Journal articles on the topic 'Computer decision support systems; Family history'

SummaryTo summarize current excellent research in the field of computer-based decision support systems in health and healthcare.We provide a synopsis of the articles selected for the IMIA Yearbook 2012, from which we attempt to draft a synthetic overview of the activity and new trends in the field.While the state of the research in the field of medical decision support systems is illustrated by a set of fairly heterogeneous studies, it is possible to identify fundamental aspects of the fields, e.g. Decision Support Systems for Computerized Provider Order Entry, both for physicians and pharmacists, as well as more specific developments such as instruments to improve processing of data related to Clinical Trials and applications to capture family health history.The best paper selection of articles on decision support shows examples of excellent research on methods concerning original development as well as quality assurance of previously reported studies. This selected set of scientific investigations clearly question the way decision support systems are deployed in clinical environments as these systems seem to have little impact on patient safety and even could harm the patient. Furthermore, while significant research efforts are invested into translational & “omics” medicine, it is interesting to observe that simple data capture applications can reasonably lead to positive changes in healthcare.

Purpose To evaluate the potential of implementing established family cancer guidelines as clinical decision support within meaningful use (MU)–compliant health information technology systems. Methods We conducted a systematic analysis of cancer guidelines involving family health history (FHx) published before 2015. By comparing existing cancer guideline statements to current MU FHx standard requirements, we determined whether the cancer guideline statements could be implemented as clinical decision support. For guidelines that could not implemented, we determined the primary reasons for incompatibility. Results A total of 531 statements from 55 guidelines published by 11 different organizations were reviewed and analyzed. Overall, 18% to 66% of guideline statements could or could not be implemented in MU-compliant health information technology systems, depending on which MU standard was used. Health Level Seven (HL7) models performed better than SNOMED models. Implementability of guideline statements varied by cancer type and guideline organizations. The greatest deficiencies in implementability of statements were largely a result of the fact that MU standards required only first-degree relatives and that FHx terms used in guidelines statements were ambiguous. Conclusion FHx cancer guidelines and MU-based systems vary widely and are mostly incompatible. We identified sources of incompatibility and made recommendations that could improve the implementability of FHx cancer guidelines. Our findings and recommendations can enhance the use of established FHx cancer risk guidelines in routine clinical workflows.

One of the developmental directions of Future Internet technologies is the implementation of artificial intelligence systems for manipulating data and the surrounding world in a more complex way. Rule-based systems, very accessible for people’s decision-making, play an important role in the family of computational intelligence methods. The use of decision-making rules along with decision trees are one of the simplest forms of presenting complex decision-making processes. Decision support systems, according to the cross-industry standard process for data mining (CRISP-DM) framework, require final embedding of the learned model in a given computer infrastructure, integrated circuits, etc. In this work, we deal with the topic concerning placing the learned rule-based model of decision support in the database environment-exactly in the SQL database tables. Our main goal is to place the previously trained model in the database and apply it by means of single queries. In our work we assume that the decision-making rules applied are mutually consistent and additionally the Minimal Description Length (MDL) rule is introduced. We propose a universal solution for any IF THEN rule induction algorithm.

The healthcare industry is a stage which is presented with tremendous innovative headways consistently. With the perfect learning of foundation data, writing, and proposed calculation, the proposition conveys engineering for supporting computerized choices to medicinal services organizations. Electronic records are constantly gathered and sorted out to give a point by point history of patients, their sicknesses and determination plans. From the acquired data, the virtual doctoring engine (VDE) endeavors to break down the discernible attributes from the datasets utilizing the known-yet-predict (KYP) calculation to propose an ideal finding plan. This treatment plan will later be directed by a specialist for treating the patients. The exhibition of VDE framework is tried against patients experiencing cardiovascular infections. This methodology has been examined against different component extraction calculations and observed to be 18.2% progressively exact in anticipating the ideal treatment plan.

Medical Decision Support Systems (MDSS) industry collects a huge amount of data, which is not properly mined and not put to the optimum use. This data may contain valuable information that awaits extraction. The knowledge may be encapsulated in various patterns and regularities that may be hidden in the data. Such knowledge may prove to be priceless in future medical decision making. Available medical decision support systems are based on static data, which may be out of date. Thus, a medical decision support system that can learn the relationships between patient histories, diseases in the population, symptoms, pathology of a disease, family history, and test results, would be useful to physicians and hospitals. This paper provides an in-depth review of available data mining algorithms and techniques. In addition to that, data mining applications in medicine are discussed as well as techniques for evaluating them and available applications of performance metrics.

The Swiss energy strategy aims at increasing electricity generation from solar power by 2050, to fulfil Switzerland’s commitments in the Paris Agreement. However, the market of single- and two-family houses is characterized by low return rates for excess power injected to the grid, and the installation of rooftop solar photovoltaic (PV) is sensitive to financial incentives. We assess the drivers influencing the diffusion of rooftop solar PV systems until 2050, by employing an agent-based model. An agent is a single- or two-family house, and its decision to invest depends on the economic profitability of the investment, the agent’s income, environmental benefits (injunctive social norm), awareness and knowledge about the solar PV technology, and the impact of the social network (descriptive social norm). The model includes a synthetic population of agents, statistically equivalent to the true population. We also investigate the impact of different support policies, technology learning rates, electricity prices, and discount rates on the investment decision. We find that the concept of prosumer emerges, mainly via self-consumption strategies. The diffusion process of rooftop solar PV systems in single- and two-family houses gains momentum in the future. In the near-term, PV deployment is sensitive to the profitability of the investment, while after the year 2030, peer effects play an increasing role in the agents’ investment decisions.

Digital manufacturing has been considered, over the last decade, as a highly promising set of technologies for reducing product development times and cost as well as for addressing the need for customization, increased product quality, and faster response to the market. This paper describes the evolution of information technology systems in manufacturing, outlining their characteristics and the challenges to be addressed in the future. Together with the digital manufacturing and factory concepts, the technologies considered in this paper include computer-aided design, engineering, process planning and manufacturing, product data and life-cycle management, simulation and virtual reality, automation, process control, shopfloor scheduling, decision support, decision making, manufacturing resource planning, enterprise resource planning, logistics, supply chain management, and e-commerce systems. These technologies are discussed in the context of the digital factory and manufacturing concepts.

Summary Objective: To summarize recent research and propose a selection of best papers published in 2013 in the field of computer-based decision support in health care. Method: Two literature reviews were performed by the two section editors from bibliographic databases with a focus on clinical decision support systems (CDSSs) and computer provider order entry in order to select a list of candidate best papers to be peer-reviewed by external reviewers. Results: The full review process highlighted three papers, illustrating current trends in the domain of clinical decision support. The first trend is the development of theoretical approaches for CDSSs, and is exemplified by a paper proposing the integration of family histories and pedigrees in a CDSS. The second trend is illustrated by well-designed CDSSs, showing good theoretical performances and acceptance, while failing to show a clinical impact. An example is given with a paper reporting on scorecards aiming to reduce adverse drug events. The third trend is represented by research works that try to understand the limits of CDSS use, for instance by analyzing interactions between general practitioners, patients, and a CDSS. Conclusions: CDSSs can achieve good theoretical results in terms of sensibility and specificity, as well as a good acceptance, but evaluations often fail to demonstrate a clinical impact. Future research is needed to better understand the causes of this observation and imagine new effective solutions for CDSS implementation.

Introduction: Primary immunodeficiency diseases (PID) are generally rare genetic disorders affecting the immune system. Overlapping PIDs symptoms and signs is a challenge to diagnosis and treatment. On the other hand, remembering of all diagnosis criteria is difficult for practitioners. The purpose of this research is developing guideline-based clinical decision support system for diagnosis of primary immune deficiency diseases, to assist practitioner in order to diagnose of disease in early stage and to minimize complications of such diseases.Material and Methods: To provide data a checklist was used and most important demographic information, symptoms, family history, physical findings and laboratory findings to diagnose eight common PIDs extracted from guidelines and literature under specialists opinion. The diagnosis inference model design and develop in Protégé (version 3.4.8) frame based ontology modeling using "Noy and McGuinness" method. Then the mobile based inference model in Eclipse (SDK version 3.7.1) software has been developed and clinical decision support system of primary immunodeficiency has been created.Results: To design the diagnosis inference model in Protégé software, data were classified in 5 main classes and 24 subclasses as hierarchical. Then, specific properties of each class, and determine the value of each property. Then define Instances of each class and initialized instance properties. Then use this model to develop CDSS based on mobile in Eclipse software. At the end, the inference model and the CDSS test with 110 patient’s record data and both of them recognized all 110 patient correctly such as specialist recognition.Conclusion:Guideline-based decision support systems help to detect diseases correctly, quickly and early. Guideline-based decision support systems are very reliable to practitioner, because guidelines are accepted to their. These systems reduce the forget probability of diagnosis stages and percentage error of diagnosis by practitioner and increase the accuracy of diagnosis.

Summary Objectives: To assist general practitioners in evaluating patients’ genetic risk of cancer on the basis of family history data. Methods: A new computer application, RAGs (Risk Assessment in Genetics), has been developed to help doctors create graphical family trees and assess the genetic risk of breast and colorectal cancer. RAGs possesses two features that distinguish it from similar software: (i) a user-centred design, which takes into account the requirements of the doctor-patient encounter; (ii) effective and accessible risk reporting by employing qualitative evidence for or against increased risk, which is more easily understood than numerical probabilities. The system allows any rule-based genetic risk guideline to be implemented, and may be readily modified to cater for the varying degrees of information required by different specialists. Results: RAGs permits fast, accurate data entry, and results in more appropriate management decisions than those made via other techniques. In addition, RAGs enables both the clinician and the patient to understand how it arrives at its conclusions, since the use of qualitative evidence allows the program to provide explanations for its reasoning. Conclusions: The RAGs system promises to help practitioners be more effective gatekeepers to genetic services. It may empower doctors both to make an informed choice when deciding to refer patients who are at increased genetic risk of breast or colorectal cancer, and to reassure those who are at low risk.

