text:
But we can hear them.
Whispering in the backs of classrooms.
Snickering in the hallways at school.
or typing statuses on Facebook.
they follow us like shadows.
He towered above them. Chains draped his hunchback and a gash circled his flattened skull like a crown, but Brentwood middle schoolers weren’t too afraid.
Frank Shelley, a monster, was there to teach them about bullying, even if he didn’t utter a word.
Don’t Be a Monster, a Denver-based bullying prevention program with a twist, hosted an assembly for Brentwood Middle School on Tuesday.
Members of Distortions Unlimited, the Downtown Development Authority and the Greeley Chamber of Commerce gathered at the beginning of the assembly to present the 501(c)(3) with a $2,000 check, courtesy of the Monster Day event hosted in August.
Don’t Be A Monster takes advantage of the Halloween season, late September to early November, to educate kids on bullying while keeping them entertained and giving them a mantra they can remember. The overall metaphor? Bullies are the real monsters.
Program Director Erin Kelley said the nonprofit partners with haunted attractions in 21 cities across the country (and one in Dubai, U.A.E.) to educate kids on bullying in a unique and exciting way. Kelley said the idea strikes a chord in many who operate haunted attractions, and they are almost always enthused to be a part of the program.
“Everyone that owns or runs a haunt was a kid with a unique interest that was bullied,” Kelley said.
The crowd of sixth graders wriggled like worms in a pail while Erin Urban, general manager of 13th Floor Haunted House in Denver, talked about the differences between traditional bullying and cyberbullying. Urban worked with students to define bullying and shed light on some statistics. Seventy percent of students say they’ve witnessed cyberbullying, but only two in 10 students inform their teachers of online attacks for fear of being bullied more, she said.
The students settled when a video depicting Frank at school lit up the projector screen.
Before he can post it, upstanders, people who stand up for those being bullied, intervene and remind Frank he’s not the problem.
Principal Nicole Petersen said she was glad Don’t Be a Monster presented at her school because she likes to take any opportunity she can to empower her students to feel physically and emotionally safe, for everyone deserves that right. Petersen said assemblies like this reiterate the notion of kindness, reminding students what it looks like and why they need to be mindful they don’t know all others have been through.


text:
Tito’s Handmade Vodka is America’s Original Craft Vodka created in 1995 by Bert “Tito” Beveridge who obtained the first legal permit to distill in Texas and created Tito’s Handmade Vodka. Tito’s Vodka batch distills the corn-based vodka using old-fashioned pot stills and the vodka is naturally Gluten-Free. Another important aspect of Bert “Tito’s” vision is the creation of “Vodka for Dog People”, his “program to unite with our friends, fans and partners to better the lives of pets and their families far and wide”.
Tart yet sweet. It’s like an Arnold Palmer, the Tito’s Vodka way.
Add Tito’s Vodka, tea and lemonade to a collins glass over ice. Stir and garnish with a lemon slice.
Tito’s Handmade Vodka’s twist on this minty, slightly sweet Cuban classic.
Muddle mint leaves in a shaker. Add Tito’s Vodka, sugar, fresh lime juice and ice. Shake well and pour everything into a rocks glass. Top with sparkling water and garnish with a mint spring and lime slice.
Expecting a crowd? Try this refreshing potent punch.
Combine all ingredients. Serve over ice in a bowl or pitcher.
Sweet sugar and spicy serrano peppers make the Tito’s Smash a fire cocktail. If you’re sensitive to spice take it easy with the serranos, they don’t play around.
Muddle all ingredients in a shaker with ice. Shake and pour everything into a rocks glass. Garnish with a slice of serrano pepper.

industry_corpus2: Others


text: here's too much subtitles with Klingon talk. It's been well established in the star trek universe that we should hear them in English thanks to the universal translators. Once in a while they'll have alittle Klingon talk like during Kirk's trial in Star Trek 6 but then they switch to English for the sake of the audience. Reading subtitles for large portions of the episode makes it drag. Plus these Klingons sound like whiney children when they try to speak in Klingon. Why are they doing this to us? Trying to appeal to the people that own the Klingon dictionaries or what?

industry_corpus2: Film & Entertainment


text:
One of my happiest times of the year is when persimmons become available. They are a delicious fruit that is slightly sweet, with a little crunch. I love them.
After working out the other night, we took a trip to Whole Foods where they were “singing me to them” (a line from the movie, Australia – loved that movie, it took my breath away!). Anyway… I bought a bunch of them and could clearly not wait until I got home to eat one. I dove right into the bag my husband was carrying before we even got to the car. I pulled one out, smelled it, adored it, and basically worshiped it right then and there. Crazy, I know. But, when you’re hungry and one of your favorite treats is in your hands – well, I just couldn’t help myself. I started chowing down, moaning, no napkin to wipe the juice dripping down my face and hands, just using my sleeve and pants.
I was finished in seconds, literally. And, after a moment of sadness that it was already gone I glanced over at my husband with a dazed look in my eyes (by now, we’re in the car driving to another store in the next complex). He was cracking up at my behavior. Crazed as I was, like a vampire after having only a little taste (huge Twilight fan girl here), I threw off my seat belt and was diving into the back seat of the car after another persimmon. Ahhhh… persimmons.

industry_corpus2: Agriculture & Fisheries


text:
Dishes by disney At The Londoner we pride ourselves on the authenticity of our traditional pub atmosphere. Relax with a great pint of beer and enjoy one of our many traditional British dishes.
33 seafood steamboat Benjamin Heating Products, Innovative heating Products, Designed for Your Home Comfort. 166 Junction Road PO Box 2079, Springhill Nova Scotia, Canada B0M 1X0 Tel: (902) 5973796Benjamin Twiggs satisfies food lovers and gift givers with delicious gourmet cherry foods including jams, jellies, preserves, dessert toppings, pie filling and many more items.
Ways of serving food in restaurants Win a year's supply of Hill's pet food. Register now. Register today for your chance to win a year's supply of Hill's Science Plan™. You'll also receive a monthly newsletter.
Probiotic foods for candida The Science Channel’s 100 GREATEST DISCOVERIES —Physics— 1. The Law of Falling Bodies (1604) Galileo Galilei overturns nearly 2,000 years of Aristotelian belief that heavier. The fairness or justice approach to ethics has its roots in the teachings of the ancient Greek philosopher Aristotle, who said that equals should be treated.

industry_corpus2: Hospitality & Catering


text:
Please note the following requirements regarding images submitted for competition and evaluation. There are some changes (highlighted in yellow) that will come into effect for 2012.
Maximum image dimensions are 1400 pixels wide and 1050 pixels tall, which equates to 1,470,000 pixels or 1.47 megapixels.
Images that are too small do not project favourably and images should therefore be at least at least 1024 pixels wide and 768 pixels tall, which equates to 786,432 pixels or 0.79 megapixels. Images smaller than this may be excluded.
Image files must be no larger than 500KB (kilobytes) in size.
Image submissions must be received by no later than 10pm (22h00) on the Sunday preceding the meeting. Should a submission be received later than this, the email header will be checked and the submission will be allowed only it the sending date is before the deadline.
Images should preferably be attached to emails as attachments rather than being embedded inline within the email.
The attached image files must be named according to the guidelines presented in the How to submit digital images for competitions and evaluation evenings page. It is not acceptable to give your image files another name and provide the correct name in the subject or body of your email.
The onus is on members to ensure that their images adhere to these standards. Failure to adhere to the requirements may result in your images being rejected and excluded from the competition or evaluation. Remember that you can check that your attachments were sent correctly by viewing the sent email/s in your email program’s sent folder.

industry_corpus2: Subject Education


text: Our Match Addon offers you to watch Football replays and highlights on Kodi. You can watch replays, highlights and information of your favourite soccer team on Kodi. All the content in this Addon is scarped from internet and the Author is not responsible for the media that you find in this Addon. If you are looking for football highlights Addon then Our Match Addon will be great addition to your Kodi.

industry_corpus2: Sports


text:
Using Confidentiality Agreements to Protect Sensitive Information When Negotiating the Sale of a Michigan Business.
It is the dream of practically every entrepreneur: build up their business and sell it for big bucks. In order to sell a business, the business owner has to talk with potential (or actual) suitors, negotiate the deal, and exchange certain information so that the parties can know whether the proposed sale is right for them.
Unfortunately, it is not uncommon for parties to go through these steps and decide for whatever reason not to pursue the deal, only for the seller to find out some time later that the former potential buyer is using the seller's confidential information shared during negotiations to unfairly compete against the seller. Fortunately, there is a way to legally protect the private and confidential business information of an entrepreneur who is contemplating selling their business.
The way to do that is to use a properly drafted confidentiality agreement. Before the parties finalize the sale of a business, the buyer will normally do an in depth investigation of the seller’s company. This investigation usually includes such subjects as customers, company finances, prospects for future business opportunities and sales, intellectual property, trade secrets, and other sensitive information. A well represented buyer will insist on being able to undertake this type of due diligence so that it can know whether the transaction is likely to work.
It is advisable (and completely accepted) in these types of transactions for the party requesting sensitive and confidential information to provide a signed confidentiality agreement to protect the party who provides the information. Generally speaking, a properly prepared confidentiality agreement will include a number of important provisions, with perhaps the most important one being an acknowledgment by the buyer that the seller will be entitled to injunctive relief if the confidential information is improperly used or disclosed.
The seller should ensure that the confidentiality agreement sufficiently details the nature and scope of the protected confidential information to ensure maximum protection for the seller. Finally, the seller should be very careful to make sure that the confidentiality agreement is not too onerous or unreasonably restrictive or the buyer could be discouraged from pursuing what might otherwise be a mutually beneficial deal.

industry_corpus2: Law & Justice


text:
For Wexham park classes, you may cancel up to 24 hours before the class and receive a full refund. If you do not, you will be charged for attending.
For all other classes, you may cancel up to 12 hours before the class and receive a full refund. If you do not, you will be charged for attending.
No discounts on Over 60's Yoga and Wexham park Yoga as these are already discounted.


