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Use the odds ratio instead of the correlation to definition of entomopathogenic fungus cheap grisactin 250 mg amex measure the association between Y1 and Y2 fungus puns cheap grisactin 250mg with visa. Chapter 5 Imputation in practice Chapters 3 and 4 describe methods to fungus zoysia grass discount 250mg grisactin free shipping generate multiple imputations fungus bacteria purchase grisactin 250 mg free shipping. The application of these techniques in practice should be done with appropriate care. The imputation model should • account for the process that created the missing data, • preserve the relations in the data, and • preserve the uncertainty about these relations. The form encompasses both the structural part and the assumed error distribu tion. The choice will be steered by the scale of the variable to be imputed, and preferably incorporates knowledge about the relation between the variables. A third choice concerns the set of variables to include as predictors in the imputation model. The general advice is to include as many relevant variables as possible, including their interactions (Collins et al. The fourth choice is whether we should impute variables that are func tions of other (incomplete) variables. Many datasets contain derived variables, sum scores, interaction variables, ratios and so on. It can be useful to incorporate the transformed variables into the multiple im putation algorithm. The visit sequence may aect the convergence of the algorithm and the synchronization between derived variables. Set ting m too low may result in large simulation error and statistical in eciency, especially if the fraction of missing information is high. There is simply no magical setting that always works, so often some tailoring is needed. The important question is, however, whether these correlations are strong enough to produce substantial bias if no measures are taken. If the missing data rate did not exceed 25% and if the correlation between the Z and Y was 0. If all possibilities for such data are exhausted and if the assumption is still sus pect, perform a concise simulation study as in Collins et al. Vary the most critical parame ters, and study their inuence on the nal inferences. Method Description Scale Type pmm Predictive mean matching Numeric norm Bayesian linear regression Numeric norm. The measurement level largely determines the form of the univariate imputation model. The mice function distinguishes numerical, binary, ordered and unordered categorical data, and sets the defaults accord ingly. The defaults have been chosen to work well in a wide variety of situations, but in particular cases dierent methods may be better. For example, if it is known that the variable is close to normally distributed, using norm instead of the default pmm may be more ecient. For large datasets where sampling variance is not an issue, it could be useful to select norm. The norm methods are an alternative to pmm in cases where pmm does not work well. For very sparse categorical data, it may be better to use pmm instead of logreg, polr or polyreg. Method lda is generally inferior to polyreg Imputation in practice 127 (Brand, 1999), and should be used only as a backup when all else fails. Finally, sample is a quick method for creating starting imputations without the need for covariates. Each row in predictorMatrix iden ties which predictors are to be used for the variable in the row name. If diagnostics=T (the default), then mice returns a mids object containing a predictorMatrix entry. A value of 1 indicates that the column variable is a predictor to impute the target (row) variable, and a 0 means that it is not used. Since age contains no missing data, mice silently sets all values in the row to 0. The default setting of the predictorMatrix species that every variable predicts all others. Conditioning on all other data is often reasonable for small to medium datasets, containing up to, say, 20–30 variables, without derived variables, in teractions eects and other complexities. As a general rule, using every bit of available information yields multiple imputations that have minimal bias and maximal eciency (Meng, 1994; Collins et al. For datasets containing hundreds or thousands of variables, using all pre dictors may not be feasible (because of multicollinearity and computational problems) to include all these variables. In my ex perience, the increase in explained variance in linear regression is typically negligible after the best, say, 15 variables have been included. For imputation purposes, it is expedient to select a suitable subset of data that contains no 128 Flexible Imputation of Missing Data more than 15 to 25 variables. Failure to do so may bias the complete data analysis, especially if the complete data model contains strong predictive relations. Note that this step is somewhat counter intuitive, as it may seem that imputation would articially strengthen the relations of the complete data model, which would be clearly unde sirable. On the contrary, not including the complete data model variables will tend to bias the results toward zero. Note that interactions of scientic interest also need to be included in the imputation model. Factors that are known to have inuenced the occurrence of missing data (stratication, reasons for nonresponse) are to be included on substan tive grounds. Other variables of interest are those for which the distri butions dier between the response and nonresponse groups. These can be found by inspecting their correlations with the response indicator of the variable to be imputed. If the magnitude of this correlation exceeds a certain level, then the variable should be included. A simple indicator is the percentage of observed cases within this subgroup, the percentage of usable cases (cf. In princi ple, one could apply the above modeling steps for each incomplete predictor in turn, but this may lead to a cascade of auxiliary imputation problems. In doing so, one runs the risk that every variable needs to be included after all. In practice, there is often a small set of key variables, for which imputations are needed, which suggests that steps 1 through 4 are to be performed for key variables only. This was the approach taken in Van Buuren and Groothuis Oudshoorn (1999), but it may miss important predictors of predictors. A safer and more ecient, though more laborious, strategy is to perform the modeling steps also for the predictors of predictors of key variables. At the terminal node, we can apply a simple Imputation in practice 129 method like mice. The mice package contains several tools that aid in automatic predictor selection. The quickpred function is a quick way to dene the predictor matrix using the strategy outlined above. The mice function detects multicollinearity, and solves the prob lem by removing one or more predictors for the matrix. Another measure to control the algorithm is the ridge parameter, denoted by in Algorithm 3. There is some room for improvement by providing automatic variable se lection that selects the, say, 20 best variables from all data. It is, however, dicult to fully automate model building since selection according to steps 1 and 2 cannot be mechanical. Care is needed if the imputation model contains derived variables, like transformations, recodes or interaction terms. As a general, rule, feedback between dierent versions of the same variable should be pre vented. The next section describes a number of techniques are useful in various situations.

