text:
Figure 1. Family and Unpaid Caregivers' Experiences With Older Adults' Health Care Workers
Estimates are weighted and reflect the experiences of family and unpaid caregivers of being listened to, being asked about understanding of treatments, and being asked about needing help always, usually, sometimes, or never. Data are from an unweighted sample of family and unpaid caregivers who interacted with older adults' health care workers within the prior year and who reported on their experiences of being listened to (913 participants), being asked about understanding (912 participants), and being asked about needing help in managing older adults' treatments (906 participants).
Figure 2. Family and Unpaid Caregivers' Experiences With Older Adults' Health Care Workers, Stratified by Dementia Status
Estimates are weighted and reflect the experiences of family and unpaid caregivers to older adults without and with dementia of being listened to, being asked about understanding of treatments, and being asked about needing help always, usually, sometimes, or never. Data are from an unweighted sample of family and unpaid caregivers who interacted with older adults' health care workers within the prior year and who reported on their experiences of being listened to (581 caregivers for patients without dementia, 332 caregivers for patients with dementia), being asked about understanding (581 caregivers for patients without dementia, 331 caregivers for patients with dementia), and being asked about needing help managing older adults' treatments (578 caregivers for patients without dementia, 328 caregivers for patients with dementia).
Table 1. Characteristics of Family and Unpaid Caregivers by Frequency of Interactions With Older Adults' Health Care Workersa
Table 2. Characteristics of Family and Other Unpaid Caregivers Who Interacted With Older Adults' Health Care Workers, Stratified by Experiences With Carea
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Wolff JL, Freedman VA, Mulcahy JF, Kasper JD. Family Caregivers' Experiences With Health Care Workers in the Care of Older Adults With Activity Limitations. JAMA Netw Open. 2020;3(1):e1919866. doi:10.1001/jamanetworkopen.2019.19866
Family Caregivers' Experiences With Health Care Workers in the Care of Older Adults With Activity Limitations
Jennifer L. Wolff, PhD1; Vicki A. Freedman, PhD2; John F. Mulcahy, MSPH1; et al Judith D. Kasper, PhD1
1Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
2Institute for Social Research, University of Michigan, Ann Arbor
JAMA Netw Open. 2020;3(1):e1919866. doi:10.1001/jamanetworkopen.2019.19866
Key Points español 中文 (chinese)
Question What are family and unpaid caregivers' experiences with health care workers in the care of older adults with activity limitations?
Findings In this national survey study, most caregivers reported that older adults' health care workers always (70.6%) or usually (18.2%) listened to them and always (54.4%) or usually (17.7%) asked about their understanding of the older adult's treatments, but fewer caregivers reported being always (21.3%) or usually (6.9%) asked whether they need help managing older adults' care.
Meaning These findings reinforce the need for health system strategies to support family and unpaid caregivers, who are the main source of assistance to older adults with physical and/or cognitive limitations.
Importance Family and unpaid caregivers often play an active role in managing the care of older adults with activity limitations.
Objective To examine caregivers' experiences with older adults' health care workers.
Design, Setting, and Participants This survey study constitutes a secondary analysis of a sample of 1916 family and unpaid caregivers to 1203 community-living older adults with activity limitations who participated in the 2017 National Health and Aging Trends Study. Data analysis was performed January to August 2019.
Exposures Caregiver sociodemographic characteristics, caregiving intensity, and frequency speaking with or emailing older adults' health care workers.
Main Outcomes and Measures Caregiver-reported experiences when interacting with older adults' health care workers in the prior year, including being listened to, being asked about understanding of treatments, and being asked about help needed in managing older adults' care.
Results Caregivers (mean [SE] age, 59.4 [0.5] years; 63.7% women) assisting community-living older adults with activity limitations reported that they never (56.3%), sometimes or rarely (33.0%), or often (10.7%) spoke with or emailed older adults' health care workers in the prior year. Most caregivers who interacted with older adults' health care workers reported being always (70.6%) or usually (18.2%) listened to and always (54.4%) or usually (17.7%) being asked about their understanding of older adults' treatments. Fewer caregivers reported being always (21.3%) or usually (6.9%) asked whether they needed help managing older adults' care, and nearly one-half (45.0%) were never asked. Caregivers who interacted with older adults' health care workers often (vs sometimes or rarely) were more likely to report being always or usually listened to (94.8% vs 86.9%; P = .004), being asked about understanding treatments (80.1% vs 69.5%; P = .02), and being asked about needing help (40.8% vs 24.1%; P < .001). No other exposures were consistently associated with caregiver experiences. Measures of caregiving intensity, including caring for an older adult with dementia, were not associated with being listened to or asked about understanding, but were associated with being asked about needed help. Although caregivers of persons with dementia were more likely than caregivers of persons without dementia to report always being asked about needed help (26.9% vs 19.0%), a high percentage in both groups were never asked (41.2% vs 46.5%) (P = .007).
Conclusions and Relevance These findings reinforce the need for strategies to better support family and unpaid caregivers, who are the main source of assistance to older adults with physical and/or cognitive limitations.
Family and other unpaid caregivers provide most of the assistance to community-living older adults with disability.1 In addition to helping with household and self-care activities, nearly one-half of caregivers assist with health care activities, such as managing medications, coordinating care, or attending medical encounters.2 Although caregivers often participate in the exchange of patients' health information and in medical decision-making,3-5 supporting their involvement in health care interactions is not straightforward. Patients vary in their preferences for communication assistance,6,7 and caregivers vary in their knowledge of patient health conditions and priorities.8,9 Interacting with caregivers poses challenges for health care workers (eg, physicians, nurses, other clinicians, and social workers), who are responsible for ensuring patient privacy and promoting patient autonomy but are not reimbursed for additional time spent educating or counseling family and unpaid caregivers or nurturing productive partnerships.10-12
Available evidence—largely anecdotal and setting specific—has described interactions between family and unpaid caregivers and health care workers as being tense or adversarial.11,13 Although the communication challenges of surrogate decision-makers are well documented,14-17 little is known about the experiences of family and unpaid caregivers during routine interactions with older adults' health care workers. Having a better understanding of caregivers' experiences during interactions with older adults' health care workers is especially timely given the growing interest in the contribution of social risk to outcomes of care.18 Recent changes to Medicare conditions of participation and reimbursement models that set forth an expectation and the possibility of more explicit caregiver support heighten the importance of better understanding critical elements of person-centered and family-centered care.19,20
This study draws on 2 linked nationally representative, population-based studies21,22 that are uniquely able to provide insight regarding the experiences of family and unpaid caregivers to a well-characterized sample of community-living older adults with physical or cognitive impairment. Our study has 2 broad objectives. First, we assess the frequency and nature of family and unpaid caregivers' interactions with health care workers, including whether these interactions are associated with characteristics of older adults, family and unpaid caregivers, or caregiving circumstances and appraisal. In doing so, we examine caregivers' perceptions of aspects of communication that have been identified as important in person-centered and family-centered care, including being listened to, being asked about understanding of treatments, and being asked about the need for help in managing older adults' care.23-25 Second, we comparatively examine family caregivers' experiences by whether they assist an older adult with or without dementia, recognizing that family caregivers' interactions with health care workers are likely to be both more frequent and important in the context of impaired memory and judgment.26,27
This study was approved by the institutional review board at the Johns Hopkins Bloomberg School of Public Health. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Data for this study are drawn from the 2017 National Health and Aging Trends Study (NHATS)21 and the National Study of Caregiving (NSOC).22 The initial NHATS sample was drawn from the Medicare enrollment file in 2011 and replenished in 2015; written informed consent was obtained from participants.21 In 2017, the study was conducted with surviving beneficiaries aged 67 years and older. In-person interviews were conducted with NHATS study participants or with proxy respondents if the participant was unable to respond. Study participants were asked whether and how they performed daily activities in the month before the interview. Among those receiving assistance, a detailed roster was created that lists the relationship of each helper and the specific activities with which they provided help.
The NSOC22 is a nationally representative survey of family and other unpaid caregivers to older persons with activity limitations. Participants in the NSOC were eligible if they were family or other unpaid helpers to NHATS study participants receiving help with mobility, self-care, or household activities for health and functioning reasons or living in a residential care facility with supportive services. Upon obtaining oral consent, a telephone interview was conducted with up to 5 eligible helpers for each older adult. For older adults with more than 5 eligible helpers, 5 helpers were selected at random for interview.