text:
The font descent, expressed in the glyph coordinate system.
See TransformationMatrix for more detail about glyph coordinate system.
Descent is the maximum depth below the baseline reached by glyphs in this font. The value is a negative number.

industry_corpus2: Computing & Telecommunications


text:
Nangarhar, on the porous border with Pakistan, has become a stronghold for ISIS, generally known as Daesh in Afghanistan.
Jalalabad, Afghanistan:Â Islamic State of Iraq and Syria beheaded 15 of its own fighters due to infighting in Afghanistan's eastern province of Nangarhar, officials said, while a separate suicide attack on Thursday tore into a crowd in the provincial capital, Jalalabad, killing at least eight.
The two incidents underline the insecurity and lawlessness across Afghanistan, where thousands of civilians have been killed or wounded this year amid unrelenting violence involving militant groups including Islamic State and the Taliban.
Nangarhar, on the porous border with Pakistan, has become a stronghold for ISIS, generally known as Daesh in Afghanistan, which has grown to become one of the country's most dangerous militant groups since it appeared around the start of 2015. Attaullah Khogyani, the provincial governor's spokesman, said that the 15 ISIS fighters were executed after an infighting in the group.

industry_corpus2: Politics & Administration


text:
, Programming Trainee at Orange & Bronze Software Labs. Inc.
1. Chi-SquareGoodness-of-Fit TestLOZANO, ALDRIN T.
4. Test for Goodness-of-Fit The chi-square statistic can be used to seewhether a frequency distribution fits a specificpattern. This is referred to as the chi-squared goodness-of-fit test.
6. Observed Frequencies vs ExpectedFrequencies Since the frequencies for each flavor wereobtained from a sample, these actual frequenciesare called the observed frequencies. The frequencies obtained by calculation (as ifthere were no preference) are called the expectedfrequencies.
14. SolutionStep 5: Summarize the results There is enough evidence to reject the claim that consumersshow no preference for the flavors.
17. Chi-Square Goodness-of-FitProcedure SummaryStep 1: State the hypotheses and define the claim.Step 2: Find the critical value. (test is always right tailed)Step 3: Compute the test value.Step 4: Make the decision.Step 5: Summarize the results.
21. Another Example continued … The casino becomes suspicious of the gambler and wishes todetermine whether the dice are fair. What do they conclude?
27. Chi-Square StatisticThe chi-square statistic is the sum of the squares of the plottedvalues,(48 – 58)2/58 + (35 – 34.5)2/34.5 + (15 – 7)2/7 + (2 – 0.5)2/0.51.72 + 0.007 + 9.14 + 4.5 = 15.367Given this statistic, are the observed values likely under theassumed model?
28. Making a decision In the gambling example above, the chi-square test statistic X2 wascalculated to be 15.367. Since k = 4 in this case (the possibilities are 0,1,2, and3 sixes) the test statistic is associated with the chi-square distribution with 3degrees of freedom. If we are interested in a significance level of 0.05, we may reject thenull hypothesis (that the dice is fair) if X2 ≥ 7.815, the value corresponding tothe 0.05 significance level for the X2 distribution. Since 15.367 is clearly greaterthan 7.815, we may reject the null hypothesis that the dice is fair at a 0.05significance level.
29. Making a decisionGiven this information, the casino can ask the gambler to take hisdice (and business) somewhere else.

industry_corpus2: Programming


text:
Engagement is a measurement of a combination of factors made by receiving ISPs to determine if recipients want to receive your email. This is a distinction from merely having agreed to receive it by, for example, filling out an opt-in form in order to get a whitepaper or other resource.
With this data, they're looking beyond complaints and into the heart of the matter: Do your recipients really want to hear from you?
Thanks, Jeff! We have those corrected now.


text:
Cozy Chicks: GOT THE DOLDRUMS YET?
For much of the United States, winter has hit in a big way, with too much snow, frigid temperatures, and wind gusts that make it unpleasant to step outside. A week or two I can take, but when it drags on and on, I can feel the doldrums setting in. Have they hit you, too?
I was thinking about that word today – doldrums. It’s obviously plural so it made me wonder: Can one have a single doldrum or do they only come in sets?
As is usually the case when I ponder a word, I have to look it up to see when it originated and why. So I hoisted my ginormous Webster’s New Universal Unabridged Dictionary off the shelf and began my research.
Doldrums, n. 1. a state of inactivity or stagnation as in business or art; 2. The doldrums, a belt of calm and light baffling winds north of the equator between the northern and southern trade winds in the Atlantic and Pacific oceans; 3. A dull, listless, depressed mood; low spirits. (1795-1805. )Obscure origins, dold, stupid (see dolt) + rum(s) (pl) n. suffix (see trantrum).
2. The word doldrum originated from another word meaning stupid plus a suffix. Would that be stupid-ish? Stupid-ment? Again, no explanation. Come on, Mr. Webster, I need more!
3. Doldrums is preceded by: Dolce vita, Italian, sweet life; the good life perceived as one of physical pleasure and self-indulgence (usually preceded by la). Ergo, I would surmise that too much la dolce vita can bring forth a case of the doldrums. Wait. A pair? A set? A flock?
Digress v.i. 1. To deviate or wander away from the main topic or purpose in speaking or writing; depart from the principal line of argument, plot, study, etc. (1520-30) L. Digressus, ptp of digredi to go off, depart.
But I di . . . Anyway, back to the origins of doldrums, and having been told to see tantrum, I looked up tantrum, only to discover this: Tantrum, n. a violent demonstration of rage or frustration; a sudden burst of ill temper. 1740-50, orig. uncert.
Here’s my theory. The reason that tantrum is associated with doldrums is because they both end with rum, which, when consumed, may help one forget the doldrums and/or calm the tantrum resulting from not finding enough of an explanation from a dictionary entry!
A final observation: If you will note, the word digress, which is widely popular now, originated in the early fifteen hundreds. So if you think you’re really with it when you pause to say, “But I digress,” think again. You’re much better off using a really cool phrase like “Easy peasy,” or “Glam-glam” or “Par-tay!” Am I right?
Ennui: French, n. a feeling of utter weariness and discontent resulting from satiety or lack of interest; boredom. 1660-70, Syn: listlessness, tedium, lassitude, languor.
Someone hand me the rum.
P.S. As part of our Cozy Chicks Love Pets Valentine’s Day celebration, one person will be chosen from the comments on this blog to receive a special gift – a donation to your favorite animal shelter/animal charity group.
um…. did you par tay, um.. i mean partake of the rum, before settling down with websters?
Best wishes to most of the eastern parts of the country! doldrums or not, it seems to be COLD!
I don't often pick up a physical dictionary (I usually just take a quick look online) but when I do use a dictionary, I have a tendency to go from word to word, like you did. The dictionary can actually be an interesting read when you don't want to concentrate too much.
Since I haven't indulged in rum or similar type beverages for almost twenty four years, I will have to go with a state of inactivity. Since retiring I have been able to deal with the snowfall a lot better. LOL We seem to be having an average winter as far as snow fall goes. But the temperatures and the winds of the last couple weeks have been brutal. They have also seem to have gotten to my Westie also, as he has been taking care of business in record time, well, for him.
LOL, Malka. Love your play on words. Sadly, no rum at hand. However, I've got my eye on a bottle of Cabernet.
Exactly, Lynda! I could keep wandering from word to word for hours. Especially enjoy the etymology aspect.
Those frigid, never-ending temperatures and strong winds of the last two years have been brutal for our area, Fred. I think both of us are in that snow belt from Lake Michigan and that seems to be one of the factors. I'm ready for spring!
This is when ships get becalmed, and they have to loll around, waiting for the wind to pick up. Sort of the way we're all sitting around and waiting for the weather to improve.
Winter in West Michigan consist of 5 months of grey, dreariness. The occaisional sunny days only bring on bitter cold. Thank you for the group Saturday, nice break if just for a couple of hours. It is up to a balmy 1 above this morning. Rock on everyone.
We try, Robert. Glad you enjoyed it.
I'm overcome by the doldrums and so are my beagles. We are bored,, bored, bored. I can read a good book to help lift my spirits but the poor beagles can't. We are just hoping that we don't get record snows in March because so far just a lot of grey but not much snow here in Minnesota.
I think the boredom bothers my husband the most. He works outside, but with the brutal cold, snow and now ice, he can't. It drives him crazy which in turn drives me crazy. Maybe that is where Tantrum comes in? Lol!
I know exactly how you feel, Sue. So much of the Minn/Wis/Ill/IN area is gray for weeks at a time. Wouldn't it be nice to have a big play area for adults? How about a ball pit? I saw one on GMA for adults. Looked like fun. Not so much for dogs probably.
Yes, Jeannie, it sure is, and that is where the RUM comes in. LOL.
Since we have had - to quote Jim Cantore of the Weather Ch. two winter's worth of snow in 23 days, my doldrums would be deep if I didn't have a fireplace and books to read in front of. I'm just happy I do not have to drive in it every day since I retired.
I had the doldrums last weekend, nothing I really wanted to do, no book or internet site captured my attention. I ended up watching old episodes of Storage Hunters and Auction Hunters.
Isn't that the best thing about retirement? Looking out the window and thinking, "I don't have to get out in that!"
Gray days are the worst! We get those with our snow and wind. When the sun finally comes out, it's beautiful. With that said, I'd still prefer to see my green lawn and flowers!
I live in Austin, so there are no huge blizzards. But, at times the grey days last too long and they make me sink - into a time when I do not feel like doing anything. I like the sun. I believe that is because in another life I was a lizard who spent the day lounging on a hot rock. Love those hot rocks.
Here in Portland, OR we're all waiting for the other shoe to drop. It's been too nice, too warm, and not wet enough for too long.
Hmm. Then maybe I was a chaise lounge in my previous life.
And there is always another shoe. Enjoy it while it lasts!
How can I not write a comment when my favorite pet charity might get a donation? Here in Alaska, we are having the warmest winter on record. The east coast has gotten all of our snow this year. The skiers are complaining and you might have heard they Iditarod dog sled race had to be moved farther north due to lack of snow; lack of snow and warmer temperatures makes it a lot harder on the dogs so it was a wise move.
Looking forward to summer, but then again I say that every year!
Kate, I think your donation idea is a wonderful thing to do!!
We had a very mild December here is NYS Capital District and the first two weeks of January were not bad, but the cold set in late January and we have had 2 pretty big snow falls in February (both about 12 inches) and still cold. So YES! all of the above stated definitions apply to me. But, I try to look on the bright side, days are getting longer and we will be changing the clocks in a couple of weeks. March 1 is two weeks away and Spring is four weeks. Unfortunately the bright side only gets me so far!
Unfortunately I don't drink alcohol, but a Dunkin Donut Brownie Batter Donut should work fine!
I have found that taking Vitamin D has kept me from feeling bad about the weather. I get out as much as I can.I even found trace mineral salt that they said was safe for animals to put on the ice.
Vitamin D helps me, too, Rachelle. I'm a big believer in taking a large dose (always with Vitamin K for absorption) for its immune system benefits.
Debbie, I was up in Alaska last summer and got to visit a dog sled camp where they train for the Iditarod. Fascinating! I got to cuddle puppies, too. Are you happy that the winters have been milder?
Thanks, Kathy. I donate to three already and always love helping animals. They're my favorite charity actually.
Oh, Cordella, that's too bad about your governor. I'll gladly donate mine. (see tongue-in-cheek).
It's been really cold for Baltimore. I'm retired so I don't have to go out. I'm getting a lot of sewing done. But I'm looking forward to nicer weather so I can ride my bicycle.
Hi Kate, Lots of Alaska love their winter sports but, after 20 years, I love a milder winter. The only hard part is when temperatures get above freezing because then things melt...when they refreeze again everything is like an ice skating rink. When I first moved here that almost never happened, now it's a fairly regular occurrence. Glad you enjoyed your trip here. It is a beautiful state!
DEBBIE, YOU WON!! YOU'RE the winner of today's blog drawing! Please contact me via Facebook message about which animal charity you'd like me to donate to. CONGRATULATIONS!!
Hi Kate, I don't have a facebook account so I contacted you through your website. I wanted to double check that you received the email. Friends of Pets (in Alaska) will put the donation to good use.


