10 Tips for Multiuse Office/guest Rooms

Friends and family who visit will need a place to store their clothes and other items. When you don't have visitors, vertical shelves are perfect for displaying office supplies, knickknacks or accessories. Then, when you're expecting guests, you can simply clear the shelves to make room for their folded garments and personal effects.A suitcase bench is another easy storage solution. Folded open, it gets luggage off the floor, which is always a plus for guests. When it's not in use, the bench can be closed and stored out of the way of your office.In terms of office storage, the digital age has helped to drastically reduce the amount of space needed for home office paperwork. Still, it's helpful to either purchase a small, lockable filing cabinet for contracts, tax forms and other hard copies if your desk does not provide such a feature.

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Home Office Interior Design Tips: Redesign Your Home ...
So, you work from home and are loving every minute of it, right? Then, it's time for some redecorating. No, not your living room, your home office.You'd probably be surprised to know that interior decorating your home-office space can be just as important as designing the rest of your house, maybe even more important. A well laid out office space can improve your productivity and your happiness.Location, Location, LocationNow, to start off, let's think about location. Your home office should be some place where you will have privacy. A spare bedroom or an out of the way alcove will work great. You still want to be part of the house, but you also need your privacy for those phone calls and business client visits.LightingNatural lighting also should be a significant part of your design plan. A window gives you something to look at when you get stressed out and some fresh air when you feel cramped. Speaking of lighting, try to avoid glaring overhead lights like you find in a regular office. Go for more diffused lighting. A good lamp may be all you need.Have extra closet space? Well, you can turn that into a home office. For more information, read Convert Your Closet into a Complete Home Office Space by MiAGon.Color and ConsolidationDecoratingNext up is color. You shouldn't paint your office in drab gray or black nor should it be too gaudy. You want to be comfortable, but not too agitated or depressed. Neutral colors work best. But, if you really want to add some personality to your walls, add artwork. Buy that artist that you admire so much. Just think of it as a business expense.Plants also are wonderful additions to home offices. They, too, will add color and personality to your space. When they bloom, it's like adding a whole different element to the room.StorageWhile you may not think of storage as an "design element", it's actually a very critical part of your home-office interior design plan. Now, when I refer to storage, I don't mean the metal filing cabinet with the key hanging from it. No. Storage can be anything: a built-in wall unit, unique shelving or even your own creation. Be artistic. It's your space. Really make it your own. Just do account for storage. A cluttered desk and work area is very distracting and will affect your work output. Another item that can greatly reduce clutter is a multifunction printer. As a home office worker, you have necessities: printer, fax and copier. Yet, these can come in one neat package. And, nowadays, these printers can be some really striking machines.For more information on what should be in a home office, read 10 Essential Items in a Telecommuting Home Office by S.A. Coggins.Functional FurnitureFinally, let's talk furniture. Forget the particle board desk that's already starting to chip. Try a roll top desk. They're great conversation pieces and fit in with any decor. Go for more decorative pieces for your desk organizers and even your trash can.Your home office is your home office. Don't try to copy the company pattern of function over style. Be your own home-office designer.
2021 07 23
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Keeping the Colonel's Secret Safe at KFC
Pssst. The secret's out at KFC. Well, sort of.Colonel Harland Sanders' handwritten recipe of 11 herbs and spices was removed Tuesday from safekeeping at KFC's corporate offices for the first time in decades. The temporary relocation is allowing KFC to revamp security around a yellowing sheet of paper that contains one of the country's most famous corporate secrets. The brand's top executive admitted his nerves were aflutter despite the tight security he lined up for the operation."I don't want to be the president who loses the recipe," KFC President Roger Eaton said. "Imagine how terrifying that would be." Trending News Couple arrested after spending mistaken $120,000 deposit Amazon to hire 30,000 workers at job fairs in 6 cities 48 states launch antitrust investigation into Google Kim Kardashian changes name of shapewear line FDA shoots down Juul claims that vaping is safer than smoking The recipe that launched the chicken chain was placed in a lock box that was handcuffed to security expert Bo Dietl, who climbed aboard an armored car that whisked away with an escort from off-duty police officers.Eaton's parting words to Dietl: "Keep it safe."So important is the 68-year-old concoction that coats the chain's Original Recipe chicken that only two company executives at any time have access to it. The company refuses to release their names or titles, and it uses multiple suppliers who produce and blend the ingredients but know only a part of the entire contents.KFC executives said they decided to upgrade security after retrieving the recipe amid preparations to add a new line of Original Recipe chicken strips.The recipe has been stashed at the company headquarters for decades, and for more than 20 years has been tucked away in a filing cabinet equipped with two combination locks. To reach the cabinet, the keepers of the recipe would first open up a vault and unlock three locks on a door that stood in front of the cabinet.Vials of the herbs and spices are also stored in the secret filing cabinet.Others have tried to replicate the recipe, and occasionally someone claims to have found a copy of Sanders' creation. The executive said none have come close, adding the actual recipe would include some surprises. Sanders developed the formula in 1940 at his tiny restaurant in southeastern Kentucky and used it to launch the KFC chain in the early 1950s.Larry Miller, a restaurant analyst with RBC Capital Markets, said the recipe's value is "almost an immeasurable thing. It's part of that important brand image that helps differentiate the KFC product."KFC had a total of 14,892 locations worldwide at the end of 2007. The chain has had strong sales overseas, especially in its fast-growing China market, but has struggled in the U.S. amid a more health-conscious public. KFC posted U.S. sales of $5.3 billion at company-owned and franchised stores in 2007.
2021 07 23
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Defeated MPs Slow Citizen Cases by Shredding Files, Instead of Sharing Them: NDP
MONTREAL - Along with a comfy seat in the House of Commons, incoming New Democrat MPs say they've also inherited empty file folders and at least one cluster of shredded paper.And, in another case, a rookie MP allegedly acquired a filing cabinet that was completely bare -- except for a sarcastic note that read: "Don't worry about it, it's all been recycled."NDP MPs in Quebec say several of their predecessors from other parties destroyed constituent files after the election, instead of passing them along.They say without these documents, there is an information vacuum about ongoing cases involving citizens in their ridings.But a House of Commons spokeswoman said most outgoing MPs choose to trash constituency documents on their way out the door because the paperwork contains personal information about citizens.With no rules governing whether a handover should -- or shouldn't -- take place, defeated MPs each have their own approach.But Guy Caron, the NDP's Quebec caucus chair, said missing documents can impede federal cases, such as a citizenship application or an immigration file.Caron said many NDP rookies in Quebec, where the party added 58 new MPs in the May 2 election, are starting from scratch, prompting some riding offices to ask citizens to bring in documents so staffers can make photocopies."It's not punishing the new MP as much as it's punishing citizens and honestly they don't deserve to have that happen to them," said Caron, adding he's not sure how many NDP MPs did not receive constituent documentation from their predecessors."I actually find it quite childish in a sense because you lose (the election) and then you destroy the file, and then you try to make things hard for the person replacing you."The NDP says some rookies have found odd remnants of documents in riding offices they took over from the outgoing MP.A spokesman for the NDP's Charmaine Borg said one new MP found a pile of shredded documents on a riding office table.Caron described another example from defeated Conservative cabinet minister Josee Verner's riding office, where he alleges a message was left behind."There was a note on the filing cabinet which said: 'Don't worry about it, it's all been recycled,' " Caron said."So, obviously it was not really appreciated -- it was kind of funny, but in a sad sort of way."A spokeswoman for Verner said in an email that the constituency documents contained "confidential and sensitive information" and that staff were simply following official guidelines on how to close a riding office by destroying the paperwork.Jessica McLean said Verner, who now sits as a senator, was not available for an interview. Her office had no comment about the alleged filing-cabinet message.Still, the NDP said that not every riding in Quebec had a bumpy transition, as some departing incumbents from other parties provided constituent documents -- including in Caron's riding.He said the defeated Bloc Quebecois MP told him he decided to leave behind citizen files because he was left with nothing when he first took office."I think it really affected him and he didn't want me to experience the same thing he experienced," Caron said.A spokeswoman for the House Speaker's Office said there are no specific rules that tell an outgoing MP to either leave -- or not to leave -- constituent files for their successor.Heather Bradley said most MPs opt for the shredder because they consider citizen information to be personal, but it's not always the case."Sometimes they pass it on, it just depends on the situation," Bradley said."I know in some offices the office staff actually give the information back to the constituent... Then they (the citizens) take up the file with the new member (of Parliament)."This is what defeated Bloc Quebecois MP Diane Bourgeois said she did for three immigration cases after losing in the Montreal-area riding of Terrebonne-Blainville.Bourgeois didn't forward any citizen files to her successor, the NDP's Borg.She believes that incoming MPs should not be allowed to see citizen documents unless a constituent gives them the legal authority by signing them over."There's no rule, but I think there's a question of confidentiality and a citizen must sign a document -- that's evident," said Bourgeois, adding the NDP is just playing a political game by raising this issue."This is how it's happened for years."The ex-MP of 11 years said the time it takes for citizens to sign the forms for their new representative probably wouldn't translate into delays of more than a couple of days."Federal civil servants understand very well that there has been a changing of the guard," Bourgeois said.But Caron argues that since an MP represents all citizens, files should move along seamlessly, regardless of political stripes.He said the party will examine whether rules can be implemented.