SummaryClinical decision support (CDS) can improve safety, quality, and cost-effectiveness of patient care, especially when implemented in computerized provider order entry (CPOE) applications. Medication-related decision support logic forms a large component of the CDS logic in any CPOE system. However, organizations wishing to implement CDS must either purchase the computable clinical content or develop it themselves. Content provided by vendors does not always meet local expectations. Most organizations lack the resources to customize the clinical content and the expertise to implement it effectively. In this paper, we describe the recommendations of a national expert panel on two basic medication-related CDS areas, specifically, drug-drug interaction (DDI) checking and duplicate therapy checking. The goals of this study were to define a starter set of medication-related alerts that health-care organizations can implement in their clinical information systems. We also draw on the experiences of diverse institutions to highlight the realities of implementing medication decision support. These findings represent the experiences of institutions with a long history in the domain of medication decision support, and the hope is that this guidance may improve the feasibility and efficiency CDS adoption across healthcare settings.

Summary Objective: Performance of computerized adverse drug event (ADE) monitoring of electronic health records through a prospective ADE Monitor and ICD9-coded clinical text review operating independently and simultaneously on the same patient population for a 10-year period are compared. Requirements are compiled for clinical decision support in pharmacy systems to enhance ADE detection. Methods: A large tertiary care facility in Utah, with a history of quality improvement using its advanced hospital information system, was leveraged in this study. ICD9-based review of clinical charts (ICD9 System) was compared quantitatively and qualitatively to computer-assisted pharmacist-verified ADEs (ADE Monitor). The capture-recapture statistical method was applied to the data to determine an estimated prevalence of ADEs. Results: A total estimated ADE prevalence of 5.53% (13,420/242,599) was calculated, with the ICD9 system identifying 2,604 or 19.4%, and the ADE monitor 3,386 or 25.2% of all estimated ADEs. Both methods commonly identified 4.9% of all estimated ADEs and matched 62.0% of the time, each having its strength in detecting a slightly different domain of ADEs. 70% of the ADE documentation in the clinical notes was found in the discharge summaries. Conclusion: Coupled with spontaneous reporting, computerized methods account for approximately half of all ADEs that can currently be detected. To enhance ADE monitoring and patient safety in a hospitalized setting, pharmacy information systems should incorporate prospective structuring and coding of the text in clinical charts and using that data alongside computer-generated alerts of laboratory results and drug orders. Natural language processing can aid computerized detection by automating the coding, in real-time, of physician text from clinical charts so that decision support rules can be created and applied. New detection strategies and enhancements to existing systems should be researched to enhance the detection of ADEs since approximately half are not currently detected.

Background Clinical decision support (CDS) embedded into the electronic health record (EHR), is a potentially powerful tool for institution of antimicrobial stewardship programs (ASPs) in emergency departments (EDs). However, design and implementation of CDS systems should be informed by the existing workflow to ensure its congruence with ED practice, which is characterized by erratic workflow, intermittent computer interactions, and variable timing of antibiotic prescription. Objective This article aims to characterize ED workflow for four provider types, to guide future design and implementation of an ED-based ASP using the EHR. Methods Workflow was systematically examined in a single, tertiary-care academic children's hospital ED. Clinicians with four roles (attending, nurse practitioner, physician assistant, resident) were observed over a 3-month period using a tablet computer-based data collection tool. Structural observations were recorded by investigators, and classified using a predetermined set of activities. Clinicians were queried regarding timing of diagnosis and disposition decision points. Results A total of 23 providers were observed for 90 hours. Sixty-four different activities were captured for a total of 6,060 times. Among these activities, nine were conducted at different frequency or time allocation across four roles. Moreover, we identified differences in sequential patterns across roles. Decision points, whereby clinicians then proceeded with treatment, were identified 127 times. The most common decision points identified were: (1) after/during examining or talking to patient or relative; (2) after talking to a specialist; and (3) after diagnostic test/image was resulted and discussed with patient/family. Conclusion The design and implementation of CDS for ASP should support clinicians in various provider roles, despite having different workflow patterns. The clinicians make their decisions about treatment at different points of overall care delivery practice; likewise, the CDS should also support decisions at different points of care.

Abstract— Patients with diabetes mellitus increased from year to year. This is due to delays in diagnosis of the disease and also because of unhealthy lifestyles. This study aims to create an application of decision support systems in the field of health, namely the diagnosis of the disease Diabetes Mellitus with Fuzzy Inference System (FIS) Mamdani, so that a layman can perform early diagnosis and immediate treatment. Decision Support System Techniques developed to improve the effectiveness of decision-makers. Samples are six puskesmas in East Jakarta. This application uses five variables as inputs consisting of glucose 2 hours after a meal, Diastolic blood pressure, body mass index, family history of diabetes, total pregnancies and one variable as output. The data obtained be processed using fuzzy logic approach to programming Matlab and made Graphical User Interface (GUI). Result is an expert system for diagnosis of Diabetes Mellitus .The trial results by midwives and nurses puskesmas is 100% of these applications in accordance with the doctor”s diagnosis. It is to help improve the quality of service in the Puskesmas in East Jakarta, thus satisfying the users and puskesmas be able to compete both nationally and internationally.

SummaryTo provide a comprehensive overview of computerinterpretable guideline (CIG) systems aimed at non-experts. The overview includes the history of efforts to develop CIGs, features of and relationships among current major CIG systems, current status of standards developments pertinent to CIGs and identification of unsolved problems and needs for future researchLiterature re view based on PubMed, AMIA conference proceedings and key references from publications identified. Search terms included practice guidelines, decision support, controlled vocabulary and medical record systems. Papers were reviewed by both authors and summarized narratively.There is a consensus that guideline delivery systems must be integrated with electronic health records (EHRs) to be most effective. Several evolving CIG formalisms have in common, use of a task network model. There is currently no dominant CIG system. The major challenge in development of interoperable CIGs, is agreement on a standard controlled vocabulary. Such standards are under development, but not widely used, particularly in commercial EHR systems. The Virtual Medical Record (VMR) concept has been proposed as a standard that would serve as an intermediary between guideline vocabulary and that used in EHR implementation.CIG systems are in a state of evolution. Standards efforts promise to improve interoperability without compromising innovation. The VMR concept can assist guideline development even before clinical systems routinely adhere to standards. Frontiers for future work include using the principles learned by computer implementation of guidelines to improve the guideline development process and evaluation methods that isolate the effects of specific CIG features.

Purpose This paper aims to present a systematic methodology to study different economic labor policies and their impacts on women and families. As women entered into the labor market, the traditional division of family labor vanished. Now, families need to make the best decision to both improve the family economy and enhance family's main functions. In addition, the government is responsible toward the consequences of the family policies. Design/methodology/approach The content analysis, fuzzy cognitive map, scenario-planning and vlse kriterijumsk optimizacija kompromisno resenje (VIKOR) have been combined to deal with the studied problem. As a case study, the focus has been on the Iranian family. According to the developed methodology, different family-oriented policies have been simulated and their results are analyzed. Findings Findings show, considering the effects that the division of the couples’ labor has on meeting the material/non-material family needs, the best policy is to support women's home-based businesses. This way, the economic factors will be improved, the couples’ dependence on meeting their needs will be more favorably affected and the family unity will be strengthened. Originality/value In this study, “family” has been analyzed as a single socioeconomic system. Never have the family economic studies been analyzed with a systematic approach by considering all the economic and non-economic factors together. This objective can be realized by applying the methodology proposed in this research because it can help to predict the consequences of any policy toward the family and provide a platform for proposing better policies and making the related decisions in this area.

BackgroundRespiratory tract infections (RTIs) account for 60% of antibiotic prescribing in primary care. Several clinical prediction rules (CPRs) have been developed to help reduce unnecessary prescribing for RTIs, but there is a lack of studies exploring whether or how these CPRs are being used in UK general practice.AimTo explore UK GPs’ views and experiences with regards to RTI CPRs, and to identify barriers and facilitators to their use in practice.Design & settingA qualitative analysis of interviews with in-hours GPs working in the South and South West of England.MethodSemi-structured qualitative telephone interviews were conducted, digitally recorded, transcribed verbatim, and analysed using an inductive thematic approach. Patient and public involvement representatives contributed to study design and interpretation of findings.ResultsThirty-two GPs were interviewed. Some CPRs were more commonly used than others. Participants used CPRs to facilitate patient—clinician discussion, confirm and support their decision, and document the consultation. GPs also highlighted concerns including lack of time, inability of CPRs to incorporate patient complexity, a shift in focus from the patient during consultations, and limited use in remote consultation (during the COVID-19 pandemic).ConclusionThis study highlights the need for user-friendly CPRs that are readily integrated into computer systems, and easily embedded into routine practice to complement clinical decision-making. Existing CPRs need to be validated for other populations where demographics and clinical characteristics may differ, as well different settings including remote consultations and self-assessment.