The same trends may be observed since 2009 fungus eating animal example grisactin 250 mg cheap, when ‘Paternity leave’ became ‘father-only Parental leave’ and ten days became obligatory fungus bottom of foot discount 250mg grisactin. Take-up of leave increased to fungus under eye generic grisactin 250 mg overnight delivery 56 per cent for the ten compulsory days and 47 per cent for the additional ten days antifungal supplements cheap grisactin 250mg online. In 2010 and 2012 take-up increased again, first to 62 and then to 68 per cent for the ten compulsory days; and to 52 and then to 58 per cent for the ten optional days (percentages based on the number of fathers who take leave in relation to the number of estimated births for 2012). If, again, take-up is calculated in relation to the total number of Initial Parental leaves granted, then the proportions in 2012 increased to 81 per cent for the ten obligatory days and 69 per cent for the ten optional days. Data on take up of the new ‘initial Parental leave’ (replacing Maternity leave), which also came into effect in 2009, points to an increasing take up rate of the ‘sharing bonus’ by parents. In 2012, 75, 553 initial Parental leaves were granted and take up of the ‘sharing bonus’ (at least 30 days) increased to 22. Quebec: take-up of leave by fathers was already higher in 2004, with 22 per cent of fathers using some leave compared with nine per cent elsewhere in Canada. The Paternity and Parental leave scheme, introduced in 2006, has had a substantial impact on fathers’ participation: in 2006, 56 per cent of eligible fathers in Quebec took a period of Paternity and/or Parental leave, rising in 2011 to 84 per cent; in the rest of Canada, take-up of Parental leave by fathers was 11 per cent. Sweden: the proportion of leave days taken by men in Sweden doubled between 1997 and 2004, with the introduction and then the extension of a father’s quota, though the doubling to two months had a less dramatic effect than the initial introduction of a quota. This may reflect a number of mediating factors, for example the design of policy. The importance of payment can also be seen in Catalonia, where there was a strong take-up by public employees of a scheme that enabled parents to reduce their working hours when they have a child under one year without loss of earnings. As noted earlier, there is little information on take-up among different socio-economic or ethnic groups within countries. Where it exists, it points towards women being less likely to take Parental leave, or to take it for shorter periods, if they are: self-employed; work in the private sector; higher educated; and/or higher earning. Fathers are more likely to take leave or to take it for longer periods if: their partners have higher education and/or earnings; if they work in female-dominated occupations or the public sector. Finally, there is also only very limited information on the use of flexible working options. The Netherlands introduced a similar, though broader, right to request more flexible hours in 2000. An evaluation after two and a half years found that 26 per cent of employees had wanted to work less (27 per cent for men, 24 per cent for women), the main reasons given by both men and women being to have more time for family or household duties (34 per cent) or to pursue hobbies and other private activities (30 per cent). Approximately half (53 per cent) of the employees who wished to reduce their working hours asked their employers; more than half (54 per cent) had their request fully granted, with a further 10 per cent partially agreed. In short, the legislation had contributed to about 9 per cent of workers reducing their hours. To summarise on take-up: Unpaid or low-paid leave of whatever kind has low take-up; Leave specifically for fathers. Paternity leave, fathers’ quotas in Parental leave) is well used if paid at or near income replacement level; Fathers take only a small portion of Parental leave that is a family entitlement; Leave is used differentially not only by women and men, but by parents with different education, income and employment both individually and in relation to their partners – the impact of leave policies, therefore, is not uniform. The publications listed are supplied by the authors of the country notes, and are not necessarily a comprehensive and systematic literature review for the period; some publications, therefore, may have been missed and the international review’s editor would welcome information about missing publications (details to peter. The number of publications varies considerably between countries, implying different levels of policy interest and/or of researchers with an interest in work/life issues. Fifty three ongoing research projects from 19 countries are reported on leave policies and related issues, ranging from cross-national studies to studies undertaken for doctoral theses. As with publications, the international review’s editor would welcome information about missing research projects. Current leave and other employment-related policies to support parents Note on federal and state industrial relations systems and awards: In Australia, the employment conditions of employees in federal and state jurisdictions have traditionally been detailed in awards, which are prescriptive documents determined by industrial tribunals that usually cover an occupation or industry. Since the mid-1990s, industrial relations legislation has facilitated the spread of enterprise-level collective agreements, which often use the relevant award as a benchmark of minimum standards, but may specify additional employment conditions. As part of the Fair Work Act 2009, the national independent workplace relations tribunal (the Fair Work Commission) has replaced more than 1500 state and federal awards with 122 industry and occupation awards (known as modern awards). The Fair Work Act also put in place a set of ten National Employment Standards that prescribe