2021 07 23
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The Write Time
The New Yorker weighed in last week with its list of the best young writers of the decade. Or maybe they meant the century, or perhaps even the millennium. Whatever. The implication is these 20 fiction writers are hip and now and we'll all be hearing lots more from them in the 21st century.I wasn't on the list -- no surprise there since I haven't published a story in the New Yorker, or anywhere else for that matter, and in fact technically don't even write fiction, but only think about writing it. Still, I felt a kind of sick little bump when I scanned the table of contents and realized literary fame wasn't going to happen for me in this century.Contributing to my momentary queasiness: Someone I know in the very vaguest sense is on the list, accompanied by a blurred-edged, overexposed picture of her in a pink silky shirt laughing it up with the rugged, arty male writers on either side of her. A year ago the same magazine ran her first story under the byline "Jhumpa Lahiri, a new author," and now she's essential enough to be included in its end-of-century fiction roundup.Lahiri may be new to readers of the New Yorker, but she's ancient history to me. We both attended a fiction workshop six years ago at Harvard University summer school. She needed the class to get enough credits to finish up an MFA at Boston University, and she presented story after polished story with a kind of exact, amiable indifference that let us all know just how important this make-up workshop was to her (not very). I was seven months pregnant with my first child and writing with the wavering intensity of the hormonally challenged. I was not the class star.Flash-forward five years: I was 10 weeks postpartum with baby No. 2, exercising a little, easing back into work, getting enough sleep to at least survive, and even, tentatively, resuming a conjugal life with my husband. The baby was fat and extraordinarily happy, and his older brother seemed genuinely glad to have him around. We were all doing better than I had expected.Then the new issue of the New Yorker arrived. With an infant in the house, there wasn't time to read anything more profound or less urgent than the grocery list, but I could still flip through the cartoons and glance at the table of contents. And there she was, Jhumpa Lahiri, new author. While I was off procreating, she'd apparently managed to climb her way up the literary ladder from a wannabe fiction workshop to the top of the slush pile.I skipped the story itself (this wasn't about the actual art, after all) and flipped straight to the contributors' page (thank you, Tina Brown, for adding one), where it said Jhumpa was a fellow in a Provincetown artists' colony and coming out with her first book next year. Standing there in my kitchen with an infant idly gnawing my shoulder, I felt both heavy and hollow. Could it be I was jealousIn the years since that workshop, I have published thousands and thousands of words under my byline, far more than could ever be in Lahiri's debut collection of short stories. My words aren't about secrets in the dark, sex on the beach or the mysteries of far-off continents, but rather about T1 lines, digital certificates and electronic document distribution. To report these high-technology profile pieces, I am paid a bit better than the prevailing wage for freelancers, I can -- and do -- work successfully out of my house and I get my ticket punched, just barely, as a working member of the ubiquitous digital society.But when you write technology features for a living rather than short, hip fiction, nobody sends mash notes saying you've changed his life, nobody invites you to cocktail parties that are later chronicled in the New York papers and nobody offers you a fellowship. Not that I could pack off to Provincetown even if it were offered: For better or worse, my place right now is at home as a full-time mother and very part-time writer.As for the new author, my emotions are equally split between honest admiration for what I remember as her precise, self-assured style and unalloyed envy over her splashy debut in the magazine that remains the Holy Grail to English-language fiction writers."It's like winning a Tony for your very first Equity role," I tried to explain to a friend and fellow stay-at-home parent who had danced off-Broadway.She was unimpressed. "But you have your children," she said, as if that cleared up everything.I do indeed have my children, and I do routinely use them as my excuse for not writing fiction. But there is nothing to prevent Lahiri from someday having children as well. More to the point, I spent my entire 20s unencumbered by children, a permanent relationship or even, at times, a steady employment and still I managed to complete not a single story that I consider worthy of publication.Maybe it's time to come clean. I have been starting, but never quite finishing, short stories since I was 17 years old. I have a whole filing cabinet of works in progress that I have dutifully (or is that pretentiously) moved from place to place and stage to stage in my life. As painful as it is to contemplate, perhaps I am not and will never be a writer of fiction.But all may not be lost. Some good bits have piled up in that cabinet over the years, funny and poignant and just absurd enough to be appealing. They just need someone with more perseverance, or maybe more talent, to finish them.The story of Lahiri's I remember most clearly from our workshop days was perfectly crafted and undeniably exotic, nearly impossible for anyone else to have written. Her New Yorker stories are a bit less intimidating -- they're good, in places very good, but the emotional ground they cover is hardly off-limits, even to a middle-aged, middle-class,middlebrow Yankee with a strong background in suburbia.What with the buzz of the new millennium and the energizing prospect of a completely toilet-trained household, I may still have time to make a mark. Splashy debuts notwithstanding, writing isn't particularly a vocation only of the young, and I don't, after all, have my heart set on winning a gymnastics medal or making the cover of Tiger Beat magazine. And I have managed to learn a few things in the years since I shared workshop space with Lahiri: How to go on day after day with very little sleep; how to work through the despair of dense material; how to write well in short, frantic bursts late at night or early in the morning; how to push deadlines to infinity and beyond with aplomb; and how happy you can be finishing something, even if that something isn't the most compelling or important piece ever written.Perhaps the worst is behind me. My fiction filing cabinet, for example, has already survived its most ignoble trip yet, displaced, by the baby, from a spare room to my newest home "office" -- a dim corner of the master bedroom mere inches from the bed itself. That cabinet may yet disgorge a story or two, sometime in the distant, toddler-free future. If and when that day ever comes, one thing is already obvious -- any honest editor, however enthusiastic, will have a hard time by then calling me a "new" writer.
2021 07 23
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'Plotto': an Algebra Book for Fiction Writing
It's been said that there are only seven basic plots in fiction. Pulp novelist William Wallace Cook would beg to differ.According to Cook, there are a whopping 1,462 plots, all of which he laid out in his 1928 book, Plotto: The Master Book of All Plots.Plotto has just been reissued for the edification of novelists everywhere. Author Paul Collins, who wrote the introduction to the new edition, tells weekends on All Things Considered guest host Mary Louise Kelly that the book came out of Cook's need to sustain a punishing writing pace: In one year, 1910, he churned out more than a book a week."He was known as the man who deforested Canada," Collins says. "He had to systematize it. He was literally manufacturing fiction, to the point that when he wrote a memoir, he titled it The Fiction Factory."Plotto looks like an algebra book at first: Protagonists A and B, and their numerically designated friends, rivals and relatives all combine and compete in pursuit of love, money, success and sometimes even a mysterious item X.Each plot is cross-referenced with other plots that combine well with it. For example, here's plot 1,258: "B, a woman criminal arrested by A-6, a detective, seeks to effect her escape by artful strategy."Cook notes that this can be preceded by plots 448 and 1,309b, and followed by 3b, 10a, and 16a - which involves A-6 finally catching up to B, but then falling in love with her.Cook, like many pulp novelists of the day, clipped ideas straight from the headlines. He kept them in a specially designed card catalog, which Collins says is "basically the larger version of this book.""It was sort of like a filing cabinet with all these plot elements," he says. Some of the plots are just plain wacky. In plot 227, "B is unable to marry A because her father, F-B, in using B for his subject in a scientific experiment, has instilled a poison into her blood."But, says Collins, as off-the-wall as Plotto can be, it was actually quite influential in its day - and not just to aspiring novelists. A young Alfred Hitchcock, just getting started as a silent film director in Britain, sent away for a copy."It's had a particularly strong afterlife, I think, among screenwriters," Collins says. "A lot of this whole idea of formulaic plotting, especially in its early versions, like Plotto, actually was associated with movies, as much as with novels."Collins says that while pulp novels like the ones Cook wrote may be mostly gone, Cook's carefully cross-referenced plots can actually teach aspiring writers a great deal about which plot elements go together best."You really do get a strong sense of how plot works," he says. "Erle Stanley Gardner, who wrote the Perry Mason books, said that he basically learned about plotting from Plotto."