Since Academic institutions contain huge volume of data regarding students such as academic scores, scores in co and extracurricular activities, family annual income, family background and other supporting documents, predicting individual students performance in all aspects manually is a difficult task. The proposed work uses data mining techniques to identify students who are eligible for scholarships and other benefits. Students are classified into different categories by means of academic, behavior, extra and co-curricular activities. Machine Learning algorithms such as Naive Bayes, Decision Tree Classifier and Support Vector Machine are used for predicting the performance of the student. With the help of this proposed model parents and instructors can monitor student’s performance and they can also provide essential technical and moral support. Also this helps in providing academic scholarship and training to the students to support them financially and to enrich their knowledge. It suggests the Academic Institutions to organize induction or training programmes at the beginning of the semester. Technical training, motivational talks, Yoga, etc are organized by the institutions by keeping in mind of students physical and mental health. Considering the e-learning platforms huge volumes of data and plethora of information are generated. In this work, various learning models are constructed and their accuracies are compared to analyse which algorithm out-performs.

Solar thermal power is nowadays one of the trendiest topics in the construction industry, and it represents a valuable energy source of heating that reduces energy consumption. As solar panels produce heating during the day and consumers demand calefaction during the whole day, we use standby tanks (for domestic hot water) and buffer tanks (for heating) for storage. The latest developments improved the efficiency and useful life while reducing the volume of tanks. So, the presented research work deals with analyzing the solar thermal power in a family house. This work presents a method to create a decision support system to compare solar energy systems in houses from economical, technical, availability, and environmental concerns. The weights of the criteria selected considering the analytical hierarchy process are computed. Parameters required for energy production calculations (location, temperature, etc.) and energy consumption (inhabitants, outdoor temperature, etc.) are summarized. It can be stated that a universal best solar thermal scheme does not exist, as energy consumption depends on the other features and limits as well as energy production, geographical latitude of the location, and so forth. According to results, Case 3 (a gas boiler and a combination tank) is the best alternative for reducing the energy required, CO2 emitted, the best energy efficiency of the installation, and the lowest transmission losses. In other scenarios when the economic criteria are not so relevant, this should be the best case in the prioritization scheme.

PURPOSE The ubiquitous adoption of electronic health records (EHRs) with family health history (FHH) data provides opportunities for tailoring cancer screening strategies to individuals. We aimed to enable a standards-based clinical decision support (CDS) platform for identifying and managing patients who meet guidelines for genetic evaluation of hereditary cancer. METHODS The CDS platform ( www.opencds.org ) was used to implement algorithms based on the 2018 National Comprehensive Cancer Network guidelines for genetic evaluation of hereditary breast/ovarian and colorectal cancer. The platform was designed to be interfaced with different EHR systems via the Health Level Seven International Fast Healthcare Interoperability Resources standard. The platform was integrated with the Epic EHR and evaluated in a pilot study at an academic health care system. RESULTS The CDS platform was executed against a target population of 143,012 patients; 5,245 (3.7%) met criteria for genetic evaluation based on the FHH recorded in the EHR. In a clinical pilot study, genetic counselors attempted to reach out to 71 of the patients. Of those patients, 25 (35%) scheduled an appointment, 10 (14%) declined, 2 (3%) did not need genetic counseling, 7 (10%) said they would consider it in the future, and 27 (38%) were unreachable. To date, 13 (52%) of the scheduled patients completed visits, and 2 (15%) of those were found to have pathogenic variants in cancer predisposition genes. CONCLUSION A standards-based CDS platform integrated with EHR systems is a promising population-based approach to identify patients who are appropriate candidates for genetic evaluation of hereditary cancers.

BackgroundNew healthcare service models are being introduced to help manage increasing demand on emergency healthcare systems including the provision of primary care services in or alongside emergency departments. There is little research evidence to guide decisions about how service models can be most effective and safe.AimFocusing on diagnostic error, the aim was to learn why errors occur to identify priority interventions.MethodTwo data sources were used to identify diagnostic error reports including: coroners’ reports to prevent future deaths; and the National Reporting and Learning System (NRLS). A cross-sectional, mixed-methods theory-generating study which used a multi-axial PISA classification system based on the recursive model for incident analysis, was carried out.ResultsNine Coroners’ reports (from a total of 1347 community and hospital reports, 2013–2018) and 217 NRLS reports (from 13 million, 2005–2015) were identified describing diagnostic error with learning relevant to primary care services in or alongside emergency departments. Clinical presentations included musculoskeletal injuries; unwell infants; headaches; and chest pains. Findings highlighted a difficulty identifying appropriate patients for the primary care service; underinvestigation; misinterpretation of diagnostic tests; underuse of safeguarding protocols; and inadequate communication and referral pathways between the services.ConclusionPriority areas to minimise risk of diagnostic error when primary care services are located in or alongside emergency departments include clinical decision support to triage and stream patients to the appropriate care setting; contextualised, workplace-based education and training for primary care staff; and standardised computer systems, communication and referral pathways between emergency and primary care services.

Today, most organizations use databases and at worst text documents and spreadsheet files as sources for data analysis, which prevent correct and error-free analysis. At best, the data can be constantly adjusted due to ambiguities and inaccuracies. The subject of the study is the intellectual analysis of outdoor advertising data. The methodology of successful data analysis is the correct storage of data, which is the basis for clear data analysis. Modern computer systems and computer networks allow the accumulation of large arrays of data to solve problems of processing and analyzing. Unfortunately, the machine form of data presentation itself contains the information that a person needs in a hidden form, and you need to use special methods of data analysis to obtain it. In order to get what you want, you need to create not just a database, but a data warehouse with a special storage structure. Thus, the data warehouse allows you to collect data from various sources, databases, table files and other things, store them throughout history and, unlike conventional databases, allows you to create systems for fast and accurate data analysis. Data warehouse is the basis for building decision support systems. Operational data is checked, cleared and aggregated before entering the data warehouse. Such integrated data is much easier to analyze. Different sources of operational data may contain data describing the same subject area from different points of view (for example, from the point of view of accounting, inventory control, planning department, etc.). A decision made on the basis of only one point of view can be ineffective or even erroneous. The goal is to use a data warehouse to integrate information that reflects different perspectives on the same subject area. Focus on the object, which will also allow the data warehouse to store only the data you need to analyze it. It will also significantly increase the speed of data access both due to the possible redundancy of the stored information and due to the exclusion of modification operations. Conclusion: the decision support system will ensure reliable storage of large amounts of data. Tasks will also be assigned to prevent unauthorized access, data backup, archiving, etc.

Abstract Pronouns as a diagnostic feature of language relatedness have been widely explored in historical and comparative linguistics. In this article, we focus on South American pronouns, as a potential example of items with their own history passing between the boundaries of language families, what has been dubbed in the literature as ‘historical markers’. Historical markers are not a direct diagnostic of genealogical relatedness among languages, but account for phenomena beyond the grasp of the historical comparative method. Relatedness between pronoun systems can thus serve as suggestions for closer studies of genealogical relationships. How can we use computational methods to help us with this process? We collected pronouns for 121 South American languages, grouped them into classes and aligned the phonemes within each class (assisted by automatic methods). We then used Bayesian phylogenetic tree inference to model the birth and death of individual phonemes within cognate sets, rather than the typical practice of modelling whole cognate sets. The reliability of the splits found in our analysis was low above the level of language family, and validation on alternative data suggested that the analysis cannot be used to infer general genealogical relatedness among languages. However, many results aligned with existing theories, and the analysis as a whole provided a useful starting point for future analyses of historical relationships between the languages of South America. We show that using automated methods with evolutionary principles can support progress in historical linguistics research.

Purpose To evaluate the impact of a CD-ROM intervention in the education of patients with suspected Lynch syndrome (LS) about microsatellite instability (MSI) and immunohisochemistry (IHC) testing. Patients and Methods Two hundred thirteen patients meeting Bethesda criteria were randomly assigned to receive either a brief educational session with a health educator (n = 105) or a brief educational session plus a CD-ROM (n = 108). Assessments were administered at baseline and 2 weeks post-treatment. Primary outcomes included MSI and IHC knowledge and level of satisfaction with and completeness of the preparation to make the decision for MSI testing. Secondary outcomes included decisional conflict, difficulty making the decision, cancer-specific and global anxiety, and level of discussion about MSI testing with family and friends. Results Participants in the education plus CD-ROM condition reported significant increases in knowledge about the MSI and IHC tests, greater satisfaction with the preparation to make a decision for testing, lower decisional conflict, and greater decisional self-efficacy. The effects of the education plus CD-ROM on most outcomes were not moderated by preintervention levels of exposure to MSI testing, family support for MSI testing, or the family history of cancer. Conclusion Incorporation of new media education strategies for individuals at risk for LS may be a valuable component of the informed consent process. As clinical criteria for MSI and IHC testing continue to expand, the need for alternative educational approaches to meet this increased demand could be met by the self-administered computer-based strategy that we described.

The Big Data and Data Analytics is a brand new paradigm, for the integration of Internet Technology in the human and machine context. For the first time in the history of the human mankind we are able to transforming raw data that are massively produced by humans and machines in to knowledge and wisdom capable of supporting smart decision making, innovative services, new business models, innovation, and entrepreneurship. For the Web Science research, this is a new methodological and technological spectrum of advanced methods, frameworks and functionalities never experienced in the past. At the same moment communities out of web science need to realize the potential of this new paradigm with the support of new sound business models and a critical shift in the perception of decision making. In this short visioning article, the authors are analyzing the main aspects of Big Data and Data Analytics Research and they provide their own metaphor for the next years. A number of research directions are outlined as well as a new roadmap towards the evolution of Big Data to Smart Decisions and Cognitive Computing. The authors do hope that the readers would like to react and to propose their own value propositions for the domain initiating a scientific dialogue beyond self-fulfilled expectations.