text:
Utilization indices exist to measure quantity of prenatal care, but currently there is no published instrument to assess quality of prenatal care. The purpose of this study was to develop and test a new instrument, the Quality of Prenatal Care Questionnaire (QPCQ).
Data for this instrument development study were collected in five Canadian cities. Items for the QPCQ were generated through interviews with 40 pregnant women and 40 health care providers and a review of prenatal care guidelines, followed by assessment of content validity and rating of importance of items. The preliminary 100-item QPCQ was administered to 422 postpartum women to conduct item reduction using exploratory factor analysis. The final 46-item version of the QPCQ was then administered to another 422 postpartum women to establish its construct validity, and internal consistency and test-retest reliability.
Exploratory factor analysis reduced the QPCQ to 46 items, factored into 6 subscales, which subsequently were validated by confirmatory factor analysis. Construct validity was also demonstrated using a hypothesis testing approach; there was a significant positive association between women’s ratings of the quality of prenatal care and their satisfaction with care (r = 0.81). Convergent validity was demonstrated by a significant positive correlation (r = 0.63) between the “Support and Respect” subscale of the QPCQ and the “Respectfulness/Emotional Support” subscale of the Prenatal Interpersonal Processes of Care instrument. The overall QPCQ had acceptable internal consistency reliability (Cronbach’s alpha = 0.96), as did each of the subscales. The test-retest reliability result (Intra-class correlation coefficient = 0.88) indicated stability of the instrument on repeat administration approximately one week later. Temporal stability testing confirmed that women’s ratings of their quality of prenatal care did not change as a result of giving birth or between the early postpartum period and 4 to 6 weeks postpartum.
The QPCQ is a valid and reliable instrument that will be useful in future research as an outcome measure to compare quality of care across geographic regions, populations, and service delivery models, and to assess the relationship between quality of care and maternal and infant health outcomes.
The evidence for the effectiveness of prenatal care remains equivocal, despite its widespread use [1, 2], and substantial amounts of health care resources “continue to be expended on a tradition of care that has not proven itself equal to the perinatal health issues of today” . Previous research has frequently relied on prenatal care utilization indices to study the association between adequacy of prenatal care and pregnancy outcomes [4–6]; however these indices focus solely on quantifying the use of care and do not adequately assess the content or quality of care . Several studies have highlighted the potential importance of content and quality of care [7–14]. In fact, the “role of adequate utilization has more recently been downplayed and greater credence has been given to the importance of the content, comprehensiveness, and quality of prenatal care” .
The content and quality of prenatal care have been measured in different ways. For example, Beeckman and colleagues recently developed the Content and Timing of Care in Pregnancy (CTP) tool to assess women’s receipt of recommended content based on recommendations in national and international guidelines . Participants recorded the timing and content of prenatal care using diaries. These investigators concluded the content items need further refinement prior to larger scale testing of the new measure . Content has also been measured in studies that examined the effect of adherence to recommended prenatal care content, assessed from medical records, on pregnancy outcomes [9–11]. Other studies have investigated the impact of enhanced or augmented prenatal services [12, 13, 15] or new models of care, such as group prenatal care , on outcomes. The quality of prenatal care has been evaluated using focus groups to explore quality as experienced by women [17–19], developing audit indicators of quality of prenatal care , or using checklists, observations and exit interviews . Wong and colleagues developed an instrument to measure the quality of interpersonal processes of care , but this instrument measures only one dimension of quality. To date, research on the effectiveness of prenatal care has been hindered by the lack of an instrument that comprehensively measures quality of prenatal care.
Assessment of prenatal care has focused primarily on women’s satisfaction, but often without clear distinction between the constructs of satisfaction and quality of care. Research to empirically test the relationships between these variables provides evidence that perceived quality affects satisfaction with health care, and that quality of care and consumer satisfaction are distinct constructs [23, 24]. Quality is defined as a judgment or evaluation of several dimensions specific to the service being delivered, whereas satisfaction is an affective or emotional response to a specific consumer experience [23, 24]. Satisfaction measures tend to include components that are considered elements of quality, such as structure of service delivery (wait time, continuity of care, physical environment) and process of care (advice received, explanations given by care provider, technical quality of care) [25–27]. These instruments have limitations in that they do not discriminate between quantity and quality of care , generally lack psychometric evaluation , and do not adequately tap varying dimensions of the uniqueness of prenatal care . Finally, satisfaction measures are insensitive, as most women report high levels of satisfaction with prenatal care [25, 26], particularly when measured after delivery .
Approaches to the assessment of quality of prenatal care have been largely atheoretical. Among the few studies that have based their selection of measures on a theoretical framework [21, 30–32], the two frameworks most commonly used were Donabedian’s [33, 34] model of quality and Aday and Andersen’s [35, 36] theoretical framework for the study of access to medical care. The latter model is primarily focused on health service utilization issues. There is a need to develop a theoretically-grounded measure of prenatal care quality that is distinct from satisfaction measures in order to better evaluate the relationship between quality of prenatal care and pregnancy outcomes. The conceptual framework guiding this research was Donabedian’s systems-based model of quality health care . The framework encompasses a three-part approach to quality assessment, in which “good structure increases the likelihood of good process, and good process increases the likelihood of a good outcome” . Structure includes attributes of the setting in which care is provided, such as material and human resources and organizational structure . The process component reflects the actual care given. There are two processes of care: clinical or technical, and interpersonal . According to Donabedian, the goodness of technical performance should be judged in comparison with best practice, while interpersonal process is the vehicle by which technical care is implemented and includes information exchange, privacy, informed choice, and sensitivity .
In keeping with the findings of qualitative studies that demonstrated the value women place on the interpersonal processes of prenatal care (including communication, decision-making and interpersonal style), recent attention has been focused on the conceptualization of these processes, their measurement, and their impact on women’s satisfaction and perception of quality of care [7, 22]. Research has demonstrated that ineffective communication is a barrier to prenatal care utilization [38–40]. Care provider characteristics, such as lack of perceived concern and respect, being task focused and conveying an authoritarian approach, also deter use of prenatal care [40–42]. These characteristics also can be a barrier to women disclosing health concerns . Thus interpersonal processes are important in keeping women engaged in prenatal care and, ultimately, in enhancing outcomes.
The development of an instrument to measure quality of prenatal care can be informed by multiple sources, including the available research evidence regarding effective clinical practices and the perspectives of care providers and women [21, 37]. Because quality of care is determined by the structure of service delivery and service-giving processes [34, 44], it encompasses content dimensions through its attention to the technical (e.g., physical examinations and tests) and interpersonal (e.g., health promotion counseling) aspects of care. Care providers are best positioned to comment on clinical aspects of care , including that which is knowledge-based but does not necessarily have scientific evidence of effectiveness . Few studies have considered the perspectives of pregnant women in the development of measurement instruments [26, 27], and only one tool incorporated both women’s and health care providers’ perspectives .
To conduct psychometric testing of the final version of the QPCQ.
This study addressed the development, validation, and evaluation of a research instrument. Guided by the methodological frameworks for developing measurement scales described by Streiner and Norman  and Pett, Lackey and Sullivan , the study consisted of five phases implemented over the course of 4 years. Refer to Figure 1 for a flow chart of the five phases. Phase One was development of an instrument to measure quality of prenatal care, and included item generation, content validity, rating of importance of items, and item presentation. Phase Two consisted of face validation and pretesting. Phase Three was item reduction using factor analysis. Phase Four involved instrument evaluation, that is, psychometric testing to establish its construct validity, internal consistency reliability, and test-retest reliability. Phase Five involved temporal stability testing. Ethical approval for this study was received from Hamilton Health Sciences/McMaster University Faculty of Health Sciences Research Ethics Board, the University of Manitoba Education/Nursing Research Ethics Board, the University of Calgary Conjoint Health Research Ethics Board, the IWK Health Centre Research Ethics Board, and the University of British Columbia Clinical Research Ethics Board.
Flow chart of five phases of development and testing of the QPCQ.
The first step of the instrument development process was to generate a comprehensive list of items to represent the various components of the construct quality of prenatal care. The items for the initial questionnaire were generated from two sources. The first source was a qualitative descriptive study involving in-depth semi-structured interviews with 40 pregnant women and 40 prenatal care providers from five urban centers across Canada (Vancouver, Calgary, Winnipeg, Hamilton, and Halifax), conducted between April and November 2008. The qualitative descriptive study is described in detail elsewhere . In keeping with Donabedian’s suggestion that the goodness of clinical or technical performance should be judged in comparison with best practice , the second source of items was a review of the evidence from 15 international guidelines that inform the provision of prenatal care. Table 1 presents a list of the prenatal care guidelines reviewed.
A clinimetric or “clinical sensibility” approach was used to select which of the 206 items in the QPCQ would be retained for the next step of instrument development . This approach relied on the judgments of patients and clinicians rather than on mathematical (psychometric) techniques to determine which items to include . The sample of 40 women and 40 health care providers who participated in the qualitative descriptive study  were mailed a copy of the 206-item instrument along with a cover letter and self-addressed, stamped envelope for return in June and July of 2009. Four randomly generated versions of the list of QPCQ items were prepared to avoid response fatigue toward the end of rating all the items. To maximize response rate, a modification of Dillman’s tailored design method was utilized, including a reminder letter and second mailing of surveys to respondents . In the cover letter, participants were given the following instructions: “When you rate the items, we are not asking you to reflect on your own experiences with prenatal care. Rather, we would like you to rate how important you think each item is in the care provided by health care professionals to pregnant women using a 7-point rating scale from 1 (not very important) to 7 (extremely important).” Data for this phase were entered into Microsoft Excel. A mean rating score was generated for each item.
Once the most important items were selected for inclusion in the QPCQ, the research team discussed and made decisions regarding instrument format, printed layout, wording of instructions to the subjects, wording and structuring of the items, and response format . Our intent was to develop an instrument suitable for self-administration to pregnant or postpartum women.
Once the newly formed instrument had been drafted, it was assessed for face validity and pretested. Face validity refers to the appearance of the instrument to a layperson, and whether the instrument appears to measure the construct . Pretesting was used to ensure that items were clearly written and were being interpreted correctly . Research assistants administered the 111- item version of the QPCQ to 11 pregnant women in two sites (Winnipeg and Hamilton) between November and December 2009 in a location of the participants’ choice (e.g., prenatal care facility, own home). Women were instructed to respond to each item as if they were actually participating in a study, but to mark items that were difficult to read or confusing. The length of time to complete the QPCQ was recorded. Women were then asked a series of questions by the research assistant about the clarity of the instructions and the items, whether the items appear to be related to the construct of quality of prenatal care, suggestions for alternate wording, items that should be added or removed, and the overall appearance of the instrument. The feedback regarding the quality of prenatal care instrument was discussed by the researchers and revisions were made accordingly.
The purpose of this step was to further reduce the number of items in the QPCQ by eliminating any that were redundant or not congruent with the overall construct being measured. We aimed to recruit a convenience sample of at least 400 women (approximately 80 women per study site) to participate in the item reduction step. A sample size of 400 women was determined to be sufficient as Devillis  suggests that a sample size of 200 is adequate in most cases of factor analysis, while Comrey and Lee state that a sample size of 300 is good and 500 is very good .