the minimum set of entitlements for employees: these include standards relating to unpaid Parental leave (which has been an entitlement under federal industrial relations legislation since 1994) and flexible working arrangements (see below). Specific minimum conditions for industry are set out in modern awards and some of the National Employment Standards may also be replicated in modern awards or enterprise agreements. Since 1990 Leave entitlements in relation to the birth or adoption of a child under Australian labour regulation have been written in gender-neutral terms and are generally referred to as Parental leave, rather than Maternity or Paternity leave. This is also the case for the entitlement to pay while on Parental leave (since January 2011), although not for the recently introduced payment specifically for fathers or mothers’ partners (called Dad and Partner Pay). However, see 1c for details of the unpaid Parental leave entitlement under the Fair Work Act, which provides for each 58 Please cite as: Whitehouse, G. For births or adoptions after 1 January 2011, eligible mothers (or their partners) may receive payment (Parental Leave Pay) for up to 18 weeks of this leave under the Government’s Paid Parental Leave scheme (see 1c for details). Historically, many female employees have also had access to employer-paid Maternity leave through industrial awards, workplace agreements, company policies, or legislation covering public sector employees. In spite of this increase there remains considerable variation across industries, with only 17. Paternity leave As outlined in 1c below, the unpaid Parental leave entitlement provided in the Fair Work Act 61 enables men to take three weeks leave immediately following the birth of the child, and to share the unpaid Parental leave entitlement with their partners for periods during which they take a ‘primary carer’ role. Under the Paid Parental Leave scheme, partners taking a primary carer role may also share the Parental Leave Pay entitlement. In addition, a specific entitlement to ‘Dad and Partner Pay’ has been introduced from 2013. This payment must be taken while on unpaid leave (such as that available under the Fair Work Act unpaid Parental leave provisions) and is non-transferrable. Employer-paid Paternity leave may also be available to some fathers and partners through company policies, industrial instruments or legislation covering public sector employees. The amount of paid leave that is granted also varies significantly across employers (see later comments) and, as for employer-paid Maternity leave, organisational policies may not deliver the same entitlement to all employees within the organisation. Parental leave Length of leave Under the relevant National Employment Standard in the Fair Work Act, each parent who meets the eligibility requirements is entitled to 12 months unpaid Parental leave; this leave is an individual entitlement. That period can be extended by a further 12 months if the employer agrees, with the limitation that a couple cannot exceed a total of 24 months between the two working parents per birth. When both members of a couple are entitled to unpaid parental leave under the National Employment Standard, they can take three weeks of their unpaid parental leave at the same time, starting immediately after the birth, or by agreement with their employer, within the period up to six weeks after the birth. Other forms of paid leave such as annual leave and long service leave can also be used. However, for each period of paid leave used, the unpaid Parental leave entitlement is reduced by the same amount so that the maximum time available for Parental leave per family is still two years. The government funded 18 weeks Parental Leave Pay is designed to be paid during the unpaid Parental leave entitlement period: it does not reduce or extend the duration of unpaid Parental leave available as it is an entitlement to pay rather than to leave. In some circumstances it can transferred to the father or other primary carer; the 18 weeks pay is, therefore, a family entitlement that initially goes to the mother. The average duration of provisions among large organisations was recently reported as 9. Flexibility in use Under the National Employment Standard in the Fair Work Act, only one parent is entitled to access unpaid Parental leave at any particular time. The exception allowing some flexibility is immediately following the birth (or adoption) of the child, when parents may take concurrent unpaid leave for up to three weeks (see footnote 61). Any agreement for an additional period of leave beyond the first 12 months will reduce the spouse or de facto partner’s entitlement by an equivalent amount. These benefits of the social security system would no longer be available to those receiving Parental Leave Pay. Any leave taken in these circumstances must be subtracted from the total entitlement to unpaid Parental leave. In these situations conditions might be attached, such as a requirement to return to work before receiving some or all of the payment or a guarantee to return for at least a period equivalent to the leave taken. For example, among respondents to the 2005 Parental Leave in Australia Survey who had taken some paid Maternity leave, around 5 per cent reported that some or all of their pay was delayed until their return to work (see footnote 64). Other statutory employment-related measures Adoption leave and pay the same statutory rights apply as to unpaid Parental leave and Parental Leave Pay when a child under 16 years old is adopted. Time off for the care of dependants All employees (except casuals) have access to a period of paid personal/carer’s leave equivalent to one twenty-sixth of their nominal annual hours (ten days leave for a regular full-time employee). In addition, employees can access up to two days unpaid carer’s leave for each ‘permissible occasion’ provided paid personal leave has not been exhausted.

