW with participation from other previous investors.
Post-funding, Gett is now valued at around $1.4 billion, CEO and founder Dave Waiser told TechCrunch in an interview. This is the first time the company has officially disclosed its value.
It may give Gett a claim to being a "unicorn," but it is still a pale number when you compare Gett to Uber, which is doing a secondary round right now at a $62 billion valuation. but Gett is playing with another strong card in its hand: Waiser said the funding will be enough to get Gett — which operates in 120 cities globally — to profitability in all of its markets by Q1 of next year, and possibly earlier.
The news comes on the heels of a report that Gett is looking to raise $350 million — a figure that Waiser dismissed, but did not deny outright when I asked about Gett's plans beyond profitability and this current investment:
"For now, we're laser focused on this important [profitability] milestone, and the funds we've raised to execute on that strategy," he said, "but when you consider competitive markets like New York and London, we will start thinking about what our next milestone should be, after we make money." The company has now raised just under $700 million with other investors including Russia's Sberbank, Access Industries, Kreos Capital and others.
Read more here: https://techcrunch.com/2018/06/07/gett-go/
Britain and Israel building new strategic partnership
The UK-Israel trade corridor
UK Israel Business member Tevva supplies UPS with zero-emission trucks
Globes: ITV Studios buys Israel's Armoza Formats
Outlook for M&A in Israel
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Don't Look Now But Red Meat And Chicken Are Hard To Find
Filed Under:chicken, coronavirus, Meat-Processing Plants, President Donald Trump, Red Meat, shortage
Where's the beef? Production shutdown leads to shortages
The effects of the coronavirus pandemic have moved beyond meat processing plants and are now hitting dinner plates.
Several U.S. production plants have been temporarily shuttered in the last two weeks after hundreds of workers were sickened by the virus. That has led to meat shortages, with Wendy's pulling some burgers off its menus and Costco limiting pork sales. Fake meat companies, meanwhile, are making their moves to capture some of those lost sales.
This photograph taken on April 7, 2020, shows a worker with slaughtered sheep carcasses in a meat processing and trading company in Thessaloniki. – Normally at this time of year, millions of people around the world are planning elaborate lamb-based menus — spits, roasts, kebabs or stews — for a celebratory Easter Sunday family lunch. But this year, there will be fewer tables groaning with holiday food as the coronavirus outbreak has put paid to religious and family gatherings. (Photo by Sakis MITROLIDIS / AFP) (Photo by SAKIS MITROLIDIS/AFP via Getty Images)
Beyond Meat, which makes burgers and sausage from pea protein, said Tuesday it's launching new value packs to entice consumers while rival Impossible Foods is expanding sales to more than 1,700 Kroger groceries.
As of Monday, U.S. beef and pork processing capacity was down 40% from last year, according to Jayson Lusk, head of the department of agricultural economics at Purdue University.
Some meatpacking plants are coming back online after President Donald Trump issued an executive order last week requiring them to stay open. But until they're back at full capacity, consumers will likely see some shortages and higher prices for beef and pork, Lusk said. Poultry production has also been impacted, but to a lesser degree.
On Tuesday, the attorneys general for 11 Midwestern states urged the Justice Department to pursue a federal investigation into market concentration and potential price fixing by meatpackers in the cattle industry, pointing out the disparity in the price of live cattle and the retail cost of boxed beef that is sold to consumers.
WASHINGTON, DC – APRIL 28: Chicken sits on the shelf at a grocery store, April 28, 2020 Washington, DC. Meat industry experts say that beef, chicken and pork could become scarce in the United States because many meat processing plants have been temporarily closed down due to the coronavirus pandemic. Tyson Foods took out a full page advertisement over the weekend in several major American newspapers, warning that the food supply chain is on the cusp of breaking. (Photo by Drew Angerer/Getty Images)
"Given the concentrated market structure of the beef industry, it may be particularly susceptible to market manipulation, particularly during times of food insecurity, such as the current COVID-19 crisis," they wrote.