Subjects were recruited from hospitals providing obstetrical services in each study site. These hospitals included BC Women’s Hospital, Vancouver, BC; Foothills Hospital, Calgary, AB; St. Boniface General Hospital and Health Sciences Centre Women’s Hospital, Winnipeg, MB; St. Joseph’s Healthcare, Hamilton, ON; and IWK Health Centre, Halifax, NS. Women were eligible to participate if they had given birth to a singleton live infant, were 16 years of age or older, had at least 3 prenatal care visits, and could read and write English. We excluded women with a known psychiatric disorder that precluded participation in data collection, and women who had a stillbirth or early neonatal death because it would be inappropriate to collect data from these women during the grieving process.
Nursing staff of the postpartum units were asked to identify women who met the inclusion criteria and determine their willingness to learn more about the study. Women were then approached by the site research assistant (Vancouver, Calgary, Winnipeg, Halifax) or the research coordinator (Hamilton), who provided a verbal explanation and written information about the study. Signed, informed consent was obtained from those who agreed to participate. Participants completed the QPCQ and a brief demographic form, and received a $20 gift certificate in appreciation for their time and contribution to the study. Data collection for Phase Three was conducted between March and June 2010.
Exploratory factor analysis was conducted using SPSS Version 18.0. Exploratory factor analysis is used when the researcher does not know how many factors are needed to explain the interrelationships among a set of items, indicators, or characteristics . This analytic approach involves a series of structure-analyzing procedures to identify the interrelationships among a large set of observed variables and group the variables into dimensions or factors that have similar characteristics . First, a correlation matrix was constructed to summarize the interrelationships among the items in the scale . The matrix was examined to identify any items that were either too highly correlated (r ≥ 0.80) or not correlated sufficiently with one another (r <0.30), and these items were dropped from the analysis. Exploratory factor analysis was then used to explore the underlying dimensions of the construct of interest , since the conceptual framework did not clearly specify a set number of subconcepts or process of care dimensions [55, 56]. Principal axis factoring was used to extract the factors, followed by oblique rotation using the direct oblimin procedure . We chose oblique rotation because we did not expect the dimensions to be orthogonal, i.e., uncorrelated with one another. A factor pattern matrix was generated, which contained the loadings that represented the unique relationship of each item to a factor, after controlling for the correlation among the factors . Items with weak loadings (less than 0.40) or that did not load reasonably on any factor were deleted.
Phase Four involved administering the newly designed 46-item QPCQ to women to establish its construct validity, internal consistency reliability, and test-retest reliability. Similarly to the previous phase, participants were recruited from hospital postpartum units in each study site using the same eligibility/ineligibility criteria and recruitment procedure. Study participants were asked to complete a brief demographic questionnaire, the 46-item QPCQ, the Patient Expectations and Satisfaction with Prenatal Care Instrument (PESPC) , and the Prenatal Interpersonal Processes of Care (PIPC) instrument . Women were given a second copy of the QPCQ to be completed 1 week later and returned in a stamped self-addressed envelope. Each participant received a $20 gift certificate in appreciation for their time and contribution to the study. Data collection for Phase Four was conducted between September and December 2010.
Validity testing of an instrument is on an ongoing process to determine whether there is sufficient evidence to support that it accurately measures the construct it was designed to measure, and the degree to which it performs according to theoretical predictions . First, confirmatory factor analysis was conducted, using the Amos version 7 statistical analysis program, to test the utility of the underlying dimensions of the construct that were previously identified though exploratory factor analysis . A second approach to determining construct validity was through hypothesis testing. According to Donabedian, patient satisfaction is one of the desired outcomes of quality of care . Although different definitions of quality were used, a randomized controlled trial  and a cross-sectional study  found that women who received “high quality” prenatal care were significantly more likely to be satisfied with their care. We hypothesized that women who rated the quality of their prenatal care higher would have higher ratings of satisfaction with prenatal care. The Pearson correlation between the total QPCQ score and the satisfaction subscale score of the Patient Expectations and Satisfaction with Prenatal Care instrument (PESPC)  was estimated. The PESPC is a 41-item self-administered questionnaire designed to measure pregnant women’s expectations and satisfaction with the prenatal care they anticipated and received. The PESPC is structurally valid, and the satisfaction subscale demonstrates an acceptable level of internal consistency (Cronbach’s alpha of 0.94). The third approach was to test the convergent validity principle, whereby different measures of the same construct should correlate highly with each other . Although there is no other instrument that measures quality prenatal care in all its dimensions, one instrument has been developed to measure the quality of interpersonal processes of prenatal care, known as the Prenatal Interpersonal Processes of Care (PIPC) . The PIPC has seven subscales and 30 items that reflect three underlying dimensions: Communication, Patient-Centered Decision Making, and Interpersonal Style. The majority of the seven subscales have acceptable internal consistency reliability (ranging from 0.66 to 0.85) and preliminary evidence of construct validity has been established. It was anticipated that one or more of the PIPC subscales (such as respectfulness/emotional support) would measure similar constructs as one or more of the QPCQ subscales, and if so, the Pearson correlation between the subscales would be estimated.
Reliability of an instrument is the degree of consistency with which it measures the attribute it is intended to measure . Both internal consistency reliability and test-retest reliability of the QPCQ were assessed.
Internal consistency is based on the average correlation among items within a test  and assesses homogeneity or the extent to which all items measure the same construct . Cronbach’s alpha was used to assess the extent to which performance of any one item on the instrument was a good indicator of performance of any other item on the same instrument , and was calculated for both the overall scale and each of the subscales. A Cronbach’s alpha coefficient of at least 0.70 is considered acceptable, while 0.80 or greater is desirable [46, 59]. In addition, item-to-total scale correlation coefficients for the instrument subscales were examined, as well as whether the Cronbach’s alpha increased if any of the items were deleted.
The test-retest method is a test of stability to determine whether the same results are obtained on repeat administration of the instrument to the same sample. As mentioned previously, women participating in this phase of the study were given a second copy of the QPCQ to be completed one week later and returned by mail. This time interval is within the recommended retest interval of 2 to 14 days . For each participant who returned the second questionnaire, their scores on the QPCQ were summed for time one and time two, and the level of agreement between the two sets of scores was determined using the intra-class correlation coefficient (ICC). Reliability coefficients above 0.70 are considered acceptable . For the sample size calculation, the minimal acceptable level of ICC was set at 0.75 and the upper limit of ICC at 0.85, with α = 0.05 and β = 0.20. Using the method suggested by Walter, Eliasziw and Donner , a minimum sample size of 79 subjects was needed.
This phase was conducted to assess whether or not women’s responses to the QPCQ were stable between late pregnancy and the postpartum period, in order to determine whether or not the birth experience and outcome might have influenced women’s recall of quality of care and their responses to the questionnaire. This information is needed to inform timing of administration of the questionnaire in future research.
For this phase of the study, we collected data from 234 women in four of the study sites. Women were asked to provide background information and complete a package of questionnaires shortly before they gave birth (after 36 weeks gestation) (Time 1), again during their postpartum hospital stay (Time 2), and then again 4 to 6 weeks after the baby was born (Time 3). Data collection was conducted between January and July 2011. Mean scores on the total QPCQ and each of the subscales were calculated. At first, we used a randomized block design (RBD) analysis of variance to evaluate the differences between the three time points. RBD was used to adjust for the correlations between time points for the same individuals. However, because of an imbalance in the number of participants at different time points and to use the most information available in the data, we followed RBD with conducting a paired t-test between each two time points (i.e., Time 1 and Time 2, Time 1 and Time 3, Time 2 and Time 3). The intra-class correlation coefficient (ICC) was used to examine stability of the QPCQ total score and subscale scores across the three time periods.
Results from the qualitative descriptive study  and the review of prenatal care guidelines were used to create a blueprint to establish the specific scope and emphasis of our instrument to measure quality of prenatal care, including the major domains to be assessed . The Co-Principal Investigators (MIH & WAS) generated an initial list of 210 items for the preliminary version of the Quality of Prenatal Care Questionnaire (QPCQ). Several of the items were generated from the interview data that informed the development of themes. These themes were organized into three main categories informed by the structure and process components of Donabedian’s  model of quality health care. Structure of care themes included access to care, staff and provider characteristics, and the physical setting. Themes under clinical care processes included screening and assessment, health promotion and illness prevention, continuity of care, information sharing, women-centeredness, and non-medicalization of pregnancy. Themes concerning interpersonal care processes included emotional support, approachable interaction style, taking time, and respectful attitude . Items generated from the guideline review reflected components of prenatal care rated as having a high certainty of net benefit (i.e., “A” grade evidence) ). The research team then met to review and discuss the list of 210 items, and as the content experts, assessed the content validity of the QPCQ by evaluating each item for its relevance and clarity, and for any repetition of items. Four items judged to duplicate other items were removed.
Ratings of the importance of the 206 items for the QPCQ were received from 56 participants (70% response rate). The overall top 100 items that were rated as most important were retained for the next version of the instrument; these items had a mean rating of 5.7 or higher on a scale of 1 to 7. In order to ensure that the perspectives of women and health care providers were equally represented, we also added any items ranked in the top 50 from either women or providers that were not in the overall top 100. Because there was generally good congruence between women and providers in rating the importance of items, this resulted in only 3 items with high ratings from health care providers and 2 items from women being added to the top 100 items. Six items derived from A-level evidence but not in the top 100 items were also retained. These steps resulted in a QPCQ with 111 items.
During the pretesting phase, the mean length of time for women to complete the 111-item version of the QPCQ ranged from 10 to 23 minutes, with a mean of 16 minutes. Women indicated that the QPCQ was easy to complete, and only a few items were identified as potentially problematic. Based on this feedback, 11 items were removed from the QPCQ, either because the item was too vague (e.g., “My prenatal care provider was thorough”) or the item was not universally applicable to all pregnant women (e.g., “My prenatal care provider took time to answer my partner’s/family member’s questions”). This resulted in a 100-item questionnaire. In addition, four items underwent wording changes to improve their clarity or completeness (e.g., The item “I fully understood the reasons for tests my prenatal care provider (s) ordered for me” was changed to “I fully understood the reasons for blood work and other tests my prenatal care provider (s) ordered for me”).
1Missing responses were excluded from analyses.
*Halifax did not participate in Phase Five of the study.
**Percentages reported for prenatal care providers do not add to 100 as women were instructed to check off all that applied.
***In Phase Five, responses for these items are reported for Time 2 participants (n = 194 postpartum women).
Information Sharing: The 9 items within this factor focus on how prenatal care providers answer questions, keep information confidential, and ensure women understand reasons for tests and their results.
Anticipatory Guidance: The 11 items in this factor focus on women being given enough information to make decisions about their prenatal care and how their prenatal care providers prepare and give women options for their birth experience.
Sufficient Time: The 4 items within this factor focus on the time prenatal care providers spend addressing women’s questions and the time spent in an appointment.
Approachability: The 4 items in this factor address the health care provider’s approachability (e.g., woman was afraid to ask questions, felt like she was wasting prenatal care provider’s time).
Availability: The 5 items in this factor include knowing how to contact the prenatal care provider and how available the clinic/office staff or prenatal care provider are to respond to questions, concerns or needs.
Support and Respect: This factor has 12 items related to women being respected and supported by their prenatal care providers in regard to their concerns and decisions.
We used the Flesch-Kincaid Grade Level test, available in Microsoft Word, to assess the readability of the 46-item QPCQ. This test rates text on a U. S. school grade level, which is similar to the Canadian grade level system. The QPCQ had a Flesch-Kincaid grade level score of 8.7, which means that women with a grade 9 education can read and understand the items in the QPCQ.
The final sample for Phase Four consisted of 422 women. Demographic characteristics of the participants are summarized in Table 2.