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The authors reported that the age distri bution of cases and controls was similar anti fungal acne order grisactin 250mg on-line. A sub sequent publication on the relation between non-Hodgkin lymphoma in men and expo sure to baking soda antifungal cheap grisactin online amex 2 urine antifungal cheap grisactin 250 mg, 4-D gives more details of the study design antifungal definition purchase grisactin 250 mg mastercard, with no mention however of chlordane (Hoar Zahm et al. In a study of leukaemia in men parallel to that of non-Hodgkin lymphoma conducted in Iowa and Minnesota, described above (Cantor et al. Among farmers using chlordane on animals, the risks rose inconsistently with frequency of use, from an odds ratio of 1. There was no evidence of increasing risk with increasing frequency of use of chlordane or heptachlor on crops. In a study conducted in Sweden, 121 cases of hairy-cell leukaemia, a rare lympho haematopoietic malignancy, that were diagnosed between 1987 and 1992 were identified from the Swedish Cancer Registry, and 484 controls were drawn from the national population registry and matched to the cases on age, sex and county (Nordstrom et al. Of these, 111 patients (91%) and 400 controls (83%) answered the mailed questionnaire. The odds ratio for having a blood concentration of chlordane above the median of controls (44 ng/g) was 1. Antibodies to Epstein-Barr virus early antigen immuno globulin G1 in blood were also measured, and the effect of the interaction with chlordane on the risk for hairy-cell leukaemia was evaluated. Logistic regression was used to obtain adjusted odds ratios for (self-reported) mixing, handling or application of specific pesticides, relative to the rates of men who were not farmers. Nine cases and 29 controls had used chlordane as animal insecticides, and the estimated odds ratio was 1. Histological examination revealed that 23 women had a mammary carcinoma, while the remaining 27 had benign disease. Twenty samples were selected from women in each group (mean age of cases, 63, range 36–86 years; mean age of controls, 59, range, 45–76 years) for analysis of several pesticides, including three metabolites of chlordane (heptachlor epoxide, oxychlordane and trans-nonachlor). The mean value (wet weight basis ± standard deviation) of the sum of heptachlor epoxide and oxy chlordane was 116 ± 50 ng/g for women with breast carcinoma and 97 ± 49 ng/g for those with benign disease (t test, p = 0. For trans-nonachlor, the corresponding figures were 87 ± 37 ng/g and 96 ± 80 ng/g (p = 0. Between November 1991 and May 1992, adipose tissue was collected from 41 women aged 40–69 who had undergone a biopsy in a hospital in Quebec City (Canada), and the organochlorine content was determined (Dewailly et al. The mean oxychlordane concentration was 31 ± 12 ng/g in breast adipose tissue from the 17 subjects with benign disease, 27 ± 7 ng/g (Student t test, p = 0. For trans nonachlor, the mean concentrations in the three groups were 42 ± 18, 35 ± 8 (p = 0. According to the Danish Cancer Registry, 268 of the women developed breast cancer between 1976 and 1993. For each case, two women free of breast cancer and matched for age, date of examination and vital status at the time of diagnosis were randomly selected as controls. Heptachlor, heptachlor epoxide, and chlordane, oxychlordane and trans-nonachlor were among the com pounds measured. Conditional logistic regression was used to estimate odds ratios for categories of pesticide concentrations. The authors did not report the concentrations of chlordane metabolites but indicated that no association was found. Although active postal follow-up continued until 1989, 70% of the cohort was last contacted in 1982–83. A histologically confirmed breast cancer was diagnosed in 105 of the 6426 women for whom at least 4 mL of serum remained in the bank and who had had no history of cancer at the time of blood collection. Two controls were selected for each case, who were alive and free of cancer and matched to the cases by age, date of blood sample collection and history of benign breast disease at enrolment. Since the serum samples of two controls could not be analysed, 208 controls were included in the analysis. Among the compounds measured by gas chromatography were heptachlor, heptachlor epoxide, cis and trans-chlordane, oxychlordane and trans-nonachlor. None of the samples contained cis or trans-chlordane or heptachlor epoxide at concentrations above the limit of detection. Of 824 women who were under the age of 80, were scheduled for biopsy in two hospitals in Toronto and Kingston (Canada) between July 1995 and June 1997, had no history of cancer, had not participated in tamoxifen trials, had not had a breast implant and were not too ill to participate, 735 (89%) agreed to participate in a case–control study and 663 (81%) completed a questionnaire by telephone or mail (Aronson et al. Organochlorine compounds were determined in benign tissue taken during biopsy from 217 women with in-situ or invasive breast cancer and in 213 women matched for age and study site whose biopsy samples showed no malignancy but most of whom had a diagnosis of some form of benign breast disease. For other compounds, the women were