The purpose of this study is to explore the drivers of job satisfaction of IT workers in the East Asian context, particularly in Taiwan, Japan, and China. Using data collected from IT workers, decision tree inductions were employed to identify the predictors of job satisfaction. Results indicate that the level of education has no effect on job satisfaction. Overall, higher uncertainty avoidance results in lower job satisfaction, and more experienced IT workers appear to be more satisfied. In Taiwan, longer serving IT workers, who are likely to hold more senior positions and spend more time on the job, are more satisfied with their jobs. Similarly, in Japan, older IT workers are more satisfied. In China, job satisfaction of IT workers differs across job roles and industries. It is recommended that management practices and policies in Taiwan focus on bridging gaps between longer serving and newer IT workers in terms of their ability to handle ambiguous work situations; whereas in Japan, these should focus on providing work flexibility and stress management programs to allow room for family support. In China, these should be tailored to specific job roles and industries in view of their different experiences with job satisfaction determinants.

SynopsisProcess of care is the most immediate, relevant and susceptible to improvement of Donabedian's three elements of quality assurance. To place the study of process in context, the history of quality assurance in English-speaking countries is reviewed, with particular emphasis on the U.S.A. A range of methods are examined in detail and examples are provided to illustrate their strengths and weaknesses. Particular attention is paid to the use of explicit and implicit criteria. The importance of information technology in monitoring the process of care cannot be over-stated. Limited audit is possible with manual records but all substantial projects require computer support. The value of capturing data from operational systems rather than from dedicated projects is emphasised. Attention is drawn to the key importance of structured records and minimum data sets; these allow information to be pooled and process studies to be generalised. Examples are given of quality assurance projects which have used information technology. Finally potential future developments are reviewed with particular reference to clinical guidelines and computer-based clinical decision support systems.

AbstractDecision support systems play an important role in medical fields as they can augment clinicians to deal more efficiently and effectively with complex decision-making processes. In the diagnosis of headache disorders, however, existing approaches and tools are still not optimal. On the one hand, to support the diagnosis of this complex and vast spectrum of disorders, the International Headache Society released in 1988 the International Classification of Headache Disorders (ICHD), now in its 3rd edition: a 200 pages document classifying more than 300 different kinds of headaches, where each is identified via a collection of specific nontrivial diagnostic criteria. On the other hand, the high number of headache disorders and their complex criteria make the medical history process inaccurate and not exhaustive both for clinicians and existing automatic tools. To fill this gap, we present head-asp, a novel decision support system for the diagnosis of headache disorders. Through a REST Web Service, head-asp implements a dynamic questionnaire that complies with ICHD-3 by exploiting two logical modules to reach a complete diagnosis while trying to minimize the total number of questions being posed to patients. Finally, head-asp is freely available on-line and it is receiving very positive feedback from the group of neurologists that is testing it.

This paper concerns with an integrated business process to be applied as a decision support for market analysis and decision making. The proposed business intelligence and analytics system makes use of an extract, transform and load mechanism for data collection and purification. As a mathematical decision optimization, dynamic pricing is formulated based on customer entry-exit rates in a history-based pricing model. The optimal prices for products are obtained so that aggregated profit is maximized. A case study is reported to show the effectiveness of the approach. Also, analytical investigations on the impacts of the sensitive parameters of the pricing model are given.

The number of people afflicted with chronic illnesses such as obesity, cancer, and diabetes has soared in recent years, generating new kinds of disparate medical challenges. In turn, these challenges have resulted in skyrocketing costs, preventable deaths, and medical malpractice claims. For example, studies have found nearly half of all US patients receive inadequate care each year, over 2 million are harmed by hospital-acquired infections, and over 1 million suffer disabling complications during surgery – even though half of these are thought to be avoidable. These challenges have catalyzed the beginning of a transformation in care delivery, from a health-care system that focuses on disease to one that must look after patients – including individuals and communities. To provide proper treatment to those who are chronically ill, the health-care system has to support improved individuals’ health-related practices prior to the manifestation of disease; ensure that a range of practitioners can deliver quality clinical care during the onset of an illness; and facilitate patient-provider-family partnerships during post-disease wellness care. As we describe in this review, key advances in networking and information technologies – spanning patient monitoring, data visualization and decision making, robotics and computer vision for diagnosis and surgery, social networking for fostering community-based support systems, and so on – stand to drive forward these changes. Together with social scientists, systems engineers, medical practitioners, and computer scientists, information systems scholars can help alter the nature of care delivery well into the twenty-first century, ultimately contributing to a system that is much more safe, effective, reliable, and timely than it is today.

Background Despite steady gains in life expectancy, individuals with cystic fibrosis (CF) lung disease still experience rapid pulmonary decline throughout their clinical course, which can ultimately end in respiratory failure. Point-of-care tools for accurate and timely information regarding the risk of rapid decline is essential for clinical decision support. Objective This study aims to translate a novel algorithm for earlier, more accurate prediction of rapid lung function decline in patients with CF into an interactive web-based application that can be integrated within electronic health record systems, via collaborative development with clinicians. Methods Longitudinal clinical history, lung function measurements, and time-invariant characteristics were obtained for 30,879 patients with CF who were followed in the US Cystic Fibrosis Foundation Patient Registry (2003-2015). We iteratively developed the application using the R Shiny framework and by conducting a qualitative study with care provider focus groups (N=17). Results A clinical conceptual model and 4 themes were identified through coded feedback from application users: (1) ambiguity in rapid decline, (2) clinical utility, (3) clinical significance, and (4) specific suggested revisions. These themes were used to revise our application to the currently released version, available online for exploration. This study has advanced the application’s potential prognostic utility for monitoring individuals with CF lung disease. Further application development will incorporate additional clinical characteristics requested by the users and also a more modular layout that can be useful for care provider and family interactions. Conclusions Our framework for creating an interactive and visual analytics platform enables generalized development of applications to synthesize, model, and translate electronic health data, thereby enhancing clinical decision support and improving care and health outcomes for chronic diseases and disorders. A prospective implementation study is necessary to evaluate this tool’s effectiveness regarding increased communication, enhanced shared decision-making, and improved clinical outcomes for patients with CF.

Big data technology has been developed rapidly in recent years. The performance improvement mechanism of targeted poverty alleviation is studied through the big data technology to further promote the comprehensive application of big data technology in poverty alleviation and development. Using the data mining knowledge to accurately identify the poor population under the framework of big data, compared with the traditional identification method, it is obviously more accurate and persuasive, which is also helpful to find out the real causes of poverty and assist the poor residents in the future. In the current targeted poverty alleviation work, the identification of poor households and the matching of assistance measures are mainly through the visiting of village cadres and the establishment of documents. Traditional methods are time-consuming, laborious, and difficult to manage. It always omits lots of useful family information. Therefore, new technologies need to be introduced to realize intelligent identification of poverty-stricken households and reduce labor costs. In this paper, we introduce a novel DBSCAN clustering algorithm via the edge computing-based deep neural network model for targeted poverty alleviation. First, we deploy an edge computing-based deep neural network model. Then, in this constructed model, we execute data mining for the poverty-stricken family. In this paper, the DBSCAN clustering algorithm is used to excavate the poverty features of the poor households and complete the intelligent identification of the poor households. In view of the current situation of high-dimensional and large-volume poverty alleviation data, the algorithm uses the relative density difference of grid to divide the data space into regions with different densities and adopts the DBSCAN algorithm to cluster the above result, which improves the accuracy of DBSCAN. This avoids the need for DBSCAN to traverse all data when searching for density connections. Finally, the proposed method is utilized for analyzing and mining the poverty alleviation data. The average accuracy is more than 96%. The average F -measure, NMI, and PRE values exceed 90%. The results show that it provides decision support for precise matching and intelligent pairing of village cadres in poverty alleviation work.

Summary Background: The Institute of Medicine (IOM) reports that at least a fourth of all medication related injuries are preventable. Therefore, the IOM recommends healthcare organizations and providers implement electronic prescribing and clinical decision support systems in practices to aid in medication error prevention. Objective: To assess the impact of noninstrusive-intrusive prompts from an electronic medical record on recommended baseline and follow up laboratory monitoring, CK and liver transaminase levels (AST and ALT), in patients initiated on statin therapy. Methods: Hybrid nonintrusive-intrusive prompts for laboratory monitoring specific for statin initiation were implemented in the electronic medical record system in a community based, university affiliated family medicine residency program. A retrospective chart review was conducted to compare and assess laboratory monitoring in patients initiated on statin therapy from two specific time periods: a six month period prior to initiation of the prompts and a six month period after initiation of the prompts. Results: One hundred seventy three patients met inclusion criteria. There were no significant differences in assessment of baseline liver transaminases and CK levels from the initial study period to the follow up study period. There were significant differences in follow up liver transaminase levels (18% vs 33%, p = 0.035) and CK levels (none vs 7%, p = 0.03) from the initial study period to the activated prompt interval. Conclusion: A hybrid nonintrusive-intrusive specific prompts for laboratory monitoring triggered by statin initiation within an electronic medical record improved follow up lab assessments for liver transaminases and CK but did not improve baseline assessments of CK or liver transaminases.