Of 6312 older adults who participated in the 2017 NHATS, 2214 were included in the NSOC cross-sectional sampling frame, and 4676 of their helpers were eligible for the NSOC. Nonresponse to the NSOC can arise from the NHATS participant (who may refuse to provide contact information for helpers) or caregivers (who may refuse to participate). Participants in the NHATS did not provide contact information for 359 eligible family caregivers, and 1665 of the remaining 4317 eligible family caregivers could not be located or refused to respond. In total, 2652 family caregivers to 1697 older adults responded to the NSOC,22 yielding 92.4% and 61.9% first-stage and second-stage response rates, respectively. We excluded caregivers to 291 older adults who died and caregivers who were helping 323 older adults living in residential care or 101 adults living in nursing facilities because the nature of caregiving is likely to vary according to availability of services.
Our main exposure measure is the frequency of caregivers' interactions with older adults' health care workers. Caregivers were asked to respond yes or no to the question "In the last year, did you ever speak to or email any of [older adult's] medical providers about [his/her] care?" Those responding "no" were categorized as never interacting with older adults' health care workers. Those responding "yes" were asked, "In the last year, how often did you speak to or email [older adult's] medical providers about [his/her] care (often, sometimes, rarely)?" We grouped caregivers reporting they interacted with health care workers sometimes or rarely together and examined mutually exclusive categories of never, sometimes or rarely, and often.
Measures of caregiver-reported experiences when interacting with older adults' health care workers were derived from 3 questions that were fielded to caregivers who reported interacting with older adults' health care workers in the last year. These caregivers were told to think about the medical professional with whom they communicated with most often and were then asked, "In the last year, how often did that provider listen to what you had to say, ask if you understood [older adult's] health treatments, and ask if you needed help managing [older adult's] health treatments?" For these 3 dimensions of communication, we contrast caregivers responding "always" or "usually" with caregivers responding "sometimes" or "never."
Additional measures included caregivers' sociodemographic characteristics, caregiving intensity, and caregiving-related appraisal. Caregivers' sociodemographic characteristics included age, gender, educational attainment, and relationship to the older adult (spouse, adult child, or other). Caregiving intensity included hours of care provided in the previous week, caregiving for 4 or more years, and types of assistance. We examined provision of help with types of assistance that have special relevance for interactions with health care workers, including medical tasks (tracking medications, administering injections, providing ostomy care or intravenous line care, and providing skin care, such as for wounds or sores) and health system logistics of care coordination.
We examined 2 measures of older adults' physical and cognitive functioning, which have distinctive outcomes on the need for care: self-care and mobility limitations and dementia. We recognize that self-care and mobility limitations may impose the need for transportation or logistical assistance to access medical care, whereas the outcomes of dementia on memory, understanding, and reasoning may impose the need for help in the exchange of medical information and decision-making. We constructed a composite measure of self-care or mobility disability that reflects whether the older adult received help in the prior month with 1 or more self-care (eg, eating, dressing, bathing, and toileting) or mobility (eg, getting outside, getting around inside, and getting out of bed) activities. We used a composite measure of probable dementia constructed from self-reported physician diagnosis of Alzheimer disease or dementia, the AD8 dementia screening interview (administered to proxy respondents),28 and cognitive tests to evaluate memory, orientation, and executive function.29
Caregiving appraisal refers to a composite measure of caregiving strain (range, 0-9), constructed from 6 items that encompass appraised emotional, physical, and financial difficulty; having no time for oneself; being overwhelmed; and exhaustion. To assess caregiving-related difficulty, caregivers were first asked "Is helping emotionally/physically/financially difficult?" Those responding "yes" were then asked to rate the difficulty of helping in each domain on a scale from 1 (a little difficult) to 5 (very difficult). These items were scored as follows: no difficulty, 0 points; 1 to 3 (some difficulty), 1 point; and 4 to 5 (a lot of difficulty), 2 points. Affirmative responses to questions about having no time for oneself, being overwhelmed, and being exhausted were coded as 1, and negative responses were coded as 0. The composite measure has previously been found to have clinical relevance.30,31
We first assessed the frequency with which family and unpaid caregivers interacted with older adults' health care workers in the prior year. We estimated the number and characteristics of family and unpaid caregivers reporting they never, sometimes or rarely, or often interacted with older adults' health care workers. We then described family caregivers' experiences during interactions with older adults' health care workers. We compared family and unpaid caregiver sociodemographic characteristics and their caregiving intensity and appraisal by whether they reported that older adults' health care workers always or usually listen to what they have to say, ask about understanding of older adults' treatments, and ask about help needed by caregivers to manage older adults' treatments, in comparison with those reporting that such interactions occurred sometimes or never. Finally, because family caregivers' interactions with health care workers are particularly important in the context of impaired memory and judgment,26,27 and the care needs of persons with dementia are particularly demanding,32 we comparatively examined family caregivers' experiences by whether they assist an older adult with or without dementia.
All analyses were conducted in SAS statistical software version 9.4 (SAS Institute) and Stata statistical software version 14 (StataCorp). Between-group differences were examined from P values associated with the Rao-Scott χ2 test for categorical measures and the adjusted Wald test for continuous measures, with 2-sided P < .05 considered statistically significant. We weighted our analytic sample to account for caregivers having different probabilities of selection and different probabilities of responding to the NSOC. To make accurate statements about the variance of those estimates, we applied design variables to account for NSOC's complex sample design. Additional details about NSOC survey weights and sampling procedures have been published elsewhere.33,34 This secondary analysis was conducted between January and August 2019.
Our analytic sample included 1203 older adults living in traditional community settings in 2017 and their 1916 family and unpaid caregivers (mean [SE] age, 59.4 [0.5] years; 63.7% women). Among an estimated 17.4 million family and unpaid caregivers, more than one-half (56.3%) reported they did not interact with older adults' health care workers in the prior year, whereas one-third (33.0%) reported speaking or emailing sometimes or rarely, and 10.7% reported speaking with or emailing older adults' health care workers often (Table 1).
Compared with family and unpaid caregivers who interacted with health care workers sometimes or rarely or never, those who interacted with older adults' health care workers often were younger (mean [SE] age, 57.5 [0.8] years vs 59.2 [0.7] years for never and 60.4 [0.7] years for sometimes or rarely; P = .02) and more likely to be female (81.0% vs 59.2% for never and 65.9% for sometimes or rarely; P < .001), better educated (education beyond high school, 74.2% vs 53.0% for never and 69.6% for sometimes or rarely; P < .001), an adult child (65.7% vs 35.0% for never and 45.2% for sometimes or rarely; P < .001), and to have been providing care for 4 or more years (66.4% vs 55.7% for never and 64.2% for sometimes or rarely; P = .01). Caregivers who interacted with health care workers often were providing care of greater intensity as measured by providing care 20 or more hours per week (44.7% vs 31.0% for those interacting sometimes or rarely and 23.3% for those with no contact; P < .001) and to be assisting with medically oriented tasks and care coordination. Caregivers who interacted with health care workers often were more likely to be caring for an older adult with dementia (36.6% of those interacting often vs 25.9% and 22.5% interacting sometimes or rarely and never, respectively; P = .001) and to report moderate or high caregiving-related strain (48.7% of those interacting often compared with those interacting with older adults' health care workers less frequently vs 31.0% and 20.7% interacting sometimes or rarely and never, respectively; P < .001).
Family and unpaid caregivers' experiences with older adults' health care workers varied markedly by type of communication support (Figure 1). Most caregivers reported that older adults' health care workers always (70.6%) or usually (18.2%) listened to what they had to say (total, 88.8%) and always (54.4%) or usually (17.7%) asked about their understanding of older adults' health treatments (total, 72.1%). Fewer caregivers reported that older adults' health care workers always (21.3%) or usually (6.9%) asked about needed help managing older adults' treatments (total, 28.2%). Approximately 1 in 4 (26.9%) reported they were sometimes asked, and nearly one-half (45.0%) were never asked.