Confirmatory factor analysis verified and confirmed the presence of six factors, and all 46 items were therefore retained in the QPCQ. Refer to Table 3 for a list of the items loading on each factor. The factor (or subscale) means and standard deviations are presented in Table 4. Each subscale mean score was calculated by first reversing the scores of any reverse scored items in the subscale, then summing the scores for the items of the subscale and dividing the sum by the number of items. The QPCQ is a norm-referenced measure, in which an individual’s score takes on meaning when compared with the scores of others (e.g., in the same sample) . Higher scores on the QPCQ and its subscales reflect a higher rating of quality of prenatal care. The mean scores for the factors ranged from 3.84 to 4.37 out of a total score of 5, indicating that women rated the quality of their prenatal care toward the higher end of the continuum. The factor “Anticipatory Guidance” had the lowest mean rating, while “Information Sharing” had the highest mean rating.
A significant positive correlation between the QPCQ total score and the satisfaction subscale score of the PESPC provided additional support for construct validity (Pearson r = 0.81). Convergent validity was demonstrated by a significant positive correlation (r = 0.63) between the “Support and Respect” subscale of the QPCQ and the “Respectfulness/Emotional Support” subscale of the PIPC, and a significant positive correlation (r = 0.59) between the “Anticipatory Guidance” subscale of the QPCQ and the “Empowerment/Self-care” subscale of the PIPC.
Testing showed acceptable internal consistency reliability for the overall scale (Cronbach’s alpha = 0.96) and for the six subscales (ranging from 0.73-0.93). Refer to Table 3 for the results. Item-total scale correlation coefficients were positive, and the Cronbach’s alpha did not increase if any of the items were deleted, with the exception of one item, “My prenatal care provider was rushed,” showing a slight increase.
Of the 422 participants, 182 women (43%) completed the retest version of the QPCQ 5 to 14 days later and returned it by mail. The QPCQ demonstrated acceptable test-retest reliability (ICC = 0.88), indicating stability of the instrument on repeat administration.
Demographic characteristics of the participants in Phase Five (Time 1) are summarized in Table 2, and the sample size for each site and time period is shown in Table 5. There were 234 participants at Time 1, 194 at Time 2, and 158 at Time 3, demonstrating some attrition over time. There were no statistically significant differences in mean scores across time periods for the majority of the QPCQ subscales (Tables 6, 7, and 8). Although there was a significant difference in mean score for the Anticipatory Guidance subscale between Time 1 and 2 (d = 0.22) and between Time 1 and 3 (d = 0.17), and for the mean QPCQ score between Time 1 and 2 (d = 0.07), the differences in mean scores were small and deemed not to be clinically significant. The intra-class correlation coefficient (ICC) was also used to examine stability of the QPCQ subscale scores across the three time periods, and varied from 0.67 to 0.76 (Table 9). The ICC for the total QPCQ score was 0.81 (95% CI: 0.76-0.85).
*T1 = time one, T2 = time two, T3 = time three.
Measurement of the quality of prenatal care is an essential step in more fully evaluating its effectiveness. We have developed a new instrument, the Quality of Prenatal Care Questionnaire (QPCQ), through a rigorous process of item generation and psychometric testing. The QPCQ was designed to be completed by women who received prenatal care, consistent with growing acknowledgement of the value of the consumer’s viewpoint in evaluating quality of health care [22, 23, 62, 63]. The final 46-item version of the QPCQ demonstrated construct validity, as well as acceptable internal consistency and test-retest reliability. Having women complete the QPCQ before delivery, during their postpartum hospital stay, and again 4 to 6 weeks after delivery confirmed that women’s ratings of their quality of prenatal care did not change as a result of giving birth or between the early postpartum period and 4 to 6 weeks postpartum. These results suggest that the QCPQ can be administered to a woman after 36 weeks gestation and up to 6 weeks postpartum.
Exploratory factor analysis resulted in a six-factor solution for the QPCQ, with six factors retained in the confirmatory factor analysis. This indicates that the concept of quality of prenatal care is multidimensional and the instrument consists of six subscales . In addition to the total QPCQ score, the score for each of the subscales can be examined separately. The derived factors made conceptual sense, and were consistent with the themes arising from our qualitative descriptive study . The six subscales of the QPCQ measure both structure and process attributes of Donabedian’s model, with more emphasis on clinical and interpersonal processes of care. Although the initial draft of the QPCQ contained several items related to structure of prenatal care, many of these items were rated low on importance in Phase One and were subsequently deleted from the questionnaire (e.g., “The office/clinic was in a convenient location,” “The waiting area was crowded.”). This is consistent with Campbell’s viewpoint that structure is not a component of care “but the conduit through which care is delivered and received” . As such, structure may influence the way in which care is provided and thus women’s assessment of quality. For example, having adequate funding, facilities and personnel may influence women’s responses to items in the “Sufficient Time” subscale (e.g., “I had as much time with my prenatal care provider as I needed”) and the “Availability” subscale (e.g., “I could always reach someone in the office/clinic if I needed something”). Items in the QPCQ “Information Sharing” and “Anticipatory Guidance” subscales primarily measured the clinical or technical processes of care, while items in the “Approachability” and “Support and Respect” subscales reflected interpersonal processes. Mean scores for the subscales ranged from 3.84 to 4.37, and indicated that women rated the quality of “Anticipatory Guidance” the lowest, and “Information Sharing” and “Support and Respect” the highest (Table 4). In the temporal stability testing phase, the Anticipatory Guidance subscale was the only one showing significant (although small) differences in mean scores over time, with both postpartum scores being higher than the prenatal score. Some of the Anticipatory Guidance items may be more accurately assessed by women in the postpartum period (e.g., “I was given enough information to meet my needs about breastfeeding”), possibly resulting in higher rating scores.
The subscales and items in the QPCQ measure components of quality of prenatal care identified by women as important in other qualitative studies [17–19] and an integrative review . Wheatley and colleagues found that markers of quality prenatal care included the extent to which the provider listened carefully, showed respect, explained things, and spent enough time with the woman . The main elements of quality of maternity care services identified in Goberna-Tricas’s study were technical expertise of the health professional, the human dimension of the relationship between the caregiver and the patient (interpersonal skill), and the structural aspects that determine the context in which the health care is provided . Hildingsson and Thomas analyzed responses of 827 Swedish pregnant women to an open ended question in a survey, and grouped the findings into the following categories: technical aspects of care (being skilled and competent), psychological aspects of care (being a good listener, being supportive, treating the woman with respect), personal characteristics (not judging, not being rushed), health-related content and information (checking the baby’s health, providing information about physical and mental changes and breastfeeding), and structural aspects of provider visits (enough time during visits, continuity of care) . The items in the QPCQ capture the majority of these aforementioned elements of quality of prenatal care.
The QPCQ was developed taking into consideration effective prenatal care practices, the diversity of the Canadian population, and variations in the way prenatal care is delivered, and with input from both consumers and providers of care. The five study sites provided a broad cross-section of the childbearing population in Canada and its multicultural uniqueness. For instance, Winnipeg has a large and growing Aboriginal population, Vancouver has a high concentration of immigrants from East Asia, and Halifax serves a large rural population. Similarly, there are differences in the options for prenatal care available to women across the five study sites. Midwifery care was not regulated or integrated into the health care system in Nova Scotia at the time of this study, but was more widely available to women living in certain areas of Ontario, such as Hamilton, and other provinces where midwifery was a regulated profession. In some provinces, obstetricians were the most common provider of prenatal care (e.g., Ontario) compared to family physicians in others (e.g., British Columbia) . Finally, some prenatal programs had integrated additional or substitutive prenatal care through nurse specialists and nurse practitioners . The study protocol thereby ensured the development of an instrument that captured core elements of quality applicable to the Canadian population as a whole under a system of universal health care.
Our study also has limitations. The QPCQ was developed in the context of the Canadian health care system, so its applicability to health care systems, prenatal care provision, or populations that are substantively different will need to be assessed prior to widespread use. The instrument was intended to be applicable to all pregnant women; therefore the items may not fully capture all elements of quality in specific situations, such as care provided to women with a complicated or high risk pregnancy. The QPCQ reflects the woman’s perception of the quality of prenatal care she received; further research is needed to determine the congruence between the woman’s assessment of quality and the extent to which the care she received conformed to guidelines for prenatal care using methods such as chart audits. The relatively high mean scores found among some of the QPCQ subscales may be a reflection of selection bias incurred as a result of using a convenience sample, in that women who agreed to participate in the study may have viewed the quality of their care more positively than women who declined participation. In addition, the response rate for completion of the retest version of the QPCQ was relatively low (43%), although the number of respondents (n = 182) exceeded the minimum sample size of 79 estimated as needed in the sample size calculation.
Finally, we acknowledge there are competing views regarding use of non-parametric versus parametric statistics to analyze Likert scales [67, 68]. Although individual Likert items are ordinal in character, we support the position that Likert scales (collections of Likert items) produce interval data, and that it is appropriate to summarize the ratings generated from Likert scales using means and standard deviations, and to use parametric statistics to analyze the scales . Health care providers may find it helpful to examine the rank order of (dis)agreement for individual items on the QPCQ to identify specific aspects of prenatal care in need of quality improvement. However, for research using the QPCQ, we agree with Carifio and Perla’s view that treating the data from Likert scales as interval in character permits “more powerful and nuanced analyses” .
This valid and reliable instrument can now be used as an outcome measure to evaluate quality of prenatal care, to identify predictors of quality of prenatal care, to compare and contrast quality of prenatal care across regions, populations, and types of health care providers and service delivery models, and to assess the relationship between quality of care and a variety of maternal and infant health outcomes. The outcomes studied should not be limited to gestational age and birth weight, but rather encompass a range of health status and behavioral indicators. As noted by Alexander and Kotelchuck, “there are several other perinatal outcomes that may be modified by prenatal care” . Rosenberg has suggested that attention should be given to studying the effect of optimal prenatal care on maternal self-esteem, attachment, connections to both the health care system and social services, and maternal physical and mental health . Other appropriate outcomes include postnatal health status of mother and infant, the adoption and maintenance of healthy behaviors, disclosure of sensitive concerns, postpartum behaviors, maternal and infant health care utilization, and infant injury and disease rates . The relationship between quality of care and a variety of outcomes may have implications for allocation of resources, program planning, and policy development. With a valid and reliable QPCQ, researchers and decision makers will be well positioned to collect evidence that can be used to design and refine programs to improve women’s experiences and enhance perinatal outcomes.
The QPCQ is a new self-report instrument that measures overall quality of prenatal care, and quality of care for six factors or subscales. Following a rigorous process of development and psychometric testing, the QPCQ has been shown to demonstrate construct validity, internal consistency reliability, and test-retest reliability. This valid and reliable instrument will be useful in future research to evaluate women’s perceptions of quality of prenatal care, to compare quality of care across regions, populations, types of health care provider, and service delivery models, and to assess the relationship between quality of care and a variety of maternal and infant health outcomes.
Maureen I Heaman, Wendy A Sword contributed equally to this work.
This study was funded by an operating grant from the Canadian Institutes of Health Research (CIHR) (MOP - 84427). Dr. Heaman received career support from a CIHR Chair in Gender and Health award. We thank our collaborators for their contributions to the study: Melanie Basso (Vancouver), Laurie Blahitka (Calgary), Patricia Gregory (Winnipeg), Lynda Tjaden (Winnipeg), Jackie Barrett (Hamilton), Glenda Carson (Halifax), and Kate Lively (Halifax).
The QPCQ is licensed under a Creative Commons Attribution – Non Commercial – No Derivatives 4.0 International License. © Copyright 2013. W. Sword, M. Heaman, and the QPCQ Research Team. McMaster University. All rights reserved.
WAS and MIH wrote the grant application, directed the implementation of the study protocol, and had overall responsibility for the research. All authors contributed to conception and design of the study, and interpretation of the results, with input from the collaborators. AB coordinated the study. MIH, WAS, ST, PAJ, and DCY supervised participant recruitment in their respective sites. NA-D performed data analysis, assisted by AB. MIH drafted the manuscript. All authors provided feedback on the draft manuscript, and read and approved the final manuscript.