divided into four categories according to the tissue concentration. For cis nonachlor, the odds ratios estimated by logistic regression and adjusted for several potential confounders were 0. When analyses were conducted separately for pre and postmenopausal women, the results were similar in the two groups. A study conducted in Quebec, Canada, between 1994 and 1997 included 315 women aged 30–70 years and residing in the Quebec City area with histologically confirmed breast cancer, 219 controls recruited in four hospitals of the study area and free of gynaecological diseases and 307 controls selected from the general population (Demers et al. Blood samples were obtained before therapy, and cis and trans-chlordane, cis-nonachlor, trans-nonachlor and oxychlordane were measured. As cis and trans-chlordane and cis-nonachlor were detected in less than 70% of the blood samples, they were excluded from further analysis. In comparison with the first quintile of oxychlordane serum concentration, the adjusted odds ratios for women with concen trations in subsequent quintiles were 1. The concentrations of oxychlordane and trans-nonachlor in blood were associated with the extent of disease. Of the 490 women enrolled, 304 had histologically confirmed breast cancer and 186 had histologically confirmed benign breast disease (excluding atypical hyperplasia). The age and lipid-adjusted geometric mean adipose tissue concentrations of oxychlordane and trans-nonachlor were similar for cases and controls. In comparison with the lowest quartile of concentration, the odds ratios adjusted for several covariates were 0. A case–control study of endometrial cancer was conducted between 1996 and 1997 in 12 Swedish counties, which included 288 (73%) of the 396 cases of histologically confirmed endometrial cancer identified through a network of personnel at the departments of gynaecology and gynaecological oncology in the study area (Weiderpass et al. An additional 134 women were excluded since they had used hormone replacement therapy, thus leaving 154 cases. Of the 742 women selected as controls from population registers and frequency matched to cases by 5-year age group, 205 were included in the study; the others were excluded because they had undergone hysterectomy, had used hormone replacement therapy or refused to participate. Serum samples were taken from all participants and analysed for organochlorine compounds. The odds ratios were obtained by logistic regression and adjusted for age and body mass index. In comparison with women in the first quartile of serum concentrations of chlordane metabolites, the odds ratios were 1. Only 113 of 611 potential cases were included in the study (108 cases included in the analysis), the most common cause of exclusion being death of the patient (55%). Age and sex-matched controls were selected by random-digit dialling (age, < 65) or from the Health Care Financing Administration lists (age 65). Eighty-two of the selected controls agreed to provide a blood sample, giving a participation rate of 78% for people < 65 and 65% for those 65. Cases had significantly higher median concentrations of trans-nonachlor than controls. The adjusted odds ratios relative to individuals with concentrations below the detection limit were 0. Two groups of controls were selected: the first consisted of friends of the children with brain cancer or of children with acute lymphocytic leukaemia (85 children; participation rate, 94%), and the second consisted of 108 children with cancer (mostly of the lymphohaematopoietic system; 71 children; participation rate, 78%). The adjusted odds ratio associated with living in a home that had been treated for termites within 1 year before residence or during residence from pregnancy to diagnosis was 2. Of the 21 patients who reported any termite control treatment, only seven reported specific use of chlordane, giving an odds ratio of 1. When 10 animals from each group that were killed for interim study at 6 months were excluded, the mortality rate at 18 months was 27–49%, with the exception of males and females receiving 50 mg/kg of diet, in which the rates were 86 and 76%, respectively. A review of the histopathology of liver samples from this study by a panel of the National Academy of Sciences (1977) indicated a significant increase in the incidence of hepatocellular carcinomas in males at the intermediate dietary concentration and in females at the two higher concentrations (Table 7). Males received an initial concentration of 20 or 40 mg/kg of diet and females received 40 or 80 mg/kg of diet; the time-weighted average dietary concentrations were 30 and 56 mg/kg for males and 30 and 64 mg/kg for females. The survival rates in all groups was relatively high, being > 60% of treated males, > 80% of treated females and > 90% of male and female controls (National Cancer Institute, 1977b). A review of the histo pathology of liver samples from this study by the panel of the National Academy of Sciences (1977) indicated a significant increase in the incidence of hepatocellular carcinomas by linear trend analysis in males and females and a significant increase in the combined incidence of hepatocellular carcinomas and ‘nodular changes’ in males and females at the higher concentration (Table 8).