Caregiver sociodemographic characteristics and caregiving-associated appraisal were not associated with being listened to, asked about understanding, or asked about the need for help in managing care during interactions with older adults' health care workers (Table 2). Those family and unpaid caregivers who interacted with older adults' health care workers often (vs sometimes or rarely) were more likely to report being listened to (94.8% vs 86.9%; P = .004), being asked about understanding treatments (80.1% vs 69.5%; P = .02), and being asked about needing help (40.8% vs 24.1%; P < .001). No other characteristics were consistently associated with all 3 types of communication support. Measures of caregiving intensity were not associated with caregivers' experiences of being listened to or asked about understanding but were associated with being asked about needed help. Those providing more hours of care per week (35.4% of those helping ≥20 hours vs 25.6% and 24.0% of those helping 10 to <20 and 0 to <10 hours, respectively; P = .01) and helping with medically oriented tasks, such as keeping track of medications (34.4% vs 16.7%; P < .001), administering injections (42.4% vs 26.8%; P = .02), and helping with ostomy or intravenous line care (40.7% vs 26.4%; P = .02), were more likely to report being always or usually asked about needed help. Caregivers assisting an older adult with dementia (37.3% vs 24.5%; P < .001) or self-care or mobility limitations (32.0% vs 22.5%; P = .02) were more likely than caregivers assisting persons without dementia or mobility limitations to report being always or usually asked about needing help.
We compared the experiences of caregivers for persons with and without dementia during interactions with health care workers (Figure 2). Caregivers for persons with dementia were no more likely than caregivers for persons without dementia to report being listened to and being asked about understanding of treatments by the older adults' health care workers, but were more likely to report they were always asked about needed help managing older adults' treatments (26.9% vs 19.0%) and were less likely to report being never asked (41.2% vs 46.5%) (P = .007).
To our knowledge, this study provides the first national information about the experiences of family and unpaid caregivers during routine interactions with older adults' health care workers. We found that caregivers overwhelmingly reported positive elements of communication when interacting with health care workers about older adults' health and treatment but were less often asked about their need for help in managing older adults' care. Although our results depict a generally respectful and constructive family-clinician partnership, they raise important questions about the role of health care workers in supporting the needs of family caregivers, who are so critical in the context of serious illness and late-life disability.
Professional societies,10,35 advocacy organizations,24,36 and consensus committees1,37 among others38,39 have called for routine assessment of family caregivers as an element of high-quality clinical care and robust systems of long-term services and supports. Our study portrays a mixed state of affairs: although nearly one-third (28.2%) of caregivers reported being always or usually asked by health care workers about whether they needed help in managing older adults' treatments, nearly one-half (45.0%) were never asked. Our finding that caregivers providing more hours of care to older adults in worse health were more likely to be asked about needed help suggests that health care workers generally recognized that higher-intensity caregivers may especially need additional support. Although consensus guidelines regarding the circumstances under which an assessment should be performed do not now exist,1,40 our finding that more than 4 in 10 caregivers for persons with dementia were not asked about needed help suggests room for improvement.
Nearly 9 in 10 family caregivers (88.8%) reported that older adults' health care workers always or usually listened to what they had to say and nearly 3 in 4 (72.1%) reported being always or usually asked about their understanding of older adults' medical treatments. The favorable communication reported by family caregivers when interacting with older adults' health care workers stands in stark contrast with the challenges that have been widely described by family caregivers when reporting on their experiences navigating health system demands.11,38,41 There are several explanations for the disconnect between our findings and the prevailing literature. First, prior studies have been largely anecdotal42,43 or specific to acute-care settings14,16,44 and may, therefore, not generalize to the experiences of family caregivers in routine care. Second, the challenges that have been reported may be less due to interpersonal interactions with individual health care workers than systemwide deficiencies, such as fragmented care,45,46 barriers to appropriate information access about the patient's health or treatments,47,48 or issues specific to surrogate decision-making, such as knowledge gaps relating to patient treatment goals and wishes.17,49 Third, our study focuses on the experiences of caregivers who spoke or emailed with health care workers in the prior year and excludes perspectives of the more than half of caregivers who did not interact with health care professionals, some of whom may have experienced difficulties accessing care or who may purposefully avoid seeking out older adults' health care workers because of prior experiences.
Given the important consequences of interpersonal communication between patients and clinicians in the delivery of high-quality care, appropriate services use, and health outcomes,50 it is encouraging that elements of information exchange were rated especially highly in the subgroup of caregivers with particularly demanding responsibilities who interacted with older adults' health care professionals most often. Although family caregivers commonly accompany older adults to medical encounters,3,4 actively participate in face-to-face discussion,3 and are influential in adherence and care coordination,1,3,51 surprisingly little is known about the frequency, nature, and consequences of these interactions. There is a growing appreciation that understanding what people view to be important is foundational to the measurement and delivery of person-centered and family-centered care.23 Findings from this study and others7,25 suggest a benefit to assessing family perspectives in the measurement of care quality. Because family caregivers are often heavily involved in the care of persons with diminished capacity to self-report on experiences with care,2,32 incorporating family caregiver-reported information may be especially important to ensuring that assessments of care quality incorporate all perspectives. Newly developing methods and instruments are encouraging in this regard.25,52
Several strengths and limitations of our study merit comment. Strengths of our study include drawing on nationally representative population-based data for a well-characterized sample of older adults and their family and unpaid caregivers. Although our study appropriately draws on caregiver-reported measures when reflecting on their experiences of care, self-reported information is subject to potential misclassification for measures such as the frequency of interactions. As a secondary analysis of a national survey, our study was constrained to available information regarding interactions with medical professionals, and we are unable to comment on factors such as the type or specialty of health care workers, their gender, their years in practice, the duration of their relationship with the older adult, and their communication style, all of which are known to be associated with interpersonal rapport and trust.50,53 We are unable to differentiate caregivers' expectations or preferences for actively engaging with health care workers, or how patient expectations or preferences about the involvement of their caregiver are associated with these interactions. Although we examined specific elements of interpersonal communication, as opposed to a psychometrically validated multi-item instrument, the measures we assess are directly pertinent to aspects of care that have been identified as important to patients and families,25,54 as well as clinicians and policy makers who seek to improve care for those with chronic and disabling conditions.39
Well-coordinated, team-based care is an important element in the delivery of care that is safe, efficient, and high quality.55 Our study affords a novel perspective on such care by contributing insight regarding the experiences of family and unpaid caregivers when interacting with older adults' health care workers. The high percentage of caregivers who reported being well supported when communicating with health care workers about older adults is indicative of their visible and better recognized role in maintaining the health and well-being of older adults with physical and/or cognitive limitations; that caregivers were less likely to report being asked about needed help reflects the greater ambiguity in clinician responsibility toward supporting family caregivers' needs. These findings are directly relevant to the movement to recognize family as contributing members of an interdisciplinary care team35,56 and contribute benchmark information that may helpful in guiding and monitoring progress toward the advancement of person-centered and family-centered care.23
Accepted for Publication: November 27, 2019.
Published: January 24, 2020. doi:10.1001/jamanetworkopen.2019.19866
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Wolff JL et al. JAMA Network Open.
Corresponding Author: Jennifer L. Wolff, PhD, Roger C. Lipitz Center for Integrated Health Care, Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, 624 N Broadway, Room 692, Baltimore, MD 21205 (jwolff2@jhu.edu).
Author Contributions: Dr Wolff and Mr Mulcahy had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Wolff, Freedman, Kasper.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Wolff.
Critical revision of the manuscript for important intellectual content: Freedman, Mulcahy, Kasper.
Statistical analysis: Wolff, Mulcahy, Kasper.
Obtained funding: Wolff, Freedman, Kasper.
Administrative, technical, or material support: Wolff, Mulcahy.
Supervision: Wolff.
Conflict of Interest Disclosures: Drs Wolff and Freedman reported receiving grants from the National Institute on Aging in addition to the grants funding the study. No other disclosures were reported.
Funding/Support: This study was supported by grants U01AG032947, R01AG047859, and R01AG054004 from the National Institute on Aging.
Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.