2021 07 23
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Donald Trump Has a Secret Shame: Every Playground Bully Has a Toxic Fuel
Donald Trump is a playground thug, said Jonathan Fast, author of "Beyond Bullying: Breaking the Cycle of Shame, Bullying, and Violence" (Oxford 2016). Like many juvenile oppressors, the Donald plays to the crowd, bragging as he advocates waterboarding and walls to keep out Mexicans. In this kindergarten drama, heightened with explosive tweets and sound bites, voters cheer from the sidelines. Possibly, they're scared of being losers.After all, most adults have been bullied at some point in their lives, according to Fast's vigorous research on the subject. A dry-witted social-work professor at New York's Yeshiva University, Fast has found the bully's secret fuel -- shame -- a word so awful that even therapists avoid it. In this page-turner(Fast has also written science fiction), he claims that narcissism is a common defense against shame, which makes Trump such a delicious feast.But Fast is also a fascinating case study. Born in New York City, this soft-spoken Connecticutresident belongs to an illustrious Jewish writing clan that includes former wife Erica Jong, who penned "Fear of Flying," and their daughter, author Molly Jong-Fast. His Communist father, Howard, wrote "Spartacus" and refused to name names when called before the House Un-American Activities Committee in 1950. While Howard possessed a strong personality, Fast said his famous dad was more negligent than controlling. Today, Fast lives with his second wife, a Unitarian minister. They raised two sons.We met Fast in his Yeshiva office overlooking Washington Heights in New York City. Slim and silver haired, the bespectacled professor delivered insights with a remarkably calm voice dotted with thoughtful pauses. But on his filing cabinet glared amassive statue: the head of a great ape wearing Fast's distinguished graduation cap.How is Donald Trump the classic bully according to Swedish psychologist Dan Olweus, whom you quote in your "Bullying In and Out Of Schools" chapter Olweus identified risk factors, including a child's "hot-headed" temperament.If you think of the definition by Olweus, the gold standard of bullying research, bullies are typically larger and stronger than the other kids kids in their class. You can say that Trump is bigger and stronger in the sense that he has more money than other people, and a television show, so he has a bigger image and a stronger financial power. Bullies are opportunistic. They pick on weaker people who won't strike back. He's done this with minorities and women. His mentors are probably saying to him, "Keep doing what you're doing. It's working." People are watching.When Trump verbally attacked Megyn Kelly, who moderated the GOP debate in August, he referred to her menstrual cycle when he said: "She gets out there and she starts asking me all sorts of ridiculous questions, and you could see there was blood coming out of her eyes, blood coming out of her ... wherever." What do you make of comments like thatHe couldn't say the word vagina, like a little kid. Bleeding from the eyes. He couldn't say the real word. The thing is that people like fights. In high school, did you ever stand around and watch kids fight I did. "Don't break it up. Let's see what happens."Should we take Trump seriously, or is he a performance artist using taunts to stand out among other candidatesWe shouldn't take him seriously. He's almost like an insult comic, like Don Rickles. Some comedians process shame through their work in a positive way. One type of human laughter is about the joy of overcoming hardship. In "Beyond Bullying," I talk about Army Staff Sergeant Bobby Henline, whose face was disfigured after a roadside explosion outside of Baghdad in 2007. He had burns over 90 percent of his body. His therapist said, "You're funny. You should do comedy." He has gotten lots of support from other wounded soldiers. People are laughing with him because he has overcome a disfiguring shame.In "Beyond Bullying," you mentioned that you were bullied by a kid named Mark when you were 8years old. You wrote that you finally lost control and knocked Mark down over a table at summer camp.He just pushed me and pushed me. Then I throttled him. Then we had a session with the counselors and it stopped for awhile. Then it happened again. I was a big strong kid. I was a big fat strong kid. I was like 5-foot-10. I am about that now.Later, in the fifth grade, a smaller kid broke my arm, which was embarrassing. But there was something really good about that. He called me up afterward and apologized because he felt bad. I said, "That's alright." That phone conversation was what is known as a restorative practice, with the idea of repairing relationships. It was nice between us after that, and I got to show off my cast at school.In your book, you mentioned restorative programs like SaferSanerSchools that have reduced disciplinary referrals. You also attended a Names Can Really Hurt Us event, where "kids laid bare their adolescent souls," from admitting the shame of ADHD to having a sister with autism. Can we ever get rid of bullyingNo, because you can't get rid of mean people. You can reduce it. Simply positioning teachers in the hallway during changes of class can be helpful. The best idea is to create the civil school with restorative practices.Are we ashamed of shameWe are. As long as you have a thread of doubt about your identity, then you're susceptible to shame. When you're in therapy, for a serious problem rather than maintenance, you get to a point in the work where it stops, like a speed bump. That's usually when you've reached a shaming situation that is too toxic to talk about. It's so horrible you feel like you're going to die if other people know it, like with incest or a situation where your buddies got blown up and you survived. What you do at that point is what psychoanalyst Helen B. Lewis did in the 1970s. You could put therapy on hold and do psycho-education on shame to demystify it for the client. The other thing is to encourage clients to keep a shame diary, which opens the way to talking about their central shaming experience that they're scared to discuss. No one ever mentioned shame to me in therapy. The first time I went, I thought, "I hope I don't have talk about that." And I never talked about it.What is Trump ashamed ofI can't imagine what his shame is. I know he went to military school. The only group he hasn't viciously attacked is gay people, but he actually did say inflammatory things in a Howard Stern interview in 2008. I looked it up because I was curious at why he wasn't bullying the LGBT community to the same degree he was everyone else. In the interview, Stern pushed him and pushed him. So it's there, but there's some reason why he's not talking about that now.