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A reduction in the costs of medications was also cited as a reason for increased satisfaction antifungal nail pills generic grisactin 250 mg on line. Reasons for decreases in satisfaction included discontinuation of home visits during enrollment and unresolved billing issues over copayments fungal growth purchase grisactin with a mastercard. The reason for disenrollment was categorized by patient perception of the problem(s) they encountered antifungal vaccine cheap 250 mg grisactin visa. Based on their experiences antifungal liquid drops order discount grisactin online, respondents discussed whether any of the aforementioned factors contributed to their decision to disenroll. Provider issues were the least common reason for disenrollment, with no respondents citing this reason in the first round and only a small percent (8%) citing this reason in the second round. Respondents mentioned different aspects of their nurse care manager’s services that they valued most, ranging from emotional support to a broader education about health benefits and health needs. Medication-related support and services were the next items most commonly listed as helpful. Other aspects included helping with the delivery of medications to respondents’ homes; and helping respondents to manage their medications. These included access to transportation, lower copayments, medical supplies, health education, and emotional support. However, within the small sample, satisfaction was clearly lower among this group. Billing and provider issues had generally become less of a problem over time for respondents in the Demonstration. Findings from the third round suggest that issues related to billing and access to providers decreased. A small percent of Spanish-speaking respondents was interviewed in the second round of the disenrollment interviews. Based on responses it appeared that the language barrier may also have exacerbated such misunderstandings. These results, along with the results from the interviews with respondents who remained enrolled, do not explain the extent to which communication challenges affected patients’ satisfaction with care due to Spanish being their primary language. However the literature suggests that language, communication, and culture have implications for patients’ perception of their care and their overall satisfaction [4, 5]. Some physicians told respondents that they should re-enroll in traditional Medicare. First, surveys were conducted with a small sample of respondents that may not be representative of all enrollees in the Demonstration. Relatedly this limits the extent to which generalizations can be made based on the responses collected from a small, possibly unrepresentative sample. Billing and provider issues that were causing problems for some beneficiaries appear to have improved and were quickly resolved when they arose. However, other research, such as by Schlesinger et al found that sicker enrollees were less likely to disenroll versus healthier patients [10]. Poor health status may limit their ability to make an informed decision to leave a health plan and act on that decision. Therefore these qualitative results need to be taken in context in that other factors, such as health status, may also influence voluntary disenrollment. Satisfaction with and perceived cultural competency of healthcare providers: the minority experience. Voluntary Disenrollment From Medicare Advantage Plans: Valuable Signals of Market Performance. An analysis of disenrollment from Medicare managed care plans by Medicare beneficiaries with diabetes. The effect of health status on dissatisfaction and disenrollment from health plans. Introduction this chapter presents findings from the provider satisfaction component of the Evaluation and explores provider acceptance of Disease Management. Such acceptance speaks to the feasibility of broader implementation of Disease Management services and may influence health outcomes. Recruitment letters were sent to the full census of providers due to the small population of each provider type. These providers were selected for interviews from stratified random samples of each provider type. First round data were collected in the fall of 2007 from a final sample of 40 providers and second round data were collected from a final sample of 33 providers in the winter of 2009. All interviews were conducted via telephone, and each provider was screened for their eligibility during the initial portion of the interview and before proceeding with the remaining interview questions. Providers were not eliminated based on the amount of time they were involved in the Demonstration. The advantage of semi-structured interviews is that their conversational nature allows for unanticipated, though often important and relevant, topics to emerge, while critical questions are addressed. Analysis Due to the qualitative nature of these analyses, as well as small sample sizes, tests for statistical significance are not reported. The notes were compiled in a database, and were analyzed and coded for central concepts and themes. Questions were meant to elicit qualitative responses, but each protocol included four semi-quantitative questions asking respondents for a discrete rating. Questions asked about the implementation of the Arbor Research Collaborative for Health 95 Final Report Chapter 14: Provider Satisfaction Disease Management program, management of comorbid conditions, quality of life (QoL), health outcomes, and overall satisfaction. Overall, the increase in scores for each provider type suggests that program stabilization may reflect how implementation of Disease Management positively impacted management of comorbid conditions. Arbor Research Collaborative for Health 96 Final Report Chapter 14: Provider Satisfaction 2. The average rating from respondents for the improvement in health outcomes in 2009 was slightly higher (second round = 4. Some respondents said that their perceptions were based on clinical outcomes that they observed for their patients. Specifically, 33% (11/33) of respondents in 2009 reported they had seen evidence. Respondents were also asked to explain how and/or provide an example of how beneficiaries’ QoL improved, and also to rate the impact of the Demonstration on QoL on a scale of 1 to 5, where 1 = significantly worse and 5 = significantly better. In most cases, average ratings across all provider types were higher in the second round of interviews. Arbor Research Collaborative for Health 97 Final Report Chapter 14: Provider Satisfaction emotional support for patients) they believed made enrollees’ lives easier as justification for why they perceived QoL to have improved. Other reasons given for a positive impression of improvements in QoL included citing improvements in enrollees’ attitude, and perceptions that patients were able to lead more active lives. A small percentage of respondents had mixed reviews, however, fewer actually described their experience as somewhat negative. However, for fourteen of the respondents, overall satisfaction did not change during the duration of the Demonstration. These findings suggest an improvement in overall provider satisfaction from 2007 to 2009. In particular, this evaluation examined whether reported problems concerning access to providers and billing diminished from 2007 to 2009. In 2009, nephrologist respondents mentioned few to no problems surrounding implementation. The few problems that were mentioned, however, did not have an effect on this provider type’s overall satisfaction. Although this study examined perceptions regarding improvements in comorbid conditions, QoL, and health outcomes in separate sections, it is worth noting that respondents perceived them as highly interrelated. Some respondents asserted the belief that an improvement in the management of comorbid conditions and an emphasis on prevention invariably leads to better QoL, which they felt in turn increased patient adherence. The result they perceived was an improvement in health outcomes which also reinforced improved QoL. An improvement in health outcomes and QoL may also encourage a patient to better manage their comorbid conditions.