We have all had guacamole. You can't miss it. It's amazingly good and of course good for you, unlike we had once thought. The days when we were afraid of fat BUT those days are long gone…or so I hope.
You can't go into a Mexican restaurant without it coming to your table or on all the food. Which is a good thing for me, the more the merrier in my book. But maybe you want to mix it up. Maybe you are looking for another dip that is good and filled with food fats but not quite the same old guacamole.
Then look no further I have just the thing! Let's embrace Peacamole!!
In a bowl, smash the peas with the back of a fork.
Add avocado and mash until well combined. Stir in garlic, lemon juice and sea salt to taste.
Transfer to a serving bowl and enjoy !
This recipe is NOT only easy but it's packed with awesomeness. Awesomeness, like fiber, healthy fat, and even Vitamin C and iron. All good things YOU need to feel good but also look good.
So, make this as an alternative to the regular guacamole at your next party or potluck. Don't tell them it has peas and let people decide for themselves. They might be pleasantly surprised.
And if you like this recipe, and want to try others just like this one…be sure to come back next week for another amazing recipe. Recipes that not only taste good, and are good for you, but also help you to lose the weight you deserve and desire to lose.


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United States Keene General news Health Coronavirus Infectious diseases Diseases and conditions Lung disease Disease outbreaks Public health COVID-19 pandemic Student exchange programs International students Education Social affairs
Keene State plans full in-person fall semester
- Mar. 17, 2021 04:17 PM EDT
KEENE, N.H. (AP) — Keene State College is planning for a fully in-person fall semester.
Currently, classes have been a mix of in-person, hybrid or online, with many campus activities curtailed because of the coronavirus pandemic. But officials are planning to resume all in-person classes, athletic events, on-campus student activities and study abroad opportunities in the fall.
Keene State President Melinda Treadwell said officials expect to be in a better place by the end of the summer with the vaccine rollout underway.
"Our students have told us loud and clear that they want to be together on campus in our community. We are having a successful spring semester, and are actively planning a shift to additional on-campus and in-person community experiences for the fall 2021 semester," she said in a statement Wednesday. "Safety guided by science will remain a priority in the fall, and we will continue to carefully monitor the pandemic to make decisions accordingly."
More than 79,000 people have tested positive for the virus in New Hampshire, including 327 cases announced Wednesday. The number of deaths stood at 1,202.
The seven-day rolling average of daily new cases in New Hampshire decreased over the past two weeks, going from 269 new cases per day on March 1 to 260 new cases per day on Monday.