Just over 1,000 Wendy's restaurants — or nearly 20% — had no beef items available on their online menus Monday night, according to an analysis by Stephens Inc., an investment bank. Stephens analyst James Rutherford said some states, like Ohio, Michigan and New York, seemed to be impacted more than others.
Wendy's responded that some menu items may be temporarily limited, but it continues to supply its restaurants with beef two to three times a week. The company said it's trying to limit disruptions to its supplies.
Costco, Sam's Club, Hy-Vee and Kroger are limiting purchases of meat to avoid panic buying. Kroger Co., which also owns Ralphs and Harris Teeter markets, said it wants to ensure buyers have a broad assortment.
"There is plenty of protein in the supply chain," Kroger said in a statement.
Empty and underfilled coolers greeted shoppers in the meat department at the Costco in the Minneapolis suburb of St. Louis Park Tuesday morning, one day after the retailer started limiting fresh meat purchases to three items per customer.
On Tuesday afternoon, a Kroger store in suburban Atlanta was limiting purchases to two packages of chicken, two packages of pork or three packages of ground beef at a time.
Marie Livingston left the store with beef stew meat and some other cuts. She accepted the limits as inevitable.
NEW YORK, NY – APRIL 17: A butcher processes some meat at Vincents Meat Market on April 17, 2020, in Bronx borough of New York City. Some of the country's largest meat processing plants closed due to the COVID-19 outbreak after a factory in South Dakota was closed after nearly 300 of its 3,700 employees tested positive. (Photo by David Dee Delgado/Getty Images)
"Ultimately, you had to see it was coming to this," Livingston said. "You have to limit the supply so everyone can get some and it's fair."
A few hundred yards away at Publix Super Markets on Tuesday afternoon, the store was limiting shoppers to two packages of chicken and was running low. But it was noticeably better stocked on beef and pork.
Some companies — including Target and McDonald's — have no restrictions in place. McDonald's said last week it has seen no supply interruptions because it uses a wide variety of suppliers.
Meat producer Tyson Foods Inc. said it's working hard to get its plants back up safely.
"It's very difficult to speculate on how challenges to the food supply will evolve in the coming weeks, but we are doing our best to maximize our production to meet demand," the company said in a statement.
Makers of alternative proteins say they can help fill the void. El Segundo, California-based Beyond Meat said Tuesday it will be offering lower-cost value packs over the next few weeks to encourage companies to try its burgers. The company said its first-quarter revenue jumped 141% to $97 million, partly because consumers stocked up ahead of lockdowns in March.
"I think we have snuck in at just the right time," Beyond Meat President and CEO Ethan Brown said.
Impossible Foods, which makes soy-based burgers and sausage, said Tuesday it's accelerating its retail sales after seeing a falloff in sales to restaurants. Its burgers will go on sale at 1,700 Kroger grocery stores starting this week, which more than doubles the number of stores offering them. In January, the burgers were only available at 250 stores nationwide.
ELMA, IA – JULY 25: Workers make pork patties as they process hogs at Elma Locker & Grocery on July 25, 2018 in Elma, Iowa. The locker custom butchers hogs and cattle and other livestock for area customers. According to the Iowa Pork Producers Association, Iowa is the number one pork producing state in the U.S. and the top state for pork exports. The state sends about 50 million hogs to market each year and its pork exports totaled more than $1.1 billion in 2017. Pork producers in Iowa are bracing for the impact a trade war with China and Mexico may have on their bottom line going forward. (Photo by Scott Olson/Getty Images)
Impossible said consumer awareness of its products is up sharply, and it's seeing evidence that more people are trying alternative meats.
Impossible says it's able to produce plant-based foods safely because workers can stay farther apart and more machinery is automated than in slaughterhouses. Beyond Meat also said it has had no reported illnesses at its facilities.
"Anytime there's a spotlight illuminating what's actually involved in slaughtering animals and producing meat it is bad news for the meat industry," Impossible CEO Pat Brown said.