Background and objectives: CVD is an important global healthcare issue; it is the leading cause of global mortality, with an increasing incidence identified in both developed and developing countries. It is also an extremely costly disease for healthcare systems unless managed effectively. In this review we aimed to: – Assess the effect of computer-assisted versus oral-and-written history taking on the quality of collected information for the prevention and management of CVD. – Assess the effect of computer-assisted versus oral-and-written history taking on the prevention and management of CVD. Methods: A systematic review of randomised controlled trials that included participants of 16 years or older at the beginning of the study, who were at risk of CVD (prevention) or were either previously diagnosed with CVD (management). We searched all major databases. We assessed risk of bias using the Cochrane Collaboration tool. Results: Two studies met the inclusion criteria. One comparing the two methods of history-taking for the prevention of cardiovascular disease n = 75. The study shows that generally the patients in the experimental group underwent more laboratory procedures, had more biomarker readings recorded and/or were given (or had reviewed), more dietary changes than the control group. The other study compares the two methods of history-taking for the management of cardiovascular disease (n = 479). The study showed that the computerized decision aid appears to increase the proportion of patients who responded to invitations to discuss CVD prevention with their doctor. The Computer- Assisted History Taking Systems (CAHTS) increased the proportion of patients who discussed CHD risk reduction with their doctor from 24% to 40% and increased the proportion who had a specific plan to reduce their risk from 24% to 37%. Discussion: With only one study meeting the inclusion criteria, for prevention of CVD and one study for management of CVD we did not gather sufficient evidence to address all of the objectives of the review. We were unable to report on most of the secondary patient outcomes in our protocol. Conclusions: We tentatively conclude that CAHTS can provide individually-tailored information about CVD prevention. However, further primary studies are needed to confirm these findings. We cannot draw any conclusions in relation to any other clinical outcomes at this stage. There is a need to develop an evidence base to support the effective development and use of CAHTS in this area of practice. In the absence of evidence on effectiveness, the implementation of computer-assisted history taking may only rely on the clinicians’ tacit knowledge, published monographs and viewpoint articles.

Purpose This paper aims to explain the uncertainties associated with food security and, in doing so, classifies them within the context of volatility, uncertainty, complexity and ambiguity (VUCA). In using this lens to frame the challenges of food security, the viewpoint proffers the need to be even more sensitive to heightened levels of uncertainty and highlights the need of governments to be prepared to meet a wider variety of external forces, risks, opportunities and threats to mitigate food insecurity. Design/methodology/approach This research constructs a novel morphology of food security and food waste policy futures based upon a range of scenario types based on contextual narratives relating to constraint, collapse, growth and transformation. In doing so, offering a representation that suggests order, complexity and chaos occur across a range of four domains of interaction: known (repeatable cause and effect); knowable (cause and effect separated over time); complex (cause and effect are unique and non-repeatable); and chaos (no cause and effect relationship perceivable). This orientation is represented in the form of a novel morphology that can be used to support decision-making and policymaking/consideration. Findings The authors have presented and identified a combination of a structured and unstructured methods to develop and hence classify a range of food security scenarios. Using the VUCA worldview and classification, the authors subsequently identify seven underlying and seven United Nations (UN) Sustainable Development Goals (SDG)-derived factors, which when combined with the Institute for the Future (IFTF) four food security scenarios in a pairwise manner led to the generation of a further 16 subsequent VUCA-inspired scenarios composed within a morphological grid. These were subsequently reclassified against three sets of stakeholders and then finally mapped to the Cynefin framework as a set of ten scenarios to show the potential of making greater sense of the VUCA nature of food security. Practical implications The paper proposes a novel conceptual approach to framing and understanding the wider holistic aspects of explaining and providing foresight to the complexities of food security. Hence, this paper provides policymakers with two contrasting, yet complementary, food security scenario planning techniques (VUCA and Cynefin), which envelope 16 narrative food security scenarios which can be used with stakeholders and advocacy groups in facilitating discussion about complex, messy and “wicked” interlinkages within the food security domain. Originality/value This is the first time in the extant literature that a combination of structured and unstructured, problem-based versus mess-based, contrasting perspectives have been brought together and developed, with the intention of creating a normative family or portfolio of narrative-driven food security scenarios. The authors present and extend four existing scenarios from the extant food security literature, and subsequently, through interpreting these scenarios via a dual and combined lens (notably using UN SDG and VUCA elements), a grid of alternative food security scenarios is produced. By then using applying the Cynefin complexity framework to these new configurations, a thematic categorisation of alternative futures is presented, which may aid policy and decision-makers when considering this topic.

Genome editing is a relevant, versatile, and preferred tool for crop improvement, as well as for functional genomics. In this review, we summarize the advances in gene-editing techniques, such as zinc-finger nucleases (ZFNs), transcription activator-like (TAL) effector nucleases (TALENs), and clustered regularly interspaced short palindromic repeats (CRISPR) associated with the Cas9 and Cpf1 proteins. These tools support great opportunities for the future development of plant science and rapid remodeling of crops. Furthermore, we discuss the brief history of each tool and provide their comparison and different applications. Among the various genome-editing tools, CRISPR has become the most popular; hence, it is discussed in the greatest detail. CRISPR has helped clarify the genomic structure and its role in plants: For example, the transcriptional control of Cas9 and Cpf1, genetic locus monitoring, the mechanism and control of promoter activity, and the alteration and detection of epigenetic behavior between single-nucleotide polymorphisms (SNPs) investigated based on genetic traits and related genome-wide studies. The present review describes how CRISPR/Cas9 systems can play a valuable role in the characterization of the genomic rearrangement and plant gene functions, as well as the improvement of the important traits of field crops with the greatest precision. In addition, the speed editing strategy of gene-family members was introduced to accelerate the applications of gene-editing systems to crop improvement. For this, the CRISPR technology has a valuable advantage that particularly holds the scientist’s mind, as it allows genome editing in multiple biological systems.

SummaryBackground: Alcohol use is a significant part of a patient’s history, but details about consumption are not always documented. Electronic Health Record (EHR) systems have the potential to improve assessment of alcohol use and misuse; however, a challenge is that critical information may be documented primarily in free-text rather than in a structured and standardized format, thereby limiting its use.Objective: To characterize the use and contents of free-text documentation for alcohol use in the social history module of an EHR.Methods: This study involved a retrospective analysis of 500 alcohol use entries that include structured fields as well as a free-text comment field. Two coding schemes were developed and used to analyze these entries for: (1) quantifying the reasons for using free-text comments and (2) categorizing information in the free-text into separate elements. In addition, for entries indicating possible alcohol misuse, a preliminary review of other structured parts of the EHR was conducted to determine if this was also documented elsewhere.Results: The top three reasons for using free-text were limited ability to describe alcohol use frequency (75%), amount (22%), and status (18%) with available structured fields. Within the free-text, descriptions of frequency were most common (79%) using words or phrases conveying occasional (61%), daily (13%), or weekly (12%) use. Of the 36 cases suggesting alcohol misuse, 44% had mention of alcohol problems in the problem list or past medical history.Conclusions: Based on the early findings, implications for improving the structured collection and use of alcohol use information in the EHR are provided in four areas: (1) system enhancements, (2) user training, (3) decision support, and (4) standards. Next steps include examining how alcohol use is documented in other parts of the EHR (e.g., clinical notes) and how documentation practices vary based on patient, provider, and clinic characteristics.Citation: Chen ES, M. Garcia-Webb M. An analysis of free-text alcohol use documentation in the electronic health record: Early findings and implications. Appl Clin Inf 2014; 5: 402–415 http://dx.doi.org/10.4338/ACI-2013-12-RA-0101

Background Digital medical interview assistant (DMIA) systems, also known as computer-assisted history taking (CAHT) systems, have the potential to improve the quality of care and the medical consultation by exploring more patient-related aspects without time constraints and, therefore, acquiring more and better-quality information prior to the face-to-face consultation. The consultation in primary care is the broadest in terms of the amount of topics to be covered and, at the same time, the shortest in terms of time spent with the patient. Objective Our aim is to explore how DMIA systems may be used specifically in the context of primary care, to improve the consultations for diabetes and depression, as exemplars of chronic conditions. Methods A narrative review was conducted focusing on (1) the characteristics of the primary care consultation in general, and for diabetes and depression specifically, and (2) the impact of DMIA and CAHT systems on the medical consultation. Through thematic analysis, we identified the characteristics of the primary care consultation that a DMIA system would be able to improve. Based on the identified primary care consultation tasks and the potential benefits of DMIA systems, we developed a sample questionnaire for diabetes and depression to illustrate how such a system may work. Results A DMIA system, prior to the first consultation, could aid in the essential primary care tasks of case finding and screening, diagnosing, and, if needed, timely referral to specialists or urgent care. Similarly, for follow-up consultations, this system could aid with the control and monitoring of these conditions, help check for additional health issues, and update the primary care provider about visits to other providers or further testing. Successfully implementing a DMIA system for these tasks would improve the quality of the data obtained, which means earlier diagnosis and treatment. Such a system would improve the use of face-to-face consultation time, thereby streamlining the interaction and allowing the focus to be the patient's needs, which ultimately would lead to better health outcomes and patient satisfaction. However, for such a system to be successfully incorporated, there are important considerations to be taken into account, such as the language to be used and the challenges for implementing eHealth innovations in primary care and health care in general. Conclusions Given the benefits explored here, we foresee that DMIA systems could have an important impact in the primary care consultation for diabetes and depression and, potentially, for other chronic conditions. Earlier case finding and a more accurate diagnosis, due to more and better-quality data, paired with improved monitoring of disease progress should improve the quality of care and keep the management of chronic conditions at the primary care level. A somewhat simple, easily scalable technology could go a long way to improve the health of the millions of people affected with chronic conditions, especially if working in conjunction with already-established health technologies such as electronic medical records and clinical decision support systems.