redpajama_set_name: RedPajamaCommonCrawl


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Photo Credit: EzraZonia O'Neal | Instagram: @_godbodye_
The Black Expat: Why The Universe Called Me To Teach In Thailand
Asia , black expat , Thailand , Bangkok , Thailand , vegan
Rachel George • Nov 19, 2019
EzraZonia O'Neal Morris grew up in Hattiesburg, Mississippi, where the only traveling experiences he had included family trips to Sea World and Busch Gardens in Florida. Now, the 27-year-old lives and teaches over 9,000 miles away in Bangkok, Thailand.
Travel Noire spoke to EzraZonia about his move to Bangkok and what made him choose Thailand to call home.
"What better way to learn how things work but through the youth," he tells Travel Noire. "The universe called me to Thailand. I'm glad I answered back."
Between the great food, cheap currency exchange, beautiful scenery, and enchanting culture, Thailand is the Land of Smiles. When he needs his locs retwisted or cocoa butter, he hits up his black expat family in Bangkok. Meeting kind-hearted people, like the non-English speaking Thai man who helped fix his motorbike on the highway, was a regular for Morris. But life in the city has been what he calls "an interesting dynamic."
Being black in Thailand means standing out in a crowd, sometimes receiving stares and unapologetic comments. Morris recalled seeing promo ads for skin whitening cream at the airport and being denied jobs because he was black.
"I've been denied jobs because I'm black and there was no shame in telling me so. People stare at me, sometimes it's unapologetic. I'm still kind of getting used to it," he said.
The first few months were a bit of a challenge for Morris. It wasn't easy adapting to a new culture, especially when it came to the language barriers and finding vegan alternatives amongst Thailand's carnivorous culture. He became vegan two years ago after watching documentaries like Netflix's The Game Changers and reading books by Dr. Max Gerson about healing from diseases through plant-based diets.
"In Thai culture, meat is a big staple in their diet," Morris says. "I had to learn the language and where I could eat. Now there's a lot more western influence, so vegan spots are popping up everywhere."
Most traditional Thai dishes include shrimp, beef, chicken, and pork. Morris was able to find vegan alternatives for all of these meals and others. He frequents vegan/vegetarian-friendly places like Chaingmai Cafe in Bangkok and Rasayana Raw Food Cafe.
Mushroom pizza and Cocoa Smoothie from Rasayana Raw Food Cafe
Although he spent summers volunteering at Special Kids: Camp Ability camp with his mother, Morris didn't initially intend on teaching formally. Yet, his family and friends always thought he was a natural at it, and helping others.
Morris currently teaches listening, speaking, and writing at a school in Samut Songkhram, just an hour south of Bangkok. "I always try to mirror the teachers that had the most influence in my life and incorporate my own style."
Photo Courtesy of EzraZonia O'Neal | Instagram: @_godbodye_
For him, teaching was a way to exchange cultures and learn the Thai language. His favorite moments are spent with his students, and from the looks of his Facebook page, his students seem to truly love and appreciate Mr. Morris and his attention to being there for them, whether that means simply listening or talking to the students about self-harm and suicidal thoughts.
"For me, teaching is an avenue to get settled into living here. I choose to teach to exchange culture, language, and learn the mindset of Thailand and the people here," he said.
Last month, he was able to introduce his family to his new home in Thailand. They spent the day visiting iconic temples such as Wat Arun, Wat Pho, and backpacker hub Khao San Road. Then his family took a train ride to the ancient city of Ayutthaya and hit up the Samut Songkhram train market. Before ending their vacation, Morris and his family relaxed on the quiet island of Koh Mak.
In his spare time, you can catch Morris at the Erawan Waterfall, visiting wild monkeys at Khao Yai National Park, cooling off from the heat in the mountains of Chaing Mai, partying under a full moon on the island of Koh Chang, or whale shark diving at Koh Tao.
Keep up with Ezra's vegan and fitness journey in Thailand on Instagram at @_godbodye_ or through his YouTube channel.
Taste of Soul: West Africa
Travel Noire, Cooking with Mai, African Food, Cooking, Entrepreneurship, Chef Mai, West African food