2021 07 16
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Professionalisation and Social Attitudes: a Protocol for Measuring Changes in Hiv/aids-related Stigm
AbstractIntroduction HIV/AIDS-related stigma affects the access and utilisation of health services. Although HIV/AIDS-related stigma in the health services has been studied, little work has attended to the relationship between professional development and stigmatising attitudes. Hence, in this study, we will extend earlier research by examining the relationship between the stage of professional development and the kinds of stigmatising attitudes held about people living with HIV/AIDS.Methods and analysis A serial cross-sectional design will be combined with a two-point in time longitudinal design to measure the levels of stigma among healthcare students from each year of undergraduate and graduate courses in Malaysia and Australia. In the absence of suitable measures, we will carry out a sequential mixed methods design to develop such a tool. The questionnaire data will be analysed using mixed effects linear models to manage the repeated measures.Ethics and dissemination We have received ethical approval from the Monash MBBS executive committee as well as the Monash University Human Research Ethics Committee. We will keep the data in a locked filing cabinet in the Monash University (Sunway campus) premises for 5 years, after which the information will be shredded and disposed of in secure bins, and digital recordings will be erased in accordance with Monash University's regulations. Only the principal investigator and the researcher will have access to the filing cabinet. We aim to present and publish the results of this study in national and international conferences and peer-reviewed journals, respectively.Introduction HIV/AIDS-related stigma affects the access and utilisation of health services. Although HIV/AIDS-related stigma in the health services has been studied, little work has attended to the relationship between professional development and stigmatising attitudes. Hence, in this study, we will extend earlier research by examining the relationship between the stage of professional development and the kinds of stigmatising attitudes held about people living with HIV/AIDS.Methods and analysis A serial cross-sectional design will be combined with a two-point in time longitudinal design to measure the levels of stigma among healthcare students from each year of undergraduate and graduate courses in Malaysia and Australia. In the absence of suitable measures, we will carry out a sequential mixed methods design to develop such a tool. The questionnaire data will be analysed using mixed effects linear models to manage the repeated measures.Ethics and dissemination We have received ethical approval from the Monash MBBS executive committee as well as the Monash University Human Research Ethics Committee. We will keep the data in a locked filing cabinet in the Monash University (Sunway campus) premises for 5 years, after which the information will be shredded and disposed of in secure bins, and digital recordings will be erased in accordance with Monash University's regulations. Only the principal investigator and the researcher will have access to the filing cabinet. We aim to present and publish the results of this study in national and international conferences and peer-reviewed journals, respectively.Article focusThe primary objective of this research is to examine the relationship between professionalisation and stigmatising attitude towards people living with HIV/AIDS among healthcare students.The secondary aim of this study is to investigate the availability of suitable measurement tool(s)-otherwise to create a scale to measure the transformation of HIV/AIDS-related stigma in the context of the health professionals' work environment.Key messagesA fair and responsive health system requires a healthcare workforce that is blind to the 'undeserving' and the 'morally reprehensible'; hence, studying the professional development in relation to the stigmatising attitude development is of great importance in addressing the inequalities in the delivery of care.Strengths and limitations of this studyThe major strength of this protocol is its design which will allow us to study the professional development and possible change(s) in attitudes over a time period.The limitation of this study is the uncertainties pertaining to the sample size calculation as well as the fact that we may measure a self-reported attitude rather than an actual attitude. The sampling limitations imposed by ethical requirements also raise issues about a selection bias. While the possibility of the bias needs to be acknowledged, the nature of the research question probably limits the bias.IntroductionA healthcare workforce that is responsive and fair in its treatment of patients is one of the central pillars of a modern health system.1 It is for this reason, among others, that healthcare workers are bound by ethical codes of practice to treat patients according to their need, and not according to their gender, religious beliefs, sexual orientation, skin colour or other socially (de)valued attributes.2 Possible exceptions to this rule of social blindness arise when those otherwise ignorable social attributes may affect the diagnosis, prognosis or choice of the most effective treatment.What should happen, however, when the patient is perceived as a complete reprobate-a repugnant individual whose very presence challenges the healthcare worker's moral foundation? In theory, the answer is simple-treat the patient in front of you according to their healthcare need.The challenge for the health system is that practice does not necessarily mirror professional intent, and personal prejudices and fear of contagion interfere in decisions for care.3-5 The literature is replete with examples of patients who are accorded different (worse) treatment because of some perceived moral taints.6 The HIV epidemic provides a classic case in point. Healthcare workers have reported not wanting to treat people living with HIV/AIDS (PLWHA) for a range of reasons, including: because the patient was undeserving, or because treating PLWHA would devalue the healthcare worker in the eyes of others.7 This situation has, in many instances, created a tiered health system in which 'deserving' patients have received treatment and the 'undeserving' have not.6 High levels of stigma and discrimination are associated with a reduction in access to treatment and care for those with undesirable attributes.8To overcome the dangers of discrimination associated with the social valuation of HIV/AIDS patients, many teaching programmes now contain explicit or integrated learning objectives that relate to professionalisation.9 The process of professionalisation fosters the inculcation of acceptable practice of healthcare workers in line with societal expectations, and the social contract between the client and the healthcare worker.10-12 In this context, increasing the professionalism of the healthcare workforce is as much about improved technical competency as it is about ethics of practice. Increasing professionalisation is thus expected to result in less stigma and discrimination in healthcare settings.13Whether professionalisation does protect patients against the creation of tiered healthcare is an empirical question, but there is reason to believe that it would work by reducing negative attitudes and discriminatory behaviour towards patients-particularly those from socially marginalised groups, such as HIV/AIDS patients. There is already some evidence in the literature to support this idea.14 ,15 For instance, it is known that targeted learning focused on attitudes to specific marginalised groups can result in a positive attitudinal change.16 What is less clear is whether a generic focus on professionalisation not focused specifically on one disease or another is sufficient to improve attitudes towards all socially marginalised groups regardless of the socially devalued attribute.In posing the idea that professionalisation may reduce stigmatising attitudes, two refinements need to be introduced. The first is a distinction between generic professionalisation and targeted learning, because it goes to the heart of ensuring a responsive and fair health system. For instance, in targeted learning, if programmes need to be developed to address stigmatising attitudes of a healthcare workforce to every marginalised group or disease, the cost will be too high and the educational process will always be reactive. By contrast, a generically professional healthcare workforce that understands and follows a holistic approach to the ethical codes of conduct is a more flexible workforce, which is less likely to create a tiered healthcare system.The second refinement is to draw a distinction between an individual as a healthcare professional and that same individual within a private, non-professional domain. There is no reason to assume that the equanimity possessed in the professional domain towards socially marginalised people will translate into the private life of health professionals. Furthermore, there is no overwhelming reason to believe that it would be appropriate for professional attitudes to be always concordant with private attitudes, and earlier investigations of social attitudes among (future) healthcare professionals have clearly depicted discordant attitudes in personal and professional domains17 For example, I may be 'blind' to the fact that a person is a paedophile for the purposes of treating their myocardial infarction, but my vision might be restored if there is some indication that they are joining my social circle.One might anticipate, therefore, that with increasing professionalisation there will arise a degree of bifurcation in the social attitudes of healthcare workers towards marginalised people. Specifically, while negative attitudes towards the socially marginalised may decrease with increasing professionalisation, for the purposes of providing treatment and care, the same change in attitude may not be observed towards the socially marginalised in the personal domain.RationaleAlthough HIV/AIDS-related stigma in the health services has been studied, little work has attended to the relationship between professional development and changes in stigmatising attitudes. Indeed, most research has relied on cross-sectional data to assess generic levels of stigma,18-28 without attempting to understand how attitudes may develop and change over time, or differences between stigma associated with the professional and private domains of life. This question is particularly crucial in the context of health service provision, because of the hypothesised link between the trajectory of stigmatising attitudes and the trajectory of