Technology is in a constantly evolving and changing structure since the existence of mankind. Because of this dynamic structure, technology fulfills a number of functions such as facilitating people's lives, time, profit from work, profit from cost, making life more enjoyable. At the same time, technology is used in all areas of life, and it also causes changes and transformations in these areas. Education is one of these areas, perhaps the most important, that technology affects. The hunter society, written with nails, made an important step with the paper's invention, and the written documents were moved from the stones to the books. The invention of computers and the internet has also opened an important milestone in human history and education. In the beginning, the course contents loaded on storage units such as floppy disks, CDs, DVDs were used by the students and teachers, computers were included in the education systems. During periods when we have not yet met with the internet, computer-assisted education has found a large place in many educational institutions and in the curriculum of education level. The development of information Technologies led to widespread use of the internet over time, and shortly thereafter examples of use in education began to increase. Computer-assisted education has also led to the rapid transition of education through internet-supported education, along with the different demands of the network society's individuals. Users are not satisfied with the internet environments where only reading authority is available, and more and more active and interacting requests have come to the agenda. Beyond reading, social networks that make it possible to comment, create content, upload/share/view images, upload video/audio files, and make video, text and voice calls have become popular for users. Social networking platforms where users interact with the environment or with other users in the environment have been attracted by the diversity of user profiles, the usage rates and durations, and the easy and versatility of accessibility. Because of these features, studies on the use of social networks in the field of education to support learning and teaching have also been accelerated and diversified. Social networks can also contain some security issues because they are huge platforms where billions of users are together. Having information about security issues as little as possible, what to do when they are encountered is important for the continuity of learning and teaching. The aim of this study is to demonstrate the importance of social networks, education, learning and teaching influences, possible security threats to be encountered in social networks, and measures to be taken. It is hoped that working in this context will shed light on the work of learners, teachers and decision makers on the subject.

Facilitating the uptake of established methodologies for risk-based decision-making in product conformity assessment taking into account measurement uncertainty by providing dedicated software is the aim of the European project EMPIR CASoft(2018–2020), involving the National Measurement Institutes from France, Sweden and the UK, and industrial partner Trescal (FR) as primary supporter. The freely available software helps end-users perform the required risk calculations in accordance with current practice and regulations and extends that current practice to include bivariate cases. The software is also aimed at supporting testing and calibration laboratories in the application of the latest version of the ISO/IEC 17025:2017 standard, which requires that“…the laboratory shall document the decision rule employed, taking into account the level of risk […] associated with the decision rule and apply the decision rule.” Initial experiences following launch of the new software in Spring 2020 are reported.