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Look through the profiles of Member users that have joined Cancer Survivor Dating that are associated with Baltic. Meeting other members that have similar interests is a great way to come up with ideas to do once you are dating. Signup for a Free Profile to Meet Someone Tonight!
Looking for a male friend.


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Some people like to shock. Julianne De Marchi can do it with her bare hands.
Jules can use the electrical current that stings and surges beneath her skin. To spark a fire, maybe even end a life. But she doesn't understand what it is. And she can barely control it, especially when she's anxious.
Then she meets Ryan Walsh.
She doesn't know he's a soldier working for a secret unit that has her under surveillance.
He doesn't know what it is that's making the sparks fly between them.
And neither of them knows who caused the explosion that has them trapped in an elevator together.
Read more Buy now
Longlisted, Book of the Year: Older Readers, CBCA, 2018
Shortlisted, Aurealis Awards, Best Young Adult Novel, 2017
Longlisted, Sisters in Crime Australia's 18th Davitt Awards, Young Adult Crime Novel, 2018
The characters are endearing and believable, the romance is meaningful without being saccharine and the plot races along with impeccable timing. Paula Weston conjures a frighteningly believable vision of near-future Australia in this incredibly timely read.
Books + Publishing
This is an explosive action thriller with a superpowered heroine, layered and complex supporting characters, an awesome romance, a high-octane adventure, and basically everything I need to make me a deliciously happy reader.
Paula Weston raises the bar for an intelligent, page-turning speculative young adult thriller full of complex issues and wonderfully varied and sculpted characters worth caring about.
Paula Weston has done it again. The Aussie who blessed us with the Rephaim series doesn't miss a beat as she unveils a new cast of well-rounded, flawed and believable characters in a fast-paced tale…Another page-turner!
SA Weekend
A readable and believable dystopian tale of nuclear energy, genetically modified crops, and corporate greed, further enlivened by a budding romance.


VPC Endpoints on Amazon Web Services (AWS) are a service that allows you to create a private connection between your VPC and a service that supports VPC endpoints without being required to traverse a NAT device, proxy server, or other similar service.
Since their launch in May 2015, VPC endpoints have only been available for connectivity to Amazon Simple Storage Service (S3) — their high performance object storage platform.
Just a few weeks ago AWS announced that VPC Endpoints for DynamoDB are now available in public preview. Of course I joined.
All of the documentation for this feature indicates using the console to activate the endpoints, but as I build my environment exclusively with CloudFormation I wanted to see if it was possible to do it here.
VPC - The VPC resource. You could set this to an existing VPC ID.
PublicRouteTable - my public route table.
Private(0/1/2)RouteTable - my private route tables. These will be updated with a route to the endpoint.
Of course the primary benefit of a VPC endpoint is the ability to restrict what it can be used for. You could for example attach a policy document that only allows the endpoint to be used to access a specific DynamoDB table.
The AWS Policy Generator is a useful tool that can be used to generate the policies that you need.
With the CloudFormation template complete I executed the revised template, and the endpoint was created as expected.


The Panasonic Toughbook Permanent Display Removable Computer (PDRC) seamlessly integrates with Toughbook mobile computers to provide a secure and ergonomic in-vehicle computing solution while maintaining the flexibility of using a computer anywhere.
SKU: ToughbookPDRCVDL03. Categories: Playback, Displays, 1"-14", Props.
The vehicle-mounted display and full-sized keyboard can be mounted independently for easy viewing and access, without interfering with the operation of the vehicle or air bags. The PDRC's backlit keyboard and 12.1″ sunlight-viewable touchscreen ensures optimal readability, day or night.


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Q: How do you create a dynamic select list from comma separated string? I am taking information from my database and trying to figure the best way to display it within the app.
This is my database info

[{"form_input_id":"1","form_id":"6","title":"Please enter your room number?","input_type":"text","identifer":"room","choices":"s:0:\"\";","heading":"Valet Request"},{"form_input_id":"2","form_id":"6","title":"Please enter any comments or feedback.","input_type":"textarea","identifer":"feedback","choices":"s:0:\"\";","heading":"Valet Request"},{"form_input_id":"3","form_id":"6","title":"Please choose office","input_type":"select","identifer":"office","choices":"s:19:\"Sales, Reservations\";","heading":"Valet Request"},{"form_input_id":"18","form_id":"6","title":"Last Name","input_type":"text","identifer":"Last_Name","choices":"s:0:\"\";","heading":"Valet Request"},{"form_input_id":"19","form_id":"6","title":"Type of Car","input_type":"select","identifer":"Car_type","choices":"s:20:\"Buick, Olds, Ferrari\";","heading":"Valet Request"}]

I am able to pull everything the way I want to except choices. I am trying to create dynamic forms and need to create a select showing the choices.
My current controller:
    controller('FormCtrl', function($scope, $ionicLoading){