professional development.The primary main objective of this study is to investigate the relationship between the stage of professional development of healthcare students and the kinds of stigmatising attitudes held about PLWHA. More specifically, we aim to measure the attitudes of students towards PLWHA to assess (1) the level of stigmatising attitudes, (2) differences between attitudes in professional and private domains and (3) changes in the differences between attitudes in professional and private domains as the students become increasingly professionalised.Although there are a number of measures of stigma, there are few separate measures of stigmatising attitudes in professional and private domains and none validated for use in our research setting. The conditional secondary objective, therefore, is to develop a suitable tool to measure the stigmatising attitudes in professional and private domains. This secondary objective, however is described in less detail and the protocol assumes that such a measure is identifiable.RationaleAlthough HIV/AIDS-related stigma in the health services has been studied, little work has attended to the relationship between professional development and changes in stigmatising attitudes. Indeed, most research has relied on cross-sectional data to assess generic levels of stigma,18-28 without attempting to understand how attitudes may develop and change over time, or differences between stigma associated with the professional and private domains of life. This question is particularly crucial in the context of health service provision, because of the hypothesised link between the trajectory of stigmatising attitudes and the trajectory of professional development.The primary main objective of this study is to investigate the relationship between the stage of professional development of healthcare students and the kinds of stigmatising attitudes held about PLWHA. More specifically, we aim to measure the attitudes of students towards PLWHA to assess (1) the level of stigmatising attitudes, (2) differences between attitudes in professional and private domains and (3) changes in the differences between attitudes in professional and private domains as the students become increasingly professionalised.Although there are a number of measures of stigma, there are few separate measures of stigmatising attitudes in professional and private domains and none validated for use in our research setting. The conditional secondary objective, therefore, is to develop a suitable tool to measure the stigmatising attitudes in professional and private domains. This secondary objective, however is described in less detail and the protocol assumes that such a measure is identifiable.Method and analysisStudy designThe ideal design for this research would be a 4-year to 5-year longitudinal study of healthcare students measuring changes in attitude over their professional course; however, an alternative approach is proposed which limits the resource expenditure while providing a good indication of the idea's merit. Instead of a longitudinal design, a serial cross-sectional design (to examine differences between cohorts in different years of study) will be combined with a two-point in time longitudinal design (to examine differences between the beginning and the end of a single year of study; figure 1). Levels of stigma will be measured once at the beginning of a single year of study and once at the end of the same year, and this will be conducted across year cohorts.Download figureOpen in new tabDownload powerpointFigure1 Study design for MBBS programme.Study populationMonash University is an Australian university that has multiple campuses in Australia as well as in Malaysia and South Africa. In this study, we will recruit Monash University healthcare students from three campuses (two campuses in Australia and one campus in Malaysia). Students over the age of 17, studying a 4-year plus, professional, healthcare qualification, degree course will be eligible.Students with a previous healthcare qualification will be excluded; for example, a nurse returning to university to pursue medicine. Also, students below the age of 17 will be excluded. There are no other exclusion criteria.Sample size calculationUsually the number of predictor variables, the variability in the outcome variable, the correlation between the repeated measures, and the type of statistical test planned are used to calculate the minimum number of respondents needed to achieve a significant result with known probability.29 The variability in the outcome measures is unknown, as is the correlation between the repeated measure of personal and professional stigma, making a realistic sample size calculation almost impossible.30 However, a recent study of HIV knowledge and stigma in a Malaysian healthcare cohort provides a crude guide.31 In that study without repeated measures, a sample size of 340 was calculated. Inflating this estimate to account for the repeated measurement, in what amounts to a conservative design effect of 2.5, leads to an estimated sample size of 850. However, the ethical mechanisms operating within the University for the use of students as participants prevent random sampling and one must, in reality, attempt to contact all students.Data analysis planIf the assumptions hold, we anticipate the use of mixed effects linear models to examine differences between the level of stigmatising attitudes between year-group cohorts, controlling for appropriate covariates, such as age, sex, ethnographic backgrounds and course.The approach to the analysis of the data assumes a serial cross-sectional design. It is conceptually simple to think of the data analysis in terms of repeated measures analysis of covariance (ANCOVA) where stigmatising attitudes are the outcome measures measured twice within a person (ie, a measure of personal and professional stigma). The level of professionalism is treated as an ordered factor based on years of study; and sex, level of HIV knowledge, and the type of degree programme are treated as nominal, interval and nominal covariates, respectively.In the preliminary stages, exploratory data analysis will be used to check and describe the data. However, rather than repeated measures of ANCOVA, which was described for its conceptual simplicity, a mixed effects linear model will be fitted to the data to control for repeated measures of stigma within a person. The great advantages of the mixed effects linear model for repeated measures designs is that if one of the outcome measures is missing (eg, if a participant fails to complete the personal stigma scale but does complete the professional stigma scale), the remaining data from the individual can still be retained. The data will be analysed using the R statistical environment.32Measurement toolThere is currently no measurement tool designed to measure stigmatising attitudes in a professional and private domain separately, and this is the secondary objective of the research. We will carry out a sequential mixed methods design to develop a measurement tool (ie, a questionnaire). We will form a group of healthcare specialist(s), health academics and healthcare team members, that is, nurses, medical doctors, pharmacists, etc with at least 5 years of clinical experience, and together we will implement a four-step approach to create the new measurement toolWe will define the main facets and domains of the measurement tool based on 'personal domains of stigma' versus 'professional domain of stigma in the context of a health professional's work environment'. We anticipate that this could be achieved by creating brief hypothetical scenarios about HIV positive individuals and HIV negative individuals in health settings. These hypothetical scenarios-vignettes-could be themed to reflect fear of contagion, etc. For example, a scenario in which 'a physician refuses to operate on a patient with HIV/AIDS to protect themselves from contracting HIV/AIDS'.We will decide on the items for 'personal domain of stigma' and 'professional domain of stigma' either by adopting the available items from the available validated measurement tools or by developing new items. For instance, we will search the relevant sources of information, that is, published articles, book chapters, organisational documents like international and national codes of professional conduct and ethics in the health field to develop new items for 'professional domain of stigma'.2 ,13 ,33-38 We anticipate that common themes reflecting the traits of professionalism could be extracted from the above said sources of information. For example, fear of contagion, risks of infectivity, confidentiality and resource allocation could be the themes that might surface.We will design the new items as such to capture the interplay between a social, either professional or personal, responsibility and a potentially stigmatised (HIV positive) or non-stigmatised (HIV negative) characteristic.We will draft the finalised items to create a scale-a questionnaire-and will validate it.We will administer the measurement tool in a series of time points to capture any change(s) in attitude.Data collectionWe will collect the data using the newly developed questionnaire by administering paper-based and/or online surveys. The online version of the survey will be available via the 'Blackboard' class management system, with a link in the announcements as the student's login (Australia). The paper-based version will be distributed in classrooms at the end of the taught session (Malaysia). There is no risk of students receiving the online version also receiving the paper-based version.The questionnaire will contain demographic questions and the initial item pool of questions on HIV/AIDS-related stigma. We will also provide each participant with the questionnaire and explanatory statement-describing the purpose of the research, methods, etc.Participating sitesWe anticipate that healthcare students from each year will be invited to participate in the study over a 1-year period. This will allow us to examine differences between the level of stigmatising attitudes between year-group cohorts, controlling for appropriate covariates, such as age, sex, ethnographic backgrounds, cultural backgrounds and course.Study designThe ideal design for this research would be a 4-year to 5-year longitudinal study of healthcare students measuring changes in attitude over their professional course; however, an alternative approach is proposed which limits the resource expenditure while providing a good indication of the idea's merit. Instead of a longitudinal design, a serial cross-sectional design (to examine differences between cohorts in different years of study) will be combined with a two-point in time longitudinal design (to examine differences between the beginning and the