Background and Objective: Suicide attempts are 10-20X more common than completed suicide and an important risk factor for death by suicide, yet most people who attempt suicide do not die by suicide. The process of recovering after a suicide attempt has not been well studied. The Reasons to go on Living (RTGOL) Project, a narrative web-based study, focuses on experiences of people who have attempted suicide and made the decision to go on living, a process not well studied. Narrative research is ideally suited to understanding personal experiences critical to recovery following a suicide attempt, including the transition to a state of hopefulness. Voices from people with lived experience can help us plan and conceptualize this work. This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. Material and Methods: A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery, a process which enabled participation from a large and diverse group of participants. The only direction given was “if you have made a suicide attempt or seriously considered suicide and now want to go on living, we want to hear from you.” The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Over 5 years, data analysis occurred in several phases over the course of the study, resulting in the identification of data that were inputted into an Excel file. This analysis used stories where participants described positive involvement with the mental health system (50 stories). Results: Several participants reflected on experiences many years previous, providing the privilege of learning how their life unfolded, what made a difference. Over a five-year period, 50 of 226 stories identified positive experiences with mental health care with sufficient details to allow analysis, and are the focus of this paper. There were a range of suicidal behaviours in these 50 stories, from suicidal ideation only to medically severe suicide attempts. Most described one or more suicide attempts. Three themes identified included: 1) trust and relationship with a health care professional, 2) the role of friends and family and friends, and 3) a wide range of services. Conclusion: Stories open a window into the experiences of the period after a suicide attempt. This study allowed for an understanding of how mental health professionals might help individuals who have attempted suicide write a different story, a life-affirming story. The stories that participants shared offer some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers, including immediately after a suicide attempt. Results of this study reinforce that just one caring professional can make a tremendous difference to a person who has survived a suicide attempt. Key Words: web-based; suicide; suicide attempt; mental health system; narrative research Word Count: 478 Introduction My Third (or fourth) Suicide AttemptI laid in the back of the ambulance, the snow of too many doses of ativan dissolving on my tongue.They hadn't even cared enough about meto put someone in the back with me,and so, frustrated,I'd swallowed all the pills I had with me— not enough to do what I wanted it to right then,but more than enough to knock me out for a good 14 hours.I remember very little after that;benzodiazepines like ativan commonly cause pre- and post-amnesia, says Google helpfullyI wake up in a locked rooma woman manically drawing on the windows with crayonsthe colors of light through the glassdiffused into rainbows of joy scattered about the roomas if she were coloring on us all,all of the tattered remnants of humanity in a psych wardmade into a brittle mosaic, a quilt of many hues, a Technicolor dreamcoatand I thoughtI am so glad to be able to see this. (Story 187)The nurse opening that door will have a lasting impact on how this story unfolds and on this person’s life. Each year, almost one million people die from suicide, approximately one death every 40 seconds. Suicide attempts are much more frequent, with up to an estimated 20 attempts for every death by suicide.1 Suicide-related behaviours range from suicidal ideation and self-injury to death by suicide. We are unable to directly study those who die by suicide, but effective intervention after a suicide attempt could reduce the risk of subsequent death by suicide. Near-fatal suicide attempts have been used to explore the boundary with completed suicides. Findings indicated that violent suicide attempters and serious attempters (seriousness of the medical consequences to define near-fatal attempts) were more likely to make repeated, and higher lethality suicide attempts.2 In a case-control study, the medically severe suicide attempts group (78 participants), epidemiologically very similar to those who complete suicide, had significantly higher communication difficulties; the risk for death by suicide multiplied if accompanied by feelings of isolation and alienation.3 Most research in suicidology has been quantitative, focusing almost exclusively on identifying factors that may be predictive of suicidal behaviours, and on explanation rather than understanding.4 Qualitative research, focusing on the lived experiences of individuals who have attempted suicide, may provide a better understanding of how to respond in empathic and helpful ways to prevent future attempts and death by suicide.4,5 Fitzpatrick6 advocates for narrative research as a valuable qualitative method in suicide research, enabling people to construct and make sense of the experiences and their world, and imbue it with meaning. A review of qualitative studies examining the experiences of recovering from or living with suicidal ideation identified 5 interconnected themes: suffering, struggle, connection, turning points, and coping.7 Several additional qualitative studies about attempted suicide have been reported in the literature. Participants have included patients hospitalized for attempting suicide8, and/or suicidal ideation,9 out-patients following a suicide attempt and their caregivers,10 veterans with serious mental illness and at least one hospitalization for a suicide attempt or imminent suicide plan.11 Relationships were a consistent theme in these studies. Interpersonal relationships and an empathic environment were perceived as therapeutic and protective, enabling the expression of thoughts and self-understanding.8 Given the connection to relationship issues, the authors suggested it may be helpful to provide support for the relatives of patients who have attempted suicide. A sheltered, friendly environment and support systems, which included caring by family and friends, and treatment by mental health professionals, helped the suicidal healing process.10 Receiving empathic care led to positive changes and an increased level of insight; just one caring professional could make a tremendous difference.11 Kraft and colleagues9 concluded with the importance of hearing directly from those who are suicidal in order to help them, that only when we understand, “why suicide”, can we help with an alternative, “why life?” In a grounded theory study about help-seeking for self-injury, Long and colleagues12 identified that self-injury was not the problem for their participants, but a panacea, even if temporary, to painful life experiences. Participant narratives reflected a complex journey for those who self-injured: their wish when help-seeking was identified by the theme “to be treated like a person”. There has also been a focus on the role and potential impact of psychiatric/mental health nursing. Through interviews with experienced in-patient nurses, Carlen and Bengtsson13 identified the need to see suicidal patients as subjective human beings with unique experiences. This mirrors research with patients, which concluded that the interaction with personnel who are devoted, hope-mediating and committed may be crucial to a patient’s desire to continue living.14 Interviews with individuals who received mental health care for a suicidal crisis following a serious attempt led to the development of a theory for psychiatric nurses with the central variable, reconnecting the person with humanity across 3 phases: reflecting an image of humanity, guiding the individual back to humanity, and learning to live.15 Other research has identified important roles for nurses working with patients who have attempted suicide by enabling the expression of thoughts and developing self-understanding8, helping to see things differently and reconnecting with others,10 assisting the person in finding meaning from their experience to turn their lives around, and maintain/and develop positive connections with others.16 However, one literature review identified that negative attitudes toward self-harm were common among nurses, with more positive attitudes among mental health nurses than general nurses. The authors concluded that education, both reflective and interactive, could have a positive impact.17 This paper is one part of a larger web-based narrative study, the Reasons to go on Living Project (RTGOL), that seeks to understand the transition from making a suicide attempt to choosing life. When invited to tell their stories anonymously online, what information would people share about their suicide attempts? This paper reports on a secondary research question of the larger study: what stories do participants tell of the positive role/impact of the mental health system. The focus on the positive impact reflects an appreciative inquiry approach which can promote better practice.18 Methods Design and Sample A website created for The RTGOL Project (www.thereasons.ca) enabled participants to anonymously submit a story about their suicide attempt and recovery. Participants were required to read and agree with a consent form before being able to submit their story through a text box or by uploading a file. No demographic information was requested. Text submissions were embedded into an email and sent to an account created for the Project without collecting information about the IP address or other identifying information. The content of the website was reviewed by legal counsel before posting, and the study was approved by the local Research Ethics Board. Stories were collected for 5 years (July 2008-June 2013). The RTGOL Project enabled participation by a large, diverse audience, at their own convenience of time and location, providing they had computer access. The unstructured narrative format allowed participants to describe their experiences in their own words, to include and emphasize what they considered important. Of the 226 submissions to the website, 112 described involvement at some level with the mental health system, and 50 provided sufficient detail about positive experiences with mental health care to permit analysis. There were a range of suicidal behaviours in these 50 stories: 8 described suicidal ideation only; 9 met the criteria of medically severe suicide attempts3; 33 described one or more suicide attempts. For most participants, the last attempt had been some years in the past, even decades, prior to writing. Results Stories of positive experiences with mental health care described the idea of a door opening, a turning point, or helping the person to see their situation differently. Themes identified were: (1) relationship and trust with a Health Care Professional (HCP), (2) the role of family and friends (limited to in-hospital experiences), and (3) the opportunity to access a range of services. The many reflective submissions of experiences told many years after the suicide attempt(s) speaks to the lasting impact of the experience for that individual. Trust and Relationship with a Health Care Professional A trusting relationship with a health professional helped participants to see things in a different way, a more hopeful way and over time. “In that time of crisis, she never talked down to me, kept her promises, didn't panic, didn't give up, and she kept believing in me. I guess I essentially borrowed the hope that she had for me until I found hope for myself.” (Story# 35) My doctor has worked extensively with me. I now realize that this is what will keep me alive. To be able to feel in my heart that my doctor does care about me and truly wants to see me get better.” (Story 34). The writer in Story 150 was a nurse, an honours graduate. The 20 years following graduation included depression, hospitalizations and many suicide attempts. “One day after supper I took an entire bottle of prescription pills, then rode away on my bike. They found me late that night unconscious in a downtown park. My heart threatened to stop in the ICU.” Then later, “I finally found a person who was able to connect with me and help me climb out of the pit I was in. I asked her if anyone as sick as me could get better, and she said, “Yes”, she had seen it happen. Those were the words I had been waiting to hear! I quickly became very motivated to get better. I felt heard and like I had just found a big sister, a guide to help me figure out how to live in the world. This person was a nurse who worked as a trauma therapist.” At the time when the story was submitted, the writer was applying to a graduate program. Role of Family and Friends Several participants described being affected by their family’s response to their suicide attempt. Realizing the impact on their family and friends was, for some, a turning point. The writer in Story 20 told of experiences more than 30 years prior to the writing. She described her family of origin as “truly dysfunctional,” and she suffered from episodes of depression and hospitalization during her teen years. Following the birth of her second child, and many family difficulties, “It was at this point that I became suicidal.” She made a decision to kill herself by jumping off the balcony (6 stories). “At the very last second as I hung onto the railing of the balcony. I did not want to die but it was too late. I landed on the parking lot pavement.” She wrote that the pain was indescribable, due to many broken bones. “The physical pain can be unbearable. Then you get to see the pain and horror in the eyes of someone you love and who loves you. Many people suggested to my husband that he should leave me in the hospital, go on with life and forget about me. During the process of recovery in the hospital, my husband was with me every day…With the help of psychiatrists and a later hospitalization, I was actually diagnosed as bipolar…Since 1983, I have been taking lithium and have never had a recurrence of suicidal thoughts or for that matter any kind of depression.” The writer in Story 62 suffered childhood sexual abuse. When she came forward with it, she felt she was not heard. Self-harm on a regular basis was followed by “numerous overdoses trying to end my life.” Overdoses led to psychiatric hospitalizations that were unhelpful because she was unable to trust staff. “My way of thinking was that ending my life was the only answer. There had been numerous attempts, too many to count. My thoughts were that if I wasn’t alive I wouldn’t have to deal with my problems.” In her final attempt, she plunged over the side of a mountain, dropping 80 feet, resulting in several serious injuries. “I was so angry that I was still alive.” However, “During my hospitalization I began to realize that my family and friends were there by my side continuously, I began to realize that I wasn't only hurting myself. I was hurting all the important people in my life. It was then that I told myself I am going to do whatever it takes.” A turning point is not to say that the difficulties did not continue. The writer of Story 171 tells of a suicide attempt 7 years previous, and the ongoing anguish. She had been depressed for years and had thoughts of suicide on a daily basis. After a serious overdose, she woke up the next day in a hospital bed, her husband and 2 daughters at her bed. “Honestly, I was disappointed to wake up. But, then I saw how scared and hurt they were. Then I was sorry for what I had done to them. Since then I have thought of suicide but know that it is tragic for the family and is a hurt that can never be undone. Today I live with the thought that I am here for a reason and when it is God's time to take me then I will go. I do believe living is harder than dying. I do believe I was born for a purpose and when that is accomplished I will be released. …Until then I try to remind myself of how I am blessed and try to appreciate the wonders of the world and the people in it.” Range of Services The important role of mental health and recovery services was frequently mentioned, including dialectical behavioural therapy (DBT)/cognitive-behavioural therapy (CBT), recovery group, group therapy, Alcoholics Anonymous, accurate diagnosis, and medications. The writer in Story 30 was 83 years old when she submitted her story, reflecting on a life with both good and bad times. She first attempted suicide at age 10 or 12. A serious post-partum depression followed the birth of her second child, and over the years, she experienced periods of suicidal intent: “Consequently, a few years passed and I got to feeling suicidal again. I had pills in one pocket and a clipping for “The Recovery Group” in the other pocket. As I rode on the bus trying to make up my mind, I decided to go to the Recovery Group first. I could always take the pills later. I found the Recovery Group and yoga helpful; going to meetings sometimes twice a day until I got thinking more clearly and learned how to deal with my problems.” Several participants described the value of CBT or DBT in learning to challenge perceptions. “I have tools now to differentiate myself from the illness. I learned I'm not a bad person but bad things did happen to me and I survived.”