industry_corpus2: Health & Medicine


text:
It’s a rare day I can’t instantly think of comparisons for a show, but Evil or Live is the type which not only is an exception but may set a precedent.
Internet addiction. This has become such a huge problem in the area that there are now about 1000 kids at the Elite Reeducation Academy. A place where it gets beat into you that obedience is not optional. Which, upon kidnap and entry, throws off those who are signed up for the academy. Such as our lead Hibiki whose mom signed him up for the program until he is 18.
Luckily for him, despite the Headmistress Jean, and Head Instructor Shian being abusive, I’m talking fist to face abusive, there is Shin. A person who, for reasons not yet explained, takes Hibiki under his wing and maybe the person who helps him survive this school. Maybe even learn something.
As of this posting, there are 155 series premieres posted and about 650 movies covered. Despite such a large number, nothing clicks in terms of what to compare this to. While there is violence, the kids aren’t necessarily fighting each other. It is the adults, and some upperclassmen, who are whooping the younger kids asses to get them in line. Also, no one committed a crime here. At worse, these kids might be NEETs but that’s it. Otherwise, we are told by Hibiki that this girl he knew in middle school was an honor’s student. So, really, outside of having an internet addiction, there is no real punishable thing here.
Well, Hibiki is a bit of a perv and grabs Shin’s chest when he thinks Shin might be a girl. So there is that.
Okay, I got a possible comparison. There is this documentary called Rock and a Hard Place which came out on HBO earlier this year. Now, what we basically see is a military school for at-risk youth where there are Major Payne styled drill sergeants and what have you. They don’t lay a hand on the kids, but they do break them down to build them up.
What I’m hoping out of Evil or Live is that we aren’t just going to get psychotic adults beating children within an inch of death. I hope, in the long run, the goals of the Academy are actually realized. Albeit through a more brutal way than what may make most comfortable, but that maybe they actually do mold independent adults. That is, rather than the abuse turning them all into psychopaths.
Do You Really Want To Invest in Hibiki?
Not all leads of shows are likable. Hibiki especially. He is addicted to the internet, has a smart mouth, is perverted, and is also a bit of a coward. To the point, he threatens to kill himself. Which, I gotta admit, does make it hard to say, “That’s is the kind of guy I want to watch grow over 12+ episodes.” And even when you add Shin to the mix, I can’t say, without pause, that he can balance Hibiki out.
I think I spoke too soon since I can come up with more examples now. One being Cross Ange, in which, yeah magic was part of the show, but when it came to brutalizing kids, including sexual assault, it was there. But, refocusing on Evil or Live, I really do believe it may lean more toward a Rock and a Hard Place type of story. For there is just something about the idea of this snot-nosed kid growing up, through abuse and adversity, that seems like the path this may go.
Leading to why I’m marking this positive. While, in the long run, I can pick up some productions to compare Evil or Live to, they are few and far between. Also, in terms of anime, there is just something here I don’t think we really get to see. That is, a fantasy without magic, noting a social issue dealt with extreme measures. Of which, could actually change the lead character’s life in a positive way. I wouldn’t bet on it, but I am going to keep the faith and hope. For it is one thing to watch a character go from fish out of water to one of the greatest heroes around. However, to watch a boy become a man? While that, by no means, is a new thing, there is something about Evil or Live that is fresh enough that at least the premiere is worth checking out. As well as a few episodes thereafter to know which direction this show may take.
I’m going to watch this one soon but I’ve seen some pretty harsh reviews of this episode already. Hoping it could be interesting.
They straight up trash this on crunchyroll’s comment section. Mostly because the lead is annoying.
Well, I guess I’ll see how annoying I find him and whether that tkaes away from the show.