end of a single year of study; figure 1). Levels of stigma will be measured once at the beginning of a single year of study and once at the end of the same year, and this will be conducted across year cohorts.Download figureOpen in new tabDownload powerpointFigure1 Study design for MBBS programme.Study populationMonash University is an Australian university that has multiple campuses in Australia as well as in Malaysia and South Africa. In this study, we will recruit Monash University healthcare students from three campuses (two campuses in Australia and one campus in Malaysia). Students over the age of 17, studying a 4-year plus, professional, healthcare qualification, degree course will be eligible.Students with a previous healthcare qualification will be excluded; for example, a nurse returning to university to pursue medicine. Also, students below the age of 17 will be excluded. There are no other exclusion criteria.Sample size calculationUsually the number of predictor variables, the variability in the outcome variable, the correlation between the repeated measures, and the type of statistical test planned are used to calculate the minimum number of respondents needed to achieve a significant result with known probability.29 The variability in the outcome measures is unknown, as is the correlation between the repeated measure of personal and professional stigma, making a realistic sample size calculation almost impossible.30 However, a recent study of HIV knowledge and stigma in a Malaysian healthcare cohort provides a crude guide.31 In that study without repeated measures, a sample size of 340 was calculated. Inflating this estimate to account for the repeated measurement, in what amounts to a conservative design effect of 2.5, leads to an estimated sample size of 850. However, the ethical mechanisms operating within the University for the use of students as participants prevent random sampling and one must, in reality, attempt to contact all students.Data analysis planIf the assumptions hold, we anticipate the use of mixed effects linear models to examine differences between the level of stigmatising attitudes between year-group cohorts, controlling for appropriate covariates, such as age, sex, ethnographic backgrounds and course.The approach to the analysis of the data assumes a serial cross-sectional design. It is conceptually simple to think of the data analysis in terms of repeated measures analysis of covariance (ANCOVA) where stigmatising attitudes are the outcome measures measured twice within a person (ie, a measure of personal and professional stigma). The level of professionalism is treated as an ordered factor based on years of study; and sex, level of HIV knowledge, and the type of degree programme are treated as nominal, interval and nominal covariates, respectively.In the preliminary stages, exploratory data analysis will be used to check and describe the data. However, rather than repeated measures of ANCOVA, which was described for its conceptual simplicity, a mixed effects linear model will be fitted to the data to control for repeated measures of stigma within a person. The great advantages of the mixed effects linear model for repeated measures designs is that if one of the outcome measures is missing (eg, if a participant fails to complete the personal stigma scale but does complete the professional stigma scale), the remaining data from the individual can still be retained. The data will be analysed using the R statistical environment.32Measurement toolThere is currently no measurement tool designed to measure stigmatising attitudes in a professional and private domain separately, and this is the secondary objective of the research. We will carry out a sequential mixed methods design to develop a measurement tool (ie, a questionnaire). We will form a group of healthcare specialist(s), health academics and healthcare team members, that is, nurses, medical doctors, pharmacists, etc with at least 5 years of clinical experience, and together we will implement a four-step approach to create the new measurement toolWe will define the main facets and domains of the measurement tool based on 'personal domains of stigma' versus 'professional domain of stigma in the context of a health professional's work environment'. We anticipate that this could be achieved by creating brief hypothetical scenarios about HIV positive individuals and HIV negative individuals in health settings. These hypothetical scenarios-vignettes-could be themed to reflect fear of contagion, etc. For example, a scenario in which 'a physician refuses to operate on a patient with HIV/AIDS to protect themselves from contracting HIV/AIDS'.We will decide on the items for 'personal domain of stigma' and 'professional domain of stigma' either by adopting the available items from the available validated measurement tools or by developing new items. For instance, we will search the relevant sources of information, that is, published articles, book chapters, organisational documents like international and national codes of professional conduct and ethics in the health field to develop new items for 'professional domain of stigma'.2 ,13 ,33-38 We anticipate that common themes reflecting the traits of professionalism could be extracted from the above said sources of information. For example, fear of contagion, risks of infectivity, confidentiality and resource allocation could be the themes that might surface.We will design the new items as such to capture the interplay between a social, either professional or personal, responsibility and a potentially stigmatised (HIV positive) or non-stigmatised (HIV negative) characteristic.We will draft the finalised items to create a scale-a questionnaire-and will validate it.We will administer the measurement tool in a series of time points to capture any change(s) in attitude.Data collectionWe will collect the data using the newly developed questionnaire by administering paper-based and/or online surveys. The online version of the survey will be available via the 'Blackboard' class management system, with a link in the announcements as the student's login (Australia). The paper-based version will be distributed in classrooms at the end of the taught session (Malaysia). There is no risk of students receiving the online version also receiving the paper-based version.The questionnaire will contain demographic questions and the initial item pool of questions on HIV/AIDS-related stigma. We will also provide each participant with the questionnaire and explanatory statement-describing the purpose of the research, methods, etc.Participating sitesWe anticipate that healthcare students from each year will be invited to participate in the study over a 1-year period. This will allow us to examine differences between the level of stigmatising attitudes between year-group cohorts, controlling for appropriate covariates, such as age, sex, ethnographic backgrounds, cultural backgrounds and course.DiscussionDefinitionsIn the context of future healthcare professionals, the years towards the professional development could be considered as one indicator of professionalisation. Clinical knowledge, as well as knowledge of contagion and transmission, will increase with years in a healthcare programme. Within a modern healthcare programme, however, there is also a focus on professional ethics and professional practice-often implicit rather than explicit-probably increasing with the shift from preclinical to clinical years in a programme. Under these circumstances, the years of training becomes a reasonable indicator of professionalisation. Unfortunately, professionalism then becomes confounded by knowledge of transmission.Strengths and weaknessesThe strength of the study is the two-point in time longitudinal design that will enable us to investigate the relationship between stigmatising attitude towards PLWHA and professionalisation by looking at change(s) in attitudes over a time period.The approach to sampling, which is not an ideal but a constraint placed by ethical requirements, raises the possibility of a selection bias. In a more general invitation to participate given to all students, those with particular attitudinal dispositions (or dispositions to change attitudes with professional exposure) may self-select. This needs to be noted as a limitation, and may warrant further study. However, the nature of the hypothesis that participants will change on one dimension of stigma attitudes but not another seems to provide some protection against the plausibility of the selection bias as an explanation for any observed difference.The lack of a universally accepted measure of 'professionalism'39-41 in healthcare students or the healthcare workforce is an issue. However, within the context of this study, years of study is a reasonable indicator in the first instance.Moreover, the bifurcation of social attitude into the private and professional domains might be less distinctive than anticipated, and requires large samples to detect the differences. We also anticipate collecting the self-reported attitude rather than the actual attitude and this, of course, would also raise questions about the practical importance of the issue, which could be a finding in its own right.ConclusionA fair and responsive health system requires a healthcare workforce that is blind to the 'undeserving' and the 'morally reprehensible'. If we do not gain a better understanding of the relationship between professionalisation and negative social attitudes and behaviour towards the socially marginalised, we are in danger of recreating a tiered healthcare system each time a new disease or a new social group is devalued. Notwithstanding the measurement challenges outlined here, the implications for professional education and the health systems agenda are sufficiently important to warrant further investigation.Ethics and disseminationParticipation in this study will be completely voluntary, where the completion and return of the questionnaire will be taken as consent. This protocol has been approved by the Monash University Human Research Ethics Committee (approval number: CF12/0829-201200368) and categorised as low risk.Data depositionWe will keep the data in a locked filing cabinet in the Monash University (Sunway campus) premises for 5 years, after which the information will be shredded and disposed of in secure bins, and digital recordings will be erased in accordance with Monash University's regulations. Only the principal investigator and the researcher will have access to the filing cabinet.Dissemination planWe aim to present and publish the results of this study in national and international conferences and peer-reviewed journals, respectively.DefinitionsIn the context of future healthcare professionals, the years towards the professional development