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Mothers in this survey fungus roses order grisactin online pills, from countries across Europe and in four other continents fungus gnats cannabis cinnamon order grisactin 250 mg without prescription, reported fears about allowing their children to antifungal kidney damage buy grisactin 250mg free shipping play outside related to antifungal b&q buy grisactin without a prescription increases in traffic, crime, harassment and violence, possible abduction, dirt and germs, and many more similar issues. This is attributed to a now well recognised phenomena of ‘nature deficit disorder’ (Louv, 2005) arising from children having very limited access to the outdoors and natural environments. Even the most playfully inclined children will not be able to play, sufficiently for them to reap the benefits in terms of their learning and development, if they are not given the time, the space and the independence to develop their own spontaneous and self-initiated play activities. Lester and Russell (2010) provide a very useful review of the now quite extensive 26 literature studying children’s use of urban and rural spaces for playful purposes. What emerges from this is that, in their play, children appropriate different spaces and features within their environment which are quite unpredictable by adults, and that the richest play spaces are mostly natural and unplanned. Many urban playgrounds, designed by adults, are often too neat and tidy, and essentially often rather barren as regards playful opportunities. The most successful urban play environments are ‘adventure playgrounds’ which are set up so that children can adapt them and build their own spaces, using a range of natural and man-made building materials (Bartlett, 2002). Having said all this, of course, much very productive playful activity can and does take place in the home and (although unfortunately to a markedly declining degree in a number of European countries) in early care and educational settings and schools. Three key factors emerge from the research concerning the support for play in these environments. These relate to the level of stimulation, the quality of interactions with adults, and the degree of independence or autonomy offered to the children concerning their play. As regards stimulation, within indoor environments, this is mostly related to the provision of play materials and toys which support the five types of play identified earlier in this report. It has been established for some time, through a number of studies, that access to a variety of materials and toys is related to children’s cognitive development (Bradley, 1985). Within this general position it is well established that materials and toys support play most effectively when they are open and flexible and provide children with a wealth of opportunities for creativity, for social interaction with their peers and adults, for authorship and for deep engagement (Gauntlett et al. However, beyond this there is currently a paucity of research as to the qualities of specific types of materials and toys, related to the different types of play, which most effectively support playfulness, learning and development. Recent studies by Howard and colleagues, for example, have shown that a key factor in children engaging with and learning most effectively from activities with toys and other materials, is that they perceive the situation to be playful (Howard, 2002; McInnes, K. For obvious ethical reasons, however, direct studies of the consequences of preventing children from playing have not been conducted. The evidence in this area, therefore, is largely circumstantial or based on animal studies (mostly rats). Nevertheless, the evidence we have is compelling and seems strong enough, combined with that of the positive benefits of playful experiences reviewed above, to suggest that the provision of rich playful opportunities, across the five types indicated, would be a wise policy position for any society wishing to fully benefit from its human potential. As we have indicated earlier, there is very clear evidence that children’s cognitive development and emotional well-being are related to the quality of their play, and a number of studies have shown that individuals who are not well developed in these areas are not playful. Brown (1998), for example, found consistent child and adult play deficits in a study of criminally violent young men. In a recent study of one to two year old children in ‘maltreating’ families Valentino et al (2011) found that children in such families displayed less child-initiated play and less socially competent behaviour than children of the same age in non-maltreating families. The many studies of the severely deprived children discovered in Romanian orphanages following the breakup of the Soviet Union reported a range of severe cognitive and emotional deficits including abnormal repetitive or brief play behaviours, together with deficient growth and functioning in a number of key brain regions (Chugani et al, 2001). There have also been numerous studies of the Romanian children, and other children kept in orphanages in deprived circumstances, documenting their recovery once adopted and exposed to life in a loving, family environment including, of course, rich play opportunities. The difficulty with much of this evidence, of course, is that the lack of play, or its provision, is just part of an overall pattern of deprivation or provision, and so it is impossible to conclude that the play experience per se was entirely responsible for the outcomes. Perhaps more telling evidence, however, arises from studies where playful opportunities are introduced to children while they are still living in the orphanage. Taneja 28 et al (2002), for example, introduced a structured play regime into an Indian orphanage and reported highly significant gains on measures of motor, cognitive and social functioning. Fearn and Howard (2011) have recently published a very useful review of studies of play therapy as a resource for children facing adversity. The other main area of research which has provided evidence relating to play deprivation, but which also has obvious limitations, has involved studies with rats. Rats have often been chosen for psychological research as they are highly intelligent mammals and learn quickly. Pellis and Pellis (2009) have been pre-eminent in research concerned with play in rats and have discovered clear relationships between their level of play behaviour and significant physiological changes in their brains. They have