Dr. Praeger's, a New Jersey-based maker of plant-based chicken tenders, veggie burgers and other products, said it has also seen higher sales since the pandemic began and is adding another production line to handle demand.
Nielsen says sales of fresh meat alternatives were up 224% the week ending April 25. It noted fresh meat sales jumped 50% in the same period.
© 2020 Associated Press. All Rights Reserved. This material may not be published, broadcast, rewritten, or redistributed.


Gateway, a petite painting inspired by the majestic natural arches found in Arches National Park. The park contains the highest concentration of arches in the world and is an amazing place to climb and find inspiration.
Lovely ornate silver/bronze wood frame cradles the painting. Dimensions of frame 7" x 7" x 2"
Painting size is 4" x 4"
"Painting the colors of my soul."


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2g Scam and Its Effect Essay
2539 Words Sep 23rd, 2011 11 Pages
The 2G spectrum scam in India involved the issue of 1232 licenses by the ruling Congress-led UPA alliance[1] of the 2G spectrum to 85 companies[1] including many new telecom companies with little or no experience in the telecom sector at a price set in the year 2001.
The scam involved allegations regarding the under pricing of the 2G spectrum by the Department of Telecommunications which resulted in a heavy loss to the exchequer, and the illegal manipulation of the spectrum allocation process to favour select companies
The issue came to light after the auction of airwaves for 3G services which amounted to 677,190 crore (US$151.01 billion) to the exchequer.[2] A report submitted by the Comptroller and Auditor General based on the money …show more content…
Kanimozhi Aravindhan, Member of Rajya Sabha : On April 25, 2011 Kanimozhi was named as a co-conspirator in the supplementary chargesheet filed by the Central Bureau of Investigation (CBI) in connection with the 2G spectrum case. The chargesheet submitted before the Supreme Court establishes how Rs 200 crore connected with the scam traveled from a partnership firm of businessman Shahid Balwa of Swan Telecom to the Karunanidhi family-owned Kalaignar TV.She has been charged with section 7 and 11 of the Prevention of Corruption Act. The sections deal with acceptance of alleged gratification.
Bureaucrats involved:
Siddhartha Behura, Civil Servant (IAS officer of 1973 batch UP cadre) : He was the Telecom secretary who served in the DOT at the time of the 2G allocation.
Pradip Baijal, Civil Servant (IAS officer of 1966 batch MP cadre) : He is alleged to have recommended policies that favored certain Telecom companies when he was heading the TRAI. Post retirement, Baijal joined Noesis, a consulting firm.Raja has made references to Baijal's decisions in 2003 as the basis for his decisions in 2008; something which has been attacked by Arun Shourie and several media pundits. The houses and offices of the bureaucrat were recently[when?] visited by the Central Bureau of Investigation as part of their investigations.However, Baijal is expected to get a clean chit in this issue.