could be considered as one indicator of professionalisation. Clinical knowledge, as well as knowledge of contagion and transmission, will increase with years in a healthcare programme. Within a modern healthcare programme, however, there is also a focus on professional ethics and professional practice-often implicit rather than explicit-probably increasing with the shift from preclinical to clinical years in a programme. Under these circumstances, the years of training becomes a reasonable indicator of professionalisation. Unfortunately, professionalism then becomes confounded by knowledge of transmission.Strengths and weaknessesThe strength of the study is the two-point in time longitudinal design that will enable us to investigate the relationship between stigmatising attitude towards PLWHA and professionalisation by looking at change(s) in attitudes over a time period.The approach to sampling, which is not an ideal but a constraint placed by ethical requirements, raises the possibility of a selection bias. In a more general invitation to participate given to all students, those with particular attitudinal dispositions (or dispositions to change attitudes with professional exposure) may self-select. This needs to be noted as a limitation, and may warrant further study. However, the nature of the hypothesis that participants will change on one dimension of stigma attitudes but not another seems to provide some protection against the plausibility of the selection bias as an explanation for any observed difference.The lack of a universally accepted measure of 'professionalism'39-41 in healthcare students or the healthcare workforce is an issue. However, within the context of this study, years of study is a reasonable indicator in the first instance.Moreover, the bifurcation of social attitude into the private and professional domains might be less distinctive than anticipated, and requires large samples to detect the differences. We also anticipate collecting the self-reported attitude rather than the actual attitude and this, of course, would also raise questions about the practical importance of the issue, which could be a finding in its own right.ConclusionA fair and responsive health system requires a healthcare workforce that is blind to the 'undeserving' and the 'morally reprehensible'. If we do not gain a better understanding of the relationship between professionalisation and negative social attitudes and behaviour towards the socially marginalised, we are in danger of recreating a tiered healthcare system each time a new disease or a new social group is devalued. Notwithstanding the measurement challenges outlined here, the implications for professional education and the health systems agenda are sufficiently important to warrant further investigation.Ethics and disseminationParticipation in this study will be completely voluntary, where the completion and return of the questionnaire will be taken as consent. This protocol has been approved by the Monash University Human Research Ethics Committee (approval number: CF12/0829-201200368) and categorised as low risk.Data depositionWe will keep the data in a locked filing cabinet in the Monash University (Sunway campus) premises for 5 years, after which the information will be shredded and disposed of in secure bins, and digital recordings will be erased in accordance with Monash University's regulations. Only the principal investigator and the researcher will have access to the filing cabinet.Dissemination planWe aim to present and publish the results of this study in national and international conferences and peer-reviewed journals, respectively.References↵Everybody's business: strengthening health systems to improve health outcomes. 2007. (accessed 1 Oct 2012).↵World Medical Association: Medical Ethics Manual. 2009. (accessed 23 Jan 2011).↵Ross MW, Hunter CE. Dimensions, content and validation of the fear of AIDS schedule in health professionals. Aids Care 1991;3:175-80.OpenUrlPubMed↵Hamra M, Ross MW, Karuri K, et al. The relationship between expressed HIV/AIDS-related stigma and beliefs and knowledge about care and support of people living with AIDS in families caring for HIV-infected children in Kenya. Aids Care 2005;17:911-22.OpenUrlPubMedWeb of Science↵Li L, Wu Z, Zhao Y, et al. Using case vignettes to measure HIV-related stigma among health professionals in China. Int J Epidemiol 2007;36:178-84.OpenUrlAbstract/FREE Full Text↵Perlick DA, Rosenheck RA, Clarkin JF, et al. Stigma as a barrier to recovery: adverse effects of perceived stigma on social adaptation of persons diagnosed with bipolar affective disorder. Psychiatr Serv 2001;52:1627-32.OpenUrlCrossRefPubMedWeb of Science↵Chan KY, Stoové MA, Sringernyuang L, et al. Stigmatization of AIDS patients: disentangling Thai nursing students' attitudes towards HIV/AIDS, drug use, and commercial sex. Aids Behav 2007;12:146-57.OpenUrlPubMed↵Leiter K, Suwanvanichkij V, Tamm I, et al. Human rights abuses and vulnerability to HIV/AIDS: the experiences of Burmese women in Thailand. Health Hum Rights 2006;9:88-111.OpenUrlCrossRefPubMed↵Roth MT, Zlatic TD. Development of student professionalism. Pharmacotherapy 2009;29:749-56.OpenUrlPubMedWeb of Science↵Cruess RL, Cruess SR. Expectations and obligations: professionalism and medicine's social contract with society. Perspect Biol Med 2008;51:579-98.OpenUrlCrossRefPubMedWeb of Science↵Robertson A, Minkler M. New health promotion movement: a critical examination. Health Educ Behav 1994;21:295-312.OpenUrlAbstract/FREE Full Text↵Cameron M, Crane N, Ings R, et al. Promoting well-being through creativity: how arts and public health can learn from each other. Perspect Public Health 2013;133:52-9.OpenUrlPubMedWeb of Science↵Good Medical Practice: a Code of Conduct for Doctors in Australia. 2009. (accessed 17 Sep 2011).↵Cutler JL, Harding KJ, Mozian SA, et al. Discrediting the notion 'working with "crazies" will make you "crazy": addressing stigma and enhancing empathy in medical student education. Adv Health Sci Educ 2008;14:487-502.OpenUrlWeb of Science↵Bhugra D, Gupta S. Alienist in the 21st century. Asian J Psychiatry 2011;4:92-5.OpenUrl↵Uys L, Chirwa M, Kohi T, et al. Evaluation of a health setting-based stigma intervention in five African countries. Aids Patient Care STDs 2009;23:1059-66.OpenUrlPubMedWeb of Science↵James VW, John SE. Professional and personal attitudes of physiotherapy students toward disabled persons. Aust J Physiother 1988;34:23-6.OpenUrl↵Agrawal HK, Rao RSP, Chandrashekar S, et al. Knowledge of and attitudes to HIV/AIDS of senior secondary school pupils and trainee teachers in Udupi District, Karnataka, India. Ann Trop Paediatr 1999;19:143-9.OpenUrlPubMed↵Herek GM, Capitanio JP, Widaman KF. Stigma, social risk, and health policy: public attitudes toward HIV surveillance policies and the social construction of illness. Health Psychol 2003;22:533.OpenUrlCrossRefPubMedWeb of Science↵Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS stigma, and voluntary HIV counselling and testing in a black township in Cape Town, South Africa. Sex Transm Infect 2003;79:442-7.OpenUrlAbstract/FREE Full Text↵Reidpath DD, Brijnath B, Chan KY. An Asia Pacific six-country study on HIV-related discrimination: introduction. Aids Care 2005;17(Suppl 2):S117-27.OpenUrlCrossRefPubMedWeb of Science↵Chan KY, Yang Y, Zhang KL, et al. Disentangling the stigma of HIV/AIDS from the stigmas of drugs use, commercial sex and commercial blood donation-a factorial survey of medical students in China. BMC Public Health 2007;7:280.OpenUrlPubMed↵Abell N, Rutledge S, McCann T, et al. Examining HIV/AIDS provider stigma: assessing regional concerns in the islands of the Eastern Caribbean. Aids Care 2007;19:242-7.OpenUrlCrossRefPubMedWeb of Science↵Chan K, Stoové MA, Reidpath DD. Stigma, social reciprocity and exclusion of HIV/AIDS patients with illicit drug histories: a study of Thai nurses' attitudes. Harm Reduct J 2008;5:28.OpenUrlCrossRefPubMed↵Varas-Díaz N, Neilands TB, Malavé Rivera S, et al. Religion and HIV/AIDS stigma: implications for health professionals in Puerto Rico. Glob Public Health 2010;5:295-312.OpenUrlWeb of Science↵Chao LW, Gow J, Akintola G, et al. HIV/AIDS stigma attitudes among educators in KwaZulu-Natal, South Africa. J Sch Health 2010;80:561-9.OpenUrlPubMedWeb of Science↵Obermeyer CM, Bott S, Carrieri P, et al. HIV testing, treatment and prevention: generic tools for operational research. Geneva: World Heal Organ, 2009.↵Nyblade L. Measuring HIV stigma: existing knowledge and gaps. Psychol Health Med 2006;11:335-45.OpenUrlCrossRefPubMed↵Overall JE, Doyle SR. Estimating sample sizes for repeated measurement designs. Control Clin Trials 1994;15:100-23.OpenUrlPubMedWeb of Science↵Proschan MA. Two-stage sample size re-estimation based on a nuisance parameter: a review. J Biopharm Stat 2005;15:559-74.OpenUrlCrossRefPubMed↵Chew BH, Cheong AT. Assessing HIV/AIDS knowledge and stigmatizing attitudes among medical students in Universiti Putra Malaysia. Med J Malaysia 2013;68:24-9.OpenUrlPubMed↵R Development Core Team. R: a language and environment for statistical computing. Vienna, Austria: R Foundation for Statistical Computing, 2012. (accessed 16 Oct 2012).↵Code of Professional Conduct-Nurses and Midwives Board. (accessed 17 Sep 2011).↵Code of Medical Ethics. 2002. (accessed 17 Sep 2011).↵Pharmaceutical Society of Australia. (accessed 17 Sep 2011)↵Malaysian Pharmaceutical Society. (accessed 17 Sep 2011)↵Principles of Ethics and Code of Professional Conduct. 2012. (accessed 14 Nov 2012).↵The ICN Code of Ethics for Nurses. 2006. (accessed 14 Nov 2012).↵Arnold L. Assessing professional behavior: yesterday, today, and tomorrow. Acad Med 2002;77:502-15.OpenUrlCrossRefPubMedWeb of Science↵Hammer DP. Professional attitudes and behaviors: the 'A's and B's' of professionalism. Am J Pharm Educ 2000;64:455.OpenUrl↵Ahmadi K, Hassali MA Ahmad. Professionalism in pharmacy: a continual societal and intellectual challenge. Am J Pharm Educ 2012;76:72.OpenUrlPubMedFootnotesContributors KA developed the concept and DDR reshaped it. KA and DDR have made substantive intellectual contributions to the manuscript. PA and MAAH have revised the manuscript critically and have improved the presentation of the ideas. All four authors have given final approval the publication of the manuscript.Funding This work was supported by an internal grant from global public health (GPH) research strength, School of Medicine and Health Sciences, Monash University Sunway Campus. The grant number was 5140056.Competing interests None.Ethics approval MBBS executive committee and Monash University Human Research Ethics Committee.Provenance and peer review Not commissioned; externally peer reviewed.
2021 07 16
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Spring Cleaning: Why Not Start with Your File Cabinet?