// Grab Form
var form = angular.fromJson(window.localStorage.getItem('form'));

// Set Title
$scope.title    = form[0].heading;

// Send Form Data
$scope.forms    = form;

})

And my view:
<ion-view title="Form" hide-nav-bar="true">
<ion-header-bar align-title="left" class="bar-dark">

        Cancel

</ion-header-bar>
<ion-content id="dynamic" scroll="true" padding="true">

{{title}}

        <form>

                {{form.title}}

                    <input type="text" name="{{form.identifier}}" />

                    <input type="time" name="{{form.identifier}}" />

                    <textarea name="{{form.identifier}}"></textarea>

                    <select name="{{form.identifier}}">
                              NEED TO FIGURE HOW TO DISPLAY CHOICES AS OPTIONS
                    </select>

        </form>
</ion-content>

A: You need to parse your options from string. Something like that:
angular.forEach($scope.forms, function(item){
    item.options=item.choices.split('"')[1].split(',');
});

And tnen use ng-options in select:
<select name="{{form.identifier}}" ng-options="choice for choice in form.options" ng-model="Your model here"></select>

https://docs.angularjs.org/api/ng/directive/ngOptions

redpajama_set_name: RedPajamaStackExchange


text:
Exit Management
Defence & Logistics
September 17, 2015 November 23, 2017 by Website Admin
A plan for the management team to succeed
This award-winning company provides critical infrastructure to the UK Ministry of Defence and US Department of Defense as well as a number of aid organisations globally.
It is a very specialist business, with a number of bespoke facilities from which it manufactures its product, designs new equipment and recycles/stores product for future reconfiguration or deployment.
The business, however, is part of a diversified group and this limits its ability to obtain funding or time from senior executives within the parent group. Whilst this freedom can be beneficial, it does limit the potential for the business and can cause frustration amongst the senior management.
We were called in at a critical time for the parent group, which meant that our client had been asked to carry out a full review of their business and propose a revised structure as well as new 3–5 year business plan. At this point they were at risk of either 'over-promising' or putting forward an 'underwhelming' future plan.
Our work consisted of a number of quick 'heads up' reviews on their business and what skills they had, which then led to research on their market and complementary sectors and enabled us to set out a 'base case' plan and identify growth opportunities into adjacent industries.
As part of this we also produced a summary outline of how the business should streamline its operations, so that it could undertake the necessary investment in people and systems without impacting their bottom line.
The team are now a key part of a new group within the same parent organisation, and with considerably more exposure to and time from the senior leadership of the holding company, they are focused on delivering a three-year plan with the resources and support now available.
Click here to download a PDF of the case study
in	Advisory / Business Advice / Defence & Logistics	0	comments
Clear direction for business and reduced expenditure
We were appointed as a result of our client, the CEO of this start-up company, having been recommended to speak to us and through having several informal meetings.
We offered the CEO initial advice and guidance on the basis of a future appointment, should he secure funding and agree a business plan with his seed funders.
Our initial support enabled our client to reconsider his initial sales plan and his proposed structure for the business, which would have a seen a 'grab for growth' against a high cost base and a low level of focus on the differentiators his business had to offer against established competitors.
He set about updating his business plan, which he reviewed with us. The updated plan was then submitted to his seed funders, who accepted it, and was also used to raise further funding from the bank.
This enabled us to undertake a more thorough set of workshops and reviews with our client and his wider team. The confidence and understanding of the business we gained from this allowed us to then 'soft test' the wider market for potential investors (who could take a more hands-on management role), partners and contract opportunities.
The business has attracted the required funding and now has a wider management team with a stronger commercial background, which complements the military experience of the forming team. This combination offers a compelling proposition in the market and key contracts have been secured as a result, with a strong pipeline of future tenders identified and being progressed.
With progress made against an agreed plan, further investors are interested in the business and the management team are now in a strong position to negotiate favourable terms to take their company to the next stage in its development.
September 15, 2015 April 3, 2018 by Website Admin
A partnering agreement to target growth in austere environments
Our client is a successful group that enables governments in fragile states to put in place internationally recognised good practice and establish robust systems to enable reconstruction. Their clients also include international aid organisations.
Solving international issues often requires different groups to come together and in this instance we identified the benefits of two groups collaborating; we facilitated meetings and workshops so that the groups could explore options and agree actions.
Our role helped identify key issues, ensure smooth programme management of the process and enabled each party to quickly identify common ground.
Working with two very different organisations (one European, the other American), we helped deliver a number of workshops where we acted as Programme Manager, with our success primarily dependent upon the groups concluding an agreement to partner.
This allowed us to take an independent brokerage position between the groups, as we did not have an agenda that was biased towards one particular organisation; in this context we were mainly success-driven.
Tender submitted on time and access to framework contract
As a result of working with our client on a number of projects, we were asked to provide initial advice on their commercial approach to bidding for services in a new sector.
The initial advice led to us working closely with the operations team to assess the key commercial issues and agree the best strategy to address these, thereby producing a best value priced proposition in order to access an international framework contract base.
Our pragmatic approach to modelling the main price inputs, and understanding the operational issues and contract terms, enabled a fast turnaround of a complex bid.
By focusing on the competitive/commercial issues we helped our client's operations team to focus on their technical response and to clearly understand the parameters they had to work within.
This allowed us as a team to identify key operational risks, pricing/specification inconsistencies in the ITT documents issued and to address these at the earliest stage, both through clarification questions and solution development.
Our client is now on recognised on a framework contract in a new target sector, despite having to compete with a number of established incumbent suppliers who have a track record and low cost base.
We continue to work with this client on a number of projects.
Click here to download a PDF copy of the case study
in	Advisory / Bidding & Tendering / Defence & Logistics	0	comments
August 29, 2015 November 23, 2017 by Website Admin
Identification of over £500m of benefits
As part of a business acquisition, we undertook a review of the property assets and worked closely with the client acquisition team to assess both cost-saving initiatives and development gain.
Our client was buying a business that had a number of production sites in a range of locations (edge of town to rural). These sites were in varying conditions of upkeep and also needed to be able to meet modern manufacturing standards.
By working closely with the operations and the estates team, we were able to quickly identify which properties could be surplus, where best value could be achieved and also how surplus funds could be reinvested in a transformation programme.
We also assessed the wider market and were able, once we had outline options, to meet with local planners and development groups. This allowed us to identify local authority grants and also how our plans could release other benefits for local stakeholders in each of the sites we had prioritised.
Through our plan we were able to not only identify a significant surplus from disposing of non-core property, but by working closely with our client's operational team, we also enabled re-investment in certain properties to create 'best in class' manufacturing sites.
Click here to download a pdf of this case study
in	Defence & Logistics / Facilities Management / Property	0	comments
Submission of tender documents
Our client was undertaking a major M&A as well as bidding for a long-term service supply contract, with a total value of over £1bn.
At a key stage in the project a number of personnel wanted to leave, there was conflict in the team and senior leadership had lost faith in the direction the bid, and in particular the strategy the Bid Director was applying.
As a result of other work we have completed for our client, we were asked to take on the bid leadership and manage a team of technical experts who we seconded into the project to fill key gaps in knowledge and specialist aspects of the operations involved.
This ranged from expert input on environmental risks through to local development valuations, specialist MRO parts supply and IT integration. In terms of the tender production, we also provided bid leadership, bid writing, graphics and technical authoring.
We also convinced those who had considered leaving to remain, and were able to bring back key specialists who had left, but had been key to the bid.
In the very tight window of time that remained, we undertook a full analysis of the chance of success and aligned resources accordingly, and developed a clear theme for the solution.
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text:
Q: GWT PhoneGap RPC - status exception 0 RPC call runs successfully in my localhost and when i pushed the project with phonegap integration and tested out in android emulator Rpc call fails and throws status exception 0 or gwt rpc Object not found-404. I did refer tutorial from gwt phonegap rpc-Daniel and did changes like mentioned in above tut:
final ServiceDefTarget serv=(ServiceDefTarget)checkuser;
Window.alert(serv.getServiceEntryPoint());
PhonegapUtil.prepareService(serv,"http://myip:8888/plac/reg","reg");