R K Chandolia, Civil Servant (IES officer of 1984 batch cadre) : He was
The 2G spectrum scam in India involved the issue of 1232 licenses by the ruling Congress-led UPA alliance[1] of the 2G spectrum to 85 companies[1] including many new telecom companies with little or no experience in the telecom sector at a price set in the year 2001. The scam involved allegations regarding the under pricing of the 2G spectrum by the Department of Telecommunications which resulted in a heavy loss to the exchequer, and the illegal manipulation of the spectrum allocation process to…
Can India Become a Superpower? Essay
courption one of the major threat which is rotening our admistrative system from inside getting us weak and if we are weak than its only a dream to become a superpower. It adversly effects our economy. No particular person is responsible for it we all are responsible for it. All those scam like 2g colgate and CWG has an immense effect on our GDP rate,4.7% fourth quatqer of 2013 from 6.2% according to 2011-12 fiscal, which make us to count on Hindu rate of growth that is slow rate of growt. The above mention…
Valuation of Idea Cellular Essay
minutes of usage indicates that company gave attractive offers to improve overall traffic. These metrics show that the price elasticity is still prevalent in Indian Telecom market. Cancellation of 122 licenses: In the judgment of case related to 2G scam, the Supreme Court ordered the cancellation of 122 licenses awarded in 2008 to different operators. Idea owns 13 licenses out of total 122 cancelled licenses. However, only 7 out of 13 are in operational condition. ICICI Direct Page 2 Mar'12…
Essay The Anti Liberal Cum Pro Market Strategy
on external financial transaction were relived, such reform helped Indian market but also raised competition in the market (kohli, 2006). This shows India's move towards global market and opening of market. First three years it has shown positive effect but later was ineffective for economic condition like less social expenditure affected the electoral support; continue disinvestment in public infrastructure was creating a strong base for industrial recession (kohli, 2006). In 1993-1994 a new term…
Wipro Essay examples
spectrum and helping the exchequer earn more revenues * Will give an impetus to telecom manufacturing, now dominated by Chinese players * Shall address the security challenges of terrorism and cyber crime * Last policy was announced in 1999 * 2G spectrum loss: 1.76 lakh crore	| Food security bill	| * Efforts made to augment food grains storage capacity under various schemes, including the Private Entrepreneur Guarantee Scheme * Efforts to ensure uninterrupted supply of grains under the…
Securities and Exchange Commission of Bangladesh Essay
depository system by 30th June 2004. These companies account for 22.02 % of market capitalization. The remaining securities listed on the exchanges would be dematerialized in phases. Apart from the above, CSE has introduced internet trading system with effect from 30th May 2004. The Commission accorded registration to Credit Rating Agency of Bangladesh Ltd (CRAB) on February 24, 2004 that increased the number of registered credit rating company into two. With the operation of new credit rating agency…
Frontline Essay
at University College London and his book derives from his Oxford D.Phil thesis. It is a highly academic work and will not be read much outside academic circles. But works of scholarship can spread ripples, and I foresee a considerable ripple effect from Dr Collins' painstaking pursuit of unity amidst the often baffling contradictions of Tagore's discursive writings. Was Tagore pro- or anti-West? Was he pro- or anti-modern? Scholars at Tagore conferences argue endlessly about such issues.…
Essay As, Ca, Pdf
32 MAKE IN INDIA OPPORTUNITY 34 Make for India or Make in India – The debate begins! 37 VULNERABILITY COMPARISON OF INDIAN ECONOMY 38 PM JAN DHAN YOJANA 39 COOPERATIVE FEDERALISM 40 ZERO DEFECT, ZERO EFFECT 41 DIGITAL INDIA 42 TWO FACTOR IDENTIFICATION ISSUE 43 MINSK AGREEMENT 44 WILFUL DEFAULT 44 ©	EssaysforIIM.com	2014‐15	Page	1	Issues	for	IIM	PI	Process	http://www…
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family-owned conglomerate? The case offers enriching scope for analysing a family business's turnaround strategies, with all the legacy costs involved. Pedagogical Objectives • To discuss the (operational) dynamics of Korean Chaebols - their influence/ effects on the country's industrial sector and the economy as a whole • To analyse how family-owned businesses manage the transition phase - from a supplier-driven economy to a demanddriven economy • To identify all the possible reasons for Korean Air 's…
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Here's where to watch every episode of ABC Afterschool Special season 2. Mouseover or tap an episode to see where to stream it. Click or tap the play icon to stream it on the best available service.
My Dad Lives in a Downtown Hotel Nov 28, 1973 Divorce, as seen through the eyes of a young boy. The youngster - whose father has been ordered out of the house and is forced to take up permanent residence in a downtown hotel - is traumatized by the imminent divorce, and it is up to his loved ones to help him cope.
Pssst! Hammerman's After You Jan 16, 1974 A small-for-his-age sixth-grade student and his wild attempts to flee a bully after word gets around he thinks of him as a Neanderthal.