(Story 3) “The fact is that we have thoughts that are helpful and thoughts that are destructive….. I knew it was up to me if I was to get better once and for all.” (Story 32): “In the hospital I was introduced to DBT. I saw a nurse (Tanya) every day and attended a group session twice a week, learning the techniques. I worked with the people who wanted to work with me this time. Tanya said the same thing my counselor did “there is no study that can prove whether or not suicide solves problems” and I felt as though I understood it then. If I am dead, then all the people that I kept pushing away and refusing their help would be devastated. If I killed myself with my own hand, my family would be so upset. DBT taught me how to ‘ride my emotional wave’. ……….. DBT has changed my life…….. My life is getting back in order now, thanks to DBT, and I have lots of reasons to go on living.”(Story 19) The writer of Story 67 described the importance of group therapy. “Group therapy was the most helpful for me. It gave me something besides myself to focus on. Empathy is such a powerful emotion and a pathway to love. And it was a huge relief to hear others felt the same and had developed tools of their own that I could try for myself! I think I needed to learn to communicate and recognize when I was piling everything up to build my despair. I don’t think I have found the best ways yet, but I am lifetimes away from that teenage girl.” (Story 67) The author of story 212 reflected on suicidal ideation beginning over 20 years earlier, at age 13. Her first attempt was at 28. “I thought everyone would be better off without me, especially my children, I felt like the worst mum ever, I felt like a burden to my family and I felt like I was a failure at life in general.” She had more suicide attempts, experienced the death of her father by suicide, and then finally found her doctor. “Now I’m on meds for a mood disorder and depression, my family watch me closely, and I see my doctor regularly. For the first time in 20 years, I love being a mum, a sister, a daughter, a friend, a cousin etc.” Discussion The 50 stories that describe positive experiences in the health care system constitute a larger group than most other similar studies, and most participants had made one or more suicide attempts. Several writers reflected back many years, telling stories of long ago, as with the 83-year old participant (Story 30) whose story provided the privilege of learning how the author’s life unfolded. In clinical practice, we often do not know – how did the story turn out? The stories that describe receiving health care speak to the impact of the experience, and the importance of the issues identified in the mental health system. We identified 3 themes, but it was often the combination that participants described in their stories that was powerful, as demonstrated in Story 20, the young new mother who had fallen from a balcony 30 years earlier. Voices from people with lived experience can help us plan and conceptualize our clinical work. Results are consistent with, and add to, the previous work on the importance of therapeutic relationships.8,10,11,14–16 It is from the stories in this study that we come to understand the powerful experience of seeing a family members’ reaction following a participant’s suicide attempt, and how that can be a potent turning point as identified by Lakeman and Fitzgerald.7 Ghio and colleagues8 and Lakeman16 identified the important role for staff/nurses in supporting families due to the connection to relationship issues. This research also calls for support for families to recognize the important role they have in helping the person understand how much they mean to them, and to promote the potential impact of a turning point. The importance of the range of services reflect Lakeman and Fitzgerald’s7 theme of coping, associating positive change by increasing the repertoire of coping strategies. These findings have implications for practice, research and education. Working with individuals who are suicidal can help them develop and tell a different story, help them move from a death-oriented to life-oriented position,15 from “why suicide” to “why life.”9 Hospitalization provides a person with the opportunity to reflect, to take time away from “the real world” to consider oneself, the suicide attempt, connections with family and friends and life goals, and to recover physically and emotionally. Hospitalization is also an opening to involve the family in the recovery process. The intensity of the immediate period following a suicide attempt provides a unique opportunity for nurses to support and coach families, to help both patients and family begin to see things differently and begin to create that different story. In this way, family and friends can be both a support to the person who has attempted suicide, and receive help in their own struggles with this experience. It is also important to recognize that this short period of opportunity is not specific to the nurses in psychiatric units, as the nurses caring for a person after a medically severe suicide attempt will frequently be the nurses in the ICU or Emergency departments. Education, both reflective and interactive, could have a positive impact.17 Helping staff develop the attitudes, skills and approach necessary to be helpful to a person post-suicide attempt is beginning to be reported in the literature.21 Further implications relate to nursing curriculum. Given the extent of suicidal ideation, suicide attempts and deaths by suicide, this merits an important focus. This could include specific scenarios, readings by people affected by suicide, both patients themselves and their families or survivors, and discussions with individuals who have made an attempt(s) and made a decision to go on living. All of this is, of course, not specific to nursing. All members of the interprofessional health care team can support the transition to recovery of a person after a suicide attempt using the strategies suggested in this paper, in addition to other evidence-based interventions and treatments. Findings from this study need to be considered in light of some specific limitations. First, the focus was on those who have made a decision to go on living, and we have only the information the participants included in their stories. No follow-up questions were possible. The nature of the research design meant that participants required access to a computer with Internet and the ability to communicate in English. This study does not provide a comprehensive view of in-patient care. However, it offers important inputs to enhance other aspects of care, such as assessing safety as a critical foundation to care. We consider these limitations were more than balanced by the richness of the many stories that a totally anonymous process allowed. Conclusion Stories open a window into the experiences of a person during the period after a suicide attempt. The RTGOL Project allowed for an understanding of how we might help suicidal individuals change the script, write a different story. The stories that participants shared give us some understanding of “how” to provide support at a most-needed critical juncture for people as they interact with health care providers immediately after a suicide attempt. While we cannot know the experiences of those who did not survive a suicide attempt, results of this study reinforce that just one caring professional can make a crucial difference to a person who has survived a suicide attempt. We end with where we began. Who will open the door? References 1. World Health Organization. Suicide prevention and special programmes. http://www.who.int/mental_health/prevention/suicide/suicideprevent/en/index.html Geneva: Author; 2013.2. Giner L, Jaussent I, Olie E, et al. Violent and serious suicide attempters: One step closer to suicide? J Clin Psychiatry 2014:73(3):3191–197.3. Levi-Belz Y, Gvion Y, Horesh N, et al. Mental pain, communication difficulties, and medically serious suicide attempts: A case-control study. Arch Suicide Res 2014:18:74–87.4. Hjelmeland H and Knizek BL. Why we need qualitative research in suicidology? Suicide Life Threat Behav 2010:40(1):74–80.5. Gunnell D. A population health perspective on suicide research and prevention: What we know, what we need to know, and policy priorities. Crisis 2015:36(3):155–60.6. Fitzpatrick S. Looking beyond the qualitative and quantitative divide: Narrative, ethics and representation in suicidology. Suicidol Online 2011:2:29–37.7. Lakeman R and FitzGerald M. How people live with or get over being suicidal: A review of qualitative studies. J Adv Nurs 2008:64(2):114–26.8. Ghio L, Zanelli E, Gotelli S, et al. Involving patients who attempt suicide in suicide prevention: A focus group study. J Psychiatr Ment Health Nurs 2011:18:510–18.9. Kraft TL, Jobes DA, Lineberry TW., Conrad, A., & Kung, S. Brief report: Why suicide? Perceptions of suicidal inpatients and reflections of clinical researchers. Arch Suicide Res 2010:14(4):375-382.10. Sun F, Long A, Tsao L, et al. The healing process following a suicide attempt: Context and intervening conditions. Arch Psychiatr Nurs 2014:28:66–61.11. Montross Thomas L, Palinkas L, et al. Yearning to be heard: What veterans teach us about suicide risk and effective interventions. Crisis 2014:35(3):161–67.12. Long M, Manktelow R, and Tracey A. The healing journey: Help seeking for self-injury among a community population. Qual Health Res 2015:25(7):932–44.13. Carlen P and Bengtsson A. Suicidal patients as experienced by psychiatric nurses in inpatient care. Int J Ment Health Nurs 2007:16:257–65.14. Samuelsson M, Wiklander M, Asberg M, et al. Psychiatric care as seen by the attempted suicide patient. J Adv Nurs 2000:32(3):635–43.15. Cutcliffe JR, Stevenson C, Jackson S, et al. A modified grounded theory study of how psychiatric nurses work with suicidal people. Int J Nurs Studies 2006:43(7):791–802.16. Lakeman, R. What can qualitative research tell us about helping a person who is suicidal? Nurs Times 2010:106(33):23–26.17. Karman P, Kool N, Poslawsky I, et al. Nurses’ attitudes toward self-harm: a literature review. J Psychiatr Ment Health Nurs 2015:22:65–75.18. Carter B. ‘One expertise among many’ – working appreciatively to make miracles instead of finding problems: Using appreciative inquiry as a way of reframing research. J Res Nurs 2006:11(1): 48–63.19. Lieblich A, Tuval-Mashiach R, Zilber T. Narrative research: Reading, analysis, and interpretation. Sage Publications; 1998.20. Braun V and Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006:3(2):77–101.21. Kishi Y, Otsuka K, Akiyama K, et al. Effects of a training workshop on suicide prevention among emergency room nurses. 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Education in Oceania continues to reflect the embedded implicit and explicit colonial practices and processes from the past. This paper conceptualises a cultural approach to education and leadership appropriate and relevant to the Republic of the Marshall Islands. As elementary school leaders, we highlight Kanne Lobal, a traditional Marshallese navigation practice based on indigenous language, values and practices. We conceptualise and develop Kanne Lobal in this paper as a framework for understanding the usefulness of our indigenous knowledge in leadership and educational practices within formal education. Through bwebwenato, a method of talk story, our key learnings and reflexivities were captured. We argue that realising the value of Marshallese indigenous knowledge and practices for school leaders requires purposeful training of the ways in which our knowledge can be made useful in our professional educational responsibilities. Drawing from our Marshallese knowledge is an intentional effort to inspire, empower and express what education and leadership partnership means for Marshallese people, as articulated by Marshallese themselves. Introduction As noted in the call for papers within the Waikato Journal of Education (WJE) for this special issue, bodies of knowledge and histories in Oceania have long sustained generations across geographic boundaries to ensure cultural survival. For Marshallese people, we cannot really know ourselves “until we know how we came to be where we are today” (Walsh, Heine, Bigler & Stege, 2012). Jitdam Kapeel is a popular Marshallese concept and ideal associated with inquiring into relationships within the family and community. In a similar way, the practice of relating is about connecting the present and future to the past. Education and leadership partnerships are linked and we look back to the past, our history, to make sense and feel inspired to transform practices that will benefit our people. In this paper and in light of our next generation, we reconnect with our navigation stories to inspire and empower education and leadership. Kanne lobal is part of our navigation stories, a conceptual framework centred on cultural practices, values, and concepts that embrace collective partnerships. Our link to this talanoa vā with others in the special issue is to attempt to make sense of connections given the global COVID-19 context by providing a Marshallese approach to address the physical and relational “distance” between education and leadership partnerships in Oceania. Like the majority of developing small island nations in Oceania, the Republic of the Marshall Islands (RMI) has had its share of educational challenges through colonial legacies of the past which continues to drive education systems in the region (Heine, 2002). The historical administration and education in the RMI is one of colonisation. Successive administrations by the Spanish, German, Japanese, and now the US, has resulted in education and learning that privileges western knowledge and forms of learning. This paper foregrounds understandings of education and learning as told by the voices of elementary school leaders from the RMI. The move to re-think education and leadership from Marshallese perspectives is an act of shifting the focus of bwebwenato or conversations that centres on Marshallese language and worldviews. The concept of jelalokjen was conceptualised as traditional education framed mainly within the community context. In the past, jelalokjen was practiced and transmitted to the younger generation for cultural continuity. During the arrival of colonial administrations into the RMI, jelalokjen was likened to the western notions of education and schooling (Kupferman, 2004). Today, the primary function of jelalokjen, as traditional and formal education, it is for “survival in a hostile [and challenging] environment” (Kupferman, 2004, p. 43). Because western approaches to learning in the RMI have not always resulted in positive outcomes for those engaged within the education system, as school leaders who value our cultural knowledge and practices, and aspire to maintain our language with the next generation, we turn to Kanne Lobal, a practice embedded in our navigation stories, collective aspirations, and leadership. The significance in the development of Kanne Lobal, as an appropriate framework for education and leadership, resulted in us coming together and working together. Not only were we able to share our leadership concerns, however, the engagement strengthened our connections with each other as school leaders, our communities, and the Public Schooling System (PSS). Prior to that, many of us were in competition for resources. Educational Leadership: IQBE and GCSL Leadership is a valued practice in the RMI. Before the IQBE programme started in 2018, the majority of the school leaders on the main island of Majuro had not engaged in collaborative partnerships with each other before. Our main educational purpose was to achieve accreditation from the Western Association of Schools and Colleges (WASC), an accreditation commission for schools in the United States. The WASC accreditation dictated our work and relationships and many school leaders on Majuro felt the pressure of competition against each other. We, the authors in this paper, share our collective bwebwenato, highlighting our school leadership experiences and how we gained strength from our own ancestral knowledge to empower “us”, to collaborate with each other, our teachers, communities, as well as with PSS; a collaborative partnership we had not realised in the past. The paucity of literature that captures Kajin Majol (Marshallese language) and education in general in the RMI is what we intend to fill by sharing our reflections and experiences. To move our educational practices forward we highlight Kanne Lobal, a cultural approach that focuses on our strengths, collective social responsibilities and wellbeing. For a long time, there was no formal training in place for elementary school leaders. School principals and vice principals were appointed primarily on their academic merit through having an undergraduate qualification. As part of the first cohort of fifteen school leaders, we engaged in the professional training programme, the Graduate Certificate in School Leadership (GCSL), refitted to our context after its