Where plac is my project space where it resides and reg is URLPattern. I end up either with status code 0 exception or StatusCodeException 404 Notfound.
Please let me know where I am wrong.
Web.xml:
<!-- Servlets -->
<servlet>
<servlet-name>Register</servlet-name>
<servlet-class>com.plac.server.Register</servlet-class>
</servlet>
<servlet-mapping>
<servlet-name>Register</servlet-name>
<url-pattern>/plac/reg</url-pattern>
</servlet-mapping>
<servlet-mapping>
<servlet-name>Register</servlet-name>
<url-pattern>/plac/signup</url-pattern>
</servlet-mapping>

A: Your code needs to look like this:
PhonegapUtil.prepareService(serv,"http://myip:8888/plac/","reg");

The first parameter is the url to your module in your case this should be:
"http://myip:8888/plac/"

and the relative url of your service (to your module)
"reg"

A: Try to add pattern:
<!-- Servlets -->
<servlet>
<servlet-name>Register</servlet-name>
<servlet-class>com.plac.server.Register</servlet-class>
</servlet>
<servlet-mapping>
<servlet-name>Register</servlet-name>
<url-pattern>/plac/reg</url-pattern>
</servlet-mapping>
<servlet-mapping>
<servlet-name>Register</servlet-name>
<url-pattern>/plac/reg/*</url-pattern>
</servlet-mapping>

You may have a / appended to you URL. In that case you'll get a 404.
Do you run in an phonegap environment?
If yes ensure to allow a wildcart access to server: PhoneGap external hosts wildcard

A: I just had the same problem which kept me struggling for lots of hours. At some point I came across the solution which looks a bit different from the one above:
When you call http://myip:8888/plac/reg from a browser it should return
HTTP Status 405 - HTTP method GET is not supported by this URL, if it refers to the desired service.
Otherwise the url is missing something - looking at the resources you provided I am guessing the name of your GWT web app is missing.
Try http://myip:8888/YourAppName/plac/reg whereas http://myip:8888/YourAppName is the url you use to pull up your GWT app from a browser.
So, the code should look like this:
PhonegapUtil.prepareService(serv,"http://myip:8888/YourAppName/plac/","reg");
Hope this helps.


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1. Have a more restful sleep.
2. Eat cruciferous veggies to help you age better, both inside and out.
3. Every evening or Saturdays, schedule 20 minutes to an hour for exercise. One of my favorite exercises that help put my lean figure in perfect shape and gives me that faultless youthful look, is walking every day.
4. Drink enough water daily before 6pm.
No doubt, you find these tips very simple. Well, they are not. The above mentioned will have you working hard, and often. It has to be if you are going to get a result. Nothing good comes easy, but if you are consistent it will sure become easy.
For a calendar of basic exercises and diet to help you sculpture a great physique and glowing looks in two months hit the comment button and let's have a chat about your appearance goals.


text:
Q: What are the different Magento 2 cron jobs doing? Magento 2 specifies three cron jobs to be run:
* * * * * <path to php binary> <magento install dir>/bin/magento cron:run | grep -v "Ran jobs by schedule" >> <magento install dir>/var/log/magento.cron.log
* * * * * <path to php binary> <magento install dir>/update/cron.php >> <magento install dir>/var/log/update.cron.log
* * * * * <path to php binary> <magento install dir>/bin/magento setup:cron:run >> <magento install dir>/var/log/setup.cron.log

https://devdocs.magento.com/guides/v2.0/config-guide/cli/config-cli-subcommands-cron.html
What are each of these three cron jobs doing, specifically?


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additional teacher based assessments are not included in the calculation of ks3 mean score. these bands form the input measure for the value added calculation.


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There is live music twice a week - on Wednesday evenings and Sunday afternoons. Sunday afternoons are great for chilling out with sea views, live jazz and a hot or cold buffet, if you fancy something to eat.