It is TOO easy to plunk files into a filing cabinet just to get them out of sight. Maybe you've done this... if you have, then you know what I'm talking about...and you also know what happens when you continually do this for many years. You end up with an overstuffed, under-utilized, scary looking filing cabinet. Consider that 80% of what we file, we never look at again and then think about your own filing cabinets either at work or at home. What comes to mind? The tricky thing about overstuffed file cabinets is that they don't bother anyone... right? They hide the mess and chaos really well and if you don't open the drawers, then who cares? Unless of course, it comes time to find that past tax return that is shoved into the back of that cabinet or when your desk and surrounding flat spaces are piled so high that you can't operate in your space functionally anymore? This method of operation can put a major damper on productivity.If spring cleaning your file cabinet feels daunting and overwhelming, follow these simple steps towards a cleaner cabinet and clearer mind.1.Block time out to work on this...if you don't, it won't happen! I usually advise clients to work for 2 hours on a clean out of paper. This work can be tiring and inspiring all at once, so know your limits and try not to leave the project half done once you've started on a particular section or area. 2.Start clearing out the first drawer by going through each paper to make a decision about. Create 3 categories: keep, recycle/toss, not sure about. 3.Once you have your categories, group together the keep piles and start to define and merge your categories. I always encourage people to create their own file map to help them see their categories clearly. Just write down your big picture categories, such as projects, HR items, invoicing, billing, etc. From here, you can break them down, but it's important to start with the big picture first. 4.Have your tools on hand. It's maddening to get to a certain point in any project and not have the proper supplies and tools on hand to support the process and help you move toward completion. In this case, you need some hanging files, insert files (I call them manila files), and a sharpie for labeling the file folders. 5.The last step aside from just "doing it" is to make sure you shred any identifying information. You will be amazed at how much of what you sort through will go into the recycle bin and get tossed. Now that your filing cabinet is clear and clean, remember to file for retrieval, not for storage. By following these steps you will be back on the path to a cleaner space and more useful file system in no time!
2021 07 15
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Mortgage Settlement Deal Confronts Legacy of Obama ...
After years of incompetence, intransigence, malevolence and whatever else may explain how mortgage companies have managed to screw over millions of troubled American homeowners, a fix is finally at hand. This is how the Obama administration invites us to view the broad, $25 billion state and federal foreclosure settlement that it struck last month with the nation's five largest mortgage companies. Officials have presented the deal as justice for the so-called robo-signing scandal, whereby major mortgage companies improperly foreclosed on millions of properties. They have touted its centerpiece: a $20 billion fund stocked with fines paid by the mortgage companies, which will deliver relief to as many as 1 million troubled borrowers via lowered monthly payments, principal reduction and refinanced loan terms.The president portrayed the deal as no less than a curative, calling it a "landmark settlement" that will "speed relief to the hardest hit homeowners" and "begin to turn the page on an era of recklessness that has left so much damage in its wake."Yet anyone who has paid even minor attention to the administration's housing policy may be permitted to ask: For real? We have heard this sort of talk many times before from the Obama administration, only to see more homes slide into the foreclosure crisis. What's special this time? A good deal, asserts Housing and Urban Development Secretary Shaun Donovan, who played a leading role in brokering the deal. In a pair of recent conversations, his message essentially boiled down to this: Thus far much of what has happened on the housing relief front has been torturously frustrating, pinning millions of distressed borrowers in Hell's own filing cabinet. But this deal reflects crucial lessons learned, yielding a new program that will work better.The keys to the deal, Donovan maintains, are new standards that mortgage companies must live by and an independent monitor empowered to watch over implementation, with possible fines reaching $1 million per violation. The deal will be filed in U.S. District Court in Washington, D.C., ensuring a venue for legal enforcement."The most important thing is that you require outcomes," Donovan said during a meeting this week with Huffington Post editors and reporters. "At the end of the day, the leverage is different."He drew a distinction between this settlement and a previous deal struck with the notorious subprime lender Countrywide, now part of (notorious) Bank of America, whose very name can induce spontaneous shrieks of agony in many U.S. homes, along with file folders jammed with inscrutable documents. In that deal, Bank of America was able to satisfy its obligations, simply by reaching out to delinquent borrowers with offers for help. "This is not 'You have to solicit X number of borrowers,'" Donovan said. "This is 'You have to deliver a result.'"Donovan noted that the new settlement relies on reductions to principal balances, addressing the fact that roughly 1 in 5 homeowners with a mortgage now owe the bank more than their home is worth. Though he acknowledged that only about 10 percent of mortgages will be eligible for this treatment, he expressed hopes that this would spur other lenders to follow suit.The HUD secretary is the right person to be talking up the settlement. Earnest and passionate, he comes off like he is generally interested in keeping homeowners in their homes, unlike Treasury Secretary Tim Geithner, who manages to convey an abiding interest in keeping bank executives in their corner offices. Still, the legacy of failure from the Obama administration on the foreclosure front is so great that a proper assessment of the settlement must go beyond its terms. It will come down to the administration's resolve in following through. On that score, legitimate reasons abound for someone to harbor doubts that this deal will amount to anything meaningful for homeowners.Three years ago, the president stood in Mesa, Ariz., a community ravaged by foreclosure and announced the creation of a new program that he said would spare 3 million to 4 million homeowners from that fate by lowering their mortgage payments. As of last month, fewer than 1 million homeowners had received permanent loan relief under the program, according to a recent scorecard. From the beginning, millions of applicants who requested help have confronted chaos, disorganization and conflicting instructions. Mortgage companies have repeatedly lost documents and demanded new sets, only to mislay the replacements, too. Borrowers seeking customer service have been switched from office to office (as if it were some corporate version of speed-dating) while enduring maddeningly long hold times. They have received letters on one day congratulating them for gaining approval for lower payments, and the next day informing them of the pending disposition of their home at a sheriff's sale.Treasury officials like to explain all this misery and confusion by noting that the banks were never built to handle loan modifications, or paperwork in general, which is perversely true. Back when they were handing out loans to anyone with a name, banks did not slow themselves down over concerns about niggling things like income verification. How can they be expected to suddenly become masters of the filing cabinet? Yet this is no excuse for mortgage companies' horrific mistreatment of borrowers. Had the banks been enjoying, say, a lucrative boom in refinancing, they would surely have managed to hire enough people to answer the telephones and keep track of the requisite files. They didn't do this for the simple reason that they didn't want to. Instead, they adopted a mode of strategic incompetence: They stocked themselves with the minimum number of people required to claim credit for participating in the program, while guaranteeing that not enough qualified people would be on hand to process the paperwork.Why didn't the banks want to go along? Because they could generally make a lot more money by dragging out delinquency and eventually foreclosing than they could by keeping borrowers in their homes via manageable payments. The mortgage companies are mere servicers, in industry parlance. They don't own most of the mortgages. They just send out the bills and collect the payments, while drawing fees from investors who do own the notes. When borrowers stop making payments, servicers put them into special insurance policies with hefty premiums, typically funneling this business through their own subsidiaries. They order up fresh appraisals, sending these orders through their subsidiaries as well. This foreclosure gravy train swiftly outperforms the meager financial incentives that the administration pays servicers when they agree to lower monthly payments.One element has been consistent throughout this ordeal: the Obama administration's repeated failure to pressure mortgage companies to do what they were supposed to do. When the program was first being crafted in early 2009, provoking complaints that it appeared toothless, a senior Treasury official who would speak to me only without being named, swore otherwise. He insisted that the agency had plenty of tools to force mortgage companies to deliver on their obligations. Once a servicer signed up for the program, this constituted a legal contract, with sanctions applicable, he said.As the months passed and horror stories mounted, the Treasury Department repeatedly chastised mortgage companies for their poor performance and vowed consequences."The banks are not doing a good enough job," Michael S. Barr, then the Treasury Department's assistant secretary for financial institutions, told me in November 2009, amid the latest batch of lousy program data. "Some of the firms ought to be embarrassed, and they will be."But as more months passed without improvement, the department's threats proved hollow and then officials began to describe the program in different terms: It was merely voluntary. Congress had not given the administration authority to do anything meaningful. As the president's speech in Mesa, Ariz., receded into history, it began to seem more and more like a photo opportunity, with the program that he launched nothing more than an effort to buy a little time and public favor while we waited for the only real fix to the foreclosure disaster -- an improving economy.The administration has said that its initial relief program was tailored to help borrowers saddled with mortgages whose interest rates have been reset higher, but not to address the defining problem of our time -- joblessness. Yet even a newer program, crafted precisely to help people who can't make their mortgage payments as a result of job loss, is foundering. Less than $218 million had been distributed from the $7.6 billion program as of the beginning of the year, according to a report in the Los Angeles Times.So, here we are, three years after Obama's bold promise, still talking about the need for new plans. Maybe the terms of the settlement will prove beneficial. Maybe the enforcement will prove robust. We certainly need it. But until the mortgage companies show genuine willingness to meet their obligations instead of gaming the system and until the Obama administration demonstrates resolve in forcing compliance, this settlement is best viewed as being like its predecessors -- an as-yet undelivered promise, with the bill long past due.
2021 07 12
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