also demonstrated that play supports novel neural connections and changes the architectural structure of significant brain regions. Play deprived rats became more aggressive to other rats, were less able to mate successfully, and showed heightened levels of fear and uncertainty in novel environments. They were asked to respond to a number of questions concerning the nature of their research and their views on the value of play, existing provision for play in their countries, the advent of screen-based play and the role of adults in children’s play. The information and views they submitted on these issues are summarised in this final section of this review of the research literature, and their most recent research papers are listed in the bibliography in Part 6 of this report. The eight experts consulted, listed in alphabetical order of their countries, were as follows: Denmark: Dr Stig Brostrom, Centre of Early Childhood Research, Department of Education, Aarhus University 29 France: Prof Gilles Brougere, Institute of the Sciences of Play, University of Paris 13 Germany: Dr. Textor, Institute of Education and Futures Research, University of Wurzburg Italy: Prof Emma Baumgartner, Department of Developmental and Social Psychology at Sapienza, University of Rome Poland: ro o ena Muchacka, Pre-school and Early Education Institute, Pedagogical University of Cracow Spain: Imma Marin, President of International Play Association in Spain Sweden: Prof Ingrid Pramling Samuelsson, Department of Education, Goteborg University United Kingdom: Dr Justine Howard, Centre for Children and Young People’s Health and Well Being, Human and Health Sciences, Swansea University Research interests, questions and findings Most of the research concerned with play carried out by these European experts is concerned with play in children from birth to six years. This research is predominantly concerned with the impact of play on development and play in pre-school and educational settings. Specifically, four main topics are addressed, related to: the definition of play and its distinction from other activities, the benefits of play (is it beneficial, and if so, should we encourage it, and how do we encourage it In addition, Baumgartner has also researched gender issues in relation to children’s play. However, there are differences regarding the definition of play and while some research suggests that play is beneficial for children’s cognitive development and is an important ‘educational tool’ (Brostrom, Pramling Samuelsson and Muchacka), others have suggested that children’s informal activities can only be defined as play if they are free. In addition, Baumgartner reports the finding that children spend 80% of their playing time in ‘gender-segregated’ groups. Views concerning the nature and value of children’s play Views were also divided along similar lines regarding the value of play for children’s development. Some felt that play is often romanticised by its advocates and needs to be researched in a more rigorous and ‘realistic’ manner. Children learn in many different ways, by observation and imitation, by rote, through reinforcement and by exploration, trial and error, all of which may or may not involve play. When children play, however, it was recognised that there are many opportunities for skill development, for example language and social skills, gross and fine motor skills, sorting and sequencing. There was more general consensus, however, that the benefits of play are related to its promotion of self-esteem, emotional wellbeing and resilience. When children engage in a task as though it is play, it was suggested, behavioural thresholds are lowered and they are able to try things out with only self-set targets and goals. As a result, resilience and esteem grow and children develop the confidence to meet physical, intellectual and emotional challenges. Children learn and develop through activities other than play, Howard argued, but they learn and develop more effectively through activities that are play. Marin, Muchacka and Brostrom expressed the view that play is beneficial as it is children’s natural way of learning and exploration. However, Baumgartner argued that viewing play as a complex set of different behaviours would be more productive in relation to understanding its contribution to development. In general, however, there was consensus that all types of play can be beneficial, and Howard argued that children need the opportunity to experience a variety of activities that will develop their full repertoire of play skills. Brostrom, Texter and Muchacka particularly emphasised the importance of socio-dramatic play in children. The provision for children’s play the view of our experts regarding provision for children’s play were also somewhat divided, with those from Denmark, Germany and Sweden believing that the children in those countries had good opportunities for play, whereas the experts from the other five European countries believing they were insufficient. Also, Textor expressed the view that, although there is good provision, play and ‘learning through play’ is quite structured in Germany. In Spain, Marin suggested that play is not completely separated from learning, and is only valued as a means to certain valued results, such as learning, but not as a process on its own right. Benefits and concerns regarding screen-based play In response to a question concerning current anxieties regarding the recent rapid increase in screen-based play, the European experts took a rather balanced view. While it is clearly the case that we live in a digital society and accordingly video games and other screen-based st technologies are a part of 21 century children’s lives, the evidence that this is at the expense of, or directly opposed to, physical and outdoor play is not clear. As we have reviewed earlier in this report, if the amount of time children spend playing outdoors has declined, this appears to be a result of changing attitudes to risk in urban environments rather than to an increase in video game technology. However, excessive, solitary screen based play in early childhood is recognised to be problematic if it limits the development of children’s other play skills, and links have been established in this case with difficulties in social development, obesity and so on. The experts also point out clear evidence of a range of benefits arising from screen-based play. For example, there are studies that indicate physical benefits of video games, such as quickened reaction time.

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