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Life Size LEGO Zelda Hylian Shield: It’s Dangerous to Go Alone! Take Bricks.
Zelda Breadstick Sword: It’s Dangerous to Go Alone, Eat This!

industry_corpus2: Gaming


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The beheaded corpse of a British aid worker has been discovered in the Pakistani city of Quetta, almost four months after he was kidnapped.
The body of Khalil Rasjed Dale was left on a road outside the city, in southern Baluchistan province, with a note attachedwhich said he had been killed because a ransom had not been paid to his captors.
Dale, who had been working for the International Committee of the Red Cross (ICRC), was kidnapped in January while driving near the organisation's Quetta office.
He was abducted by gunmen as he made his way home in a clearly-marked ICRC vehicle on 5 January. His assailants are said to have bundled him into a car about 200m from an ICRC residence.
At the time, police in Quetta said Dale was abducted by unknown assailants driving a Landcruiser following a visit to a local school. He was travelling with a Pakistani doctor and a driver, who were not seized.
Quetta police chief Ahsan Mahboob said the killers' note read: "This is the body of Khalil who we have slaughtered for not paying a ransom amount."
Dale had been a Muslim convert for more than 30 years.
William Hague, the foreign secretary, said "tireless efforts" had been made to secure Dale's release and the British government had worked closely with the Red Cross.
"I utterly condemn the kidnapping and killing of Mr Dale and send my deepest condolences to his family and loved ones as they come to terms with their tragic and distressing loss," he said.
"We are devastated," said ICRC director general Yves Daccord. "Khalil was a trusted and very experienced Red Cross staff member who significantly contributed to the humanitarian cause.
"All of us at the ICRC and at the British Red Cross share the grief and outrage of Khalil's family and friends."
Separatist militants and the Taliban are extremely active in Quetta, which is just a couple of hours' drive to the border with Afghanistan's Kandahar province, where the Taliban is battling US forces.
The ICRC has working relations with movements such as the Taliban, but its staff remain vulnerable to criminals and kidnappers.
Retired nurse Sheila Howat, a former colleague of Dale's at Dumfries and Galloway Royal Infirmary, said: "It's dreadful what has happened to him, really awful. The world has lost someone who really cared for others."


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The upgraded wire rod mill could be handed over to Saarstahl already two months earlier.
Saarstahl AG has granted acceptance to SMS group for the expansion of the high-capacity wire rod mill at the Burbach location.
To employ larger initial pass sections (180 x 180 millimeters), improve the rolling conditions and secure competitiveness in the long term, Saarstahl commissioned SMS group to expand the single-strand roughing mill of its four-strand wire rod mill at the Burbach plant. Besides the expansion of the four-stand roughing mill by two additional stands, this modernization measure included a shear, a four-strand switch and a four-strand pinch roll unit. After the expanded wire rod mill was handed over to the customer on time and ready for production the production tests took place. Hence, the modernization project could be successfully completed about two months before the deadline.
With the expansion of the single-strand roughing mill initial pass sections can now be employed without any reconstruction measures. The final cross section of the roughing train is equal for all initial pass sections and will now be distributed onto the four strands of the wire rod mill by means of the new switch.
Saarstahl AG is one of the world’s leading producers of quality steel for rolled and forged finished products with German locations in Völklingen, Burbach and Neunkirchen. One of the most important production facilities is the four-strand high-performance wire rod mill in Burbach which had been taken into operation by SMS group in 1973 for the first time and now has repeatedly been expanded by SMS group.
The SMS group is a group of companies internationally active in plant construction and mechanical engineering for the steel and nonferrous metals industry. Its 14,000 employees generate sales of over EUR 3.3 bn.

industry_corpus2: Manufacturing


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I have bought me a new embroidery machine. I had a Janome 9500. When I went in the sewing center I saw the Janome 9900 and I loved it so I got it. I really like both machines but I think that the 9900 is a lot smoother.
Did these on my new machine. I just been having fun.
I pieced this quilt and my mom did it on the sewing machine.
Mom did these the quick blankets. They are just two pieces of material.
Here is a diaper bag that I have done. It is all John Deere.
I did these burp rags on my new machine. Needless to say I will be sending all of this off today except the butterflies. Hope everyone has a nice day.
I did these on my embroidery machine. When Mom was in hospital getting her knee replaced she quilted it. This is for one of my husbands bosses. His wife wanted a lady bug blanket so we put this together.
Before my husband got sick he wanted me to make this quilt for his boss who is retiring at the end of this month. It took me awhile to do this for we found out he was sick so I did it when I could. I think he would of liked it.
This is his bosses picture that I have put on the quilt.
This quilt will be signed by the people who are going to be at the retirement party. Well my husband will not be there so I put his picture on the back of the quilt. He and his boss were really close. I sure hope that Rex likes his quilt. I will find out on the 31st of August.
Well in a day or two I will post more of what we have done.
Another quilt that Mom has made.
This is the last quilt for the grand kids. This is Troy's quilt.
Now I have some visitor's at my house. My oldest son Alfred and his wife Alyson took a plane with these two beautiful girls. Ave is the oldest and Alivia is the youngest. Alyson said the are good flyer's. We are enjoying ourselves this fine Easter day. Hope everyone has a lovely day.
The two above quilts we have finished. It took awhile to do. But we have been busy with of lot of personal stuff. So when we get a chance we try to finish old projects.
This baby blanket and bumper pad we made for a customer. It was kind of fun to do. We plan on doing more of them in the near future. Once we get our house in order again. Hopefully I can get so motivation out of myself this year. But it hasn't been a good start. But we shall move on forward.
Mom did this quilt. It is a shelf binding quilt. Took her about 15 minutes to do it, that includes cutting it out.
I pieces this quilt sometime ago and Mom just recently quilted it on the machine.
This quilt was done the same way. If we keep this up we will have a stash of quilts.


text: We are a well-known Manufacturer, Exporter and Supplier of precision made Dalia Disintegrator. Dalia Disintegrator, available with us, is suitable for making Dalia of various sizes and mesh. The sieve of Dalia Disintegrator results in offering the best results. Clients can avail compactly designed Dalia Disintegrator from us at very reasonable rates.


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> I am compiling Qt for an embedded broadcom 97405 platform.
> Final target is to get html5 video tag working.
seeing the test program and figuring out what it needs.


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Cambridge and Counties Bank (CCB) is a unique partnership between two established and respected institutions – Trinity Hall, Cambridge and Cambridgeshire Local Government Pension Fund. It is a banking specialist for small to medium enterprises (SMEs) within the UK and is dedicated to helping businesses of this type grow, consistently providing quality banking services and support.
What was the primary challenge or set of challenges facing the client? What was the business case for change?
CCB is interested in sustainable travel, to and from work, as part of its commitment to the environment. In particular, it is working towards Green Accreditation.
A thorough knowledge and understanding of the sustainable travel sector, with a particular focus on providing travel advice through workshops and advising on the availability of personalised travel planning programmes.
How the client identified a potential solution, why they chose to work with Go Travel Solutions and what solution was delivered. How did this solution address the challenge?
CCB signed up as a member of the Smartgo Leicester workplace travel network to access a range of discounts and offers from local and national travel operators, as well as strategic advice on travel planning.
Feedback from staff has been positive and very encouraging. Comments have included ‘good schemes which are varied and well presented’, ‘clear direct message of reducing our carbon footprint’, a ‘good initiative regarding rewards for every green journey you take (points)’ and ‘really pleased with the Go Travel Solutions savings on my season ticket!’.

industry_corpus2: Finance & Economics


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Set of 3 White Fine Cotton Men's Monogrammed Handkerchiefs.
Our Newest fine quality cotton handkerchiefs from Fehrlin, a Switzerland company since 1896.
Please select the monogram style from one of our four monogram styles.
About the Monogram style #1, #2 & #4, please note that for these three monogram styles, the letter in the center is suppose to be taller and represents the last name, the order of the initials is First,LAST,Middle. The Diamond Design Monogram, style #1 also available in 2-Initial monogram. The size of the tallest letter is approximately 1" tall.
About Monogram Style #3, the order of the initials is in the natural order:First, Middle, LAST. The approx. size of the letter is about 1/2" tall.


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To be able to ideal satisfy client's requirements, all of our operations are strictly performed in line with our motto "High High-quality, Competitive Price tag, Fast Service" for Oem Automobile Precision Parts Injection Moulding , OEM Automobile Precision Parts Injection Moulding , Automobile Parts Injection Molding , Welcome to visit our company and factory. Please feel free to get in touch with us if you need any further assistance.
"Our business since its inception, usually regards product or service high-quality as organization life, continuously boost production technology, improve solution top quality and repeatedly strengthen business total top quality management, in strict accordance along with the national standard ISO 9001:2000 for Oem Automobile Precision Parts Injection Moulding , OEM Automobile Precision Parts Injection Moulding , Automobile Parts Injection Molding , Our solutions are widely sold to Europe, USA, Russia, UK, France, Australia, Middle East, South America, Africa and Southeast Asia, etc. Our solutions are highly recognized by our customers from all around the world. And our company is committed to continually improving effectiveness of our management system to maximize customer satisfaction. We sincerely hope to make progress with our customers and create a win-win future together. Welcome to join us for business!

industry_corpus2: Automobiles


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Known as a major, if not most significant fashion hub in the world, Caravan Stylist Studio has, once again, set out on the streets of New York City to develop and deliver a unique project. The garment district is bursting with fiery and sophisticated fashion brands such as Kung Katherine, Randi Rahm, Lindsay Mann, Niki English and many more.
With street style becoming such a widespread phenomena, this project focuses on returning to New York’s fashion central. Named simply as The Fashion District Project, this new endeavor encompasses various individuals who have granted access along with a real live look inside the fashion industry. Not only will this project showcase designers and brands, but it will also cover individuals that help make this industry possible, including models, publicists, sales teams and sewers. Along with these different people and King our resident photographer, the project will capture city-goers and their street style of the garment center. With weekly postings on our blog, this program will also appear on social media. Ultimately, this program will feature designers, their companies and take an exploratory angle on the influence of New York City street style!
Originally from Hong Kong, Katherine Kung left to attend boarding school at a young age in the United States. From there, she attended the School of Visual Arts and The Fashion Institute of Technology, studying both Fine Art and Fashion Design. In fact, Katherine believes that fine art and fashion goes together hand in hand. Through her love of travel, she skillfully incorporates traditional Eastern influences and pairs them with Western essences. Katherine has a completely timeless design aesthetic, which appeals to women everywhere. She is completely focused on women as one of her inspirations and strives to create comfortable, well-fitted, and timeless works of art.
Slight Jewelry was founded in 2013 in Brooklyn, New York and creates quirky and unique jewelry pieces that are all handmade. All Slight Jewelry is made from brass, sterling silver, gold, and recycled gold products. Slight Jewelry also features ethically sourced stones, including black diamonds, rare gray diamonds, and Tahitian pearls.
Randi Rahm is a creative and talented designer who began her career while sewing a quilt for her newborn son. This love for sewing that transpired into being featured in a high-end children’s boutique, where she later began designing dresses. From there, Rahm has become the talented couture designer that we see today. She directly and expertly taps into a woman’s sensuality, connecting the woman’s inner self to her wardrobe. She is also heavily involved in charities that support the arts and education, as well as the less fortunate in her local community.
Kevin Shahroozi creates innovative menswear and womenswear clothing. He has been designing his own clothing line since April 2013 and offers reinterpretations on classic looks. All of his products are made with high quality fabrics and materials that come at an affordable price. Kevin was born and raised in Queens, New York and is associated with fashion houses like Burberry, Zac Posen, Marissa Webb, German Valdivia, and Giorgio Armani.
KOTOBA is a collective knitwear brand that focuses on promoting WHOLEGARMENT knitting technology, which is a revolutionary and state-of-the-art knitwear system that was developed by Shima Seiki. By integrating this technology with their knitwear, KOTOBA produces pieces that are cutting edge and timeless. In fact, KOTOBA means “language” in Japanese and was the root of development for the brand. KOTOBA produces all of their garments in the USA.
Kathlin Argiro is a dress designer that focuses specifically on the “white dress”. She custom makes white bridal, graduation, evening, wrap dresses and more. Kathlin launched her company in 1997 and her dresses have been featured on What Not To Wear, Today Throws A Wedding, The View, and Ambush Makeover. Kathlin’s designs can also be seen on influencers like Stacy London from What Not To Wear, Katie Couric, Meredith Viera, and Melissa Rivers.
Niki English is a unique and creative handbag designer. She is based in New York City and is located in the garment district. Her handbags are a mix of street style and luxury. Her main inspirations come from NYC itself and the women who envelop the need and wants for fashion savvy functional accessories for the busy life of living in NYC.
We would like to send a big thank you to Katherine Kung, Amanda Campbell, Randi Rahm, Kevin Shahroozi, Lindsay Mann, Kathlin Argiro & Niki English for giving us an inside look at their studios as well as a special thanks to Nikki Perez de Tagle for helping the Caravan team with interviewing the designers for the Fashion Distirct Project!
Check back soon for more inside looks and street style!


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Sitting here with my book in hand I notice a slight tension in my shoulder. I see that I’m holding my elbow up a bit so I relax it. Still my shoulder seems a bit too tense just to be holding a book. I focus more of my attention on it realising that gravity wants my shoulder to drop down and rest on my ribcage. Still something resists.
As my attention grows within this tension, the resistance manifests itself as subtle, almost unperceivable, multi-directional activity of micro-motions.
I ask myself: what does this tension demand of me? What does it ask that I am not giving it? Or opposite, what did I ask of this tension before I became aware of it?
It would almost appear as if this tension wants to communicate something, similar to two people who in an argument try to convince one another of the validity of their point of view.
Would it be enough to give it my full attention, to direct all my capacities on listening to this tension? Or does it need something else?


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The Netflix original hit series has finally got a start date for the long-anticipated second season. Better Call Saul season two will return on 16th February 2016.
Season one of the prequel to the award-winning Breaking Bad was first available on Netflix in February 2015. The series introduced fans to hard-working lawyer Jimmy McGill who would eventually become Saul Goodman and meet the infamous Walter White. In the season finale we left Jimmy grieving for Marco and giving us the first hint of Saul by donning Marco’s signature pinky ring. At the end of episode 10 Jimmy waved goodbye to the potential humdrum conventional lawyer life and drove away towards the thrilling future we know he has in store.
Initially commissioned for a 13-episode second season prior to the release of season one, dedicated fans will be disappointed to hear this number has now been reduced to 10 episodes.
Series co-creator Peter Gould cheerfully responded on twitter to a question concerning the reduction in episode numbers.
@drovethrughosts No mistake! 10 big, big episodes!
No comment on the original 13 then? Guess they just disappeared into thin air.
Cast favourites Michael McKean (Chuck), Rhea Seehorn (Kim) and Jonathan Banks (Mike) – seen below in a newly released image – also return for the second season.
Whilst you count down the days until February, why not catch up on season one? Click here to enter our competition to win the entire first season on Blu-ray.


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Are you a young or new mother? If you are, we'd love for you to join us for a very casual, informal time of socializing for the moms and playtime for children. We meet every other Tuesday morning from 9:30-11:30 am.
Tea and snacks will be provided!


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SUMMARY: One person’s $55,000 appendectomy bill from Sutter Health systems in California is going viral on the Web. The surgery in question took place just before Sutter agreed to an out-of-court settlement over charges of false and misleading anesthesia billing.
How much does an appendectomy cost? Well, that depends.
We’re no longer that surprised by shocking hospital bills. But people started talking on Twitter about this viral hospital bill on Imgur, the image sharing service.
“So on October 1st of this year I woke up with an excruciating pain in my lower abdomen. Turns out it was appendicitis. So after about a 24 hour stay in the hospital I was free to go. This was the bill I received earlier this month,” wrote the poster, whose name is not on the bill.
The two-hour recovery room stay of $7,501.00 raised special questions, and the anesthesia: $4,582.00!
Sutter Health came to a settlement this November in a suit that it had overcharged for anesthesia.
The chain, which runs 24 acute-care hospitals in California, agreed to pay $46 million in the out-of-court settlement, and also to give more pricing information to consumers, as the result of a whistleblower complaint charging that the chain’s billing practices were false and misleading.
“Sutter Health, which runs 24 acute-care hospitals in Northern California, said it reached the settlement Monday just prior to a trial starting this month over the allegations that it added thousands of dollars for “Code 37x” anesthesia charges that were already covered by other billing for the hospital operating room,” Chad Terhune wrote in The Los Angeles Times.
One of the most surprising pieces of this story came when the California hospital association head defended Sutter’s practices.
“The state’s hospital trade group also defended Sutter and said its billing practices were in line with industry standards,” Terhune wrote.
Which means: Sutter’s not alone. Here’s a blog post we wrote about this last year.
But in this particular case, it seems obvious that the person should take the bill back to the Sutter billing office with a copy of Chad Terhune’s story.
Scrutinize all hospital bills carefully. Some industry sources say 60 percent of hospital bills have an error; some say 100 percent of hospital bills have an error.
Ask the hospital for an itemized bill with HCPCS or CPT codes, and insist that you need to confirm the accuracy of the bill before you’ll pay it.
Look carefully at the insurance company’s explanation of benefits; compare it with the bill. Quite often an E.O.B. is also difficult to read. Question everything that seems unusual.
If the bill shows something inaccurate, point that out to the billing office and ask for the charge to be removed.
If the insurance company isn’t paying for something, ask them why and ask to see the point in the contract that allows them to refuse to pay.
Calling both the provider (hospital) and payer (insurance company) will sometimes reveal that the entire bill is an error and you owe nothing. Don’t pay until you’re sure the bill is accurate.
There are services that will argue your hospital bills for you. Some work for contingency fees; some are better than others. Do your homework if this is the path you choose.
Get used to doing this. That $11,119.53 is a lot of money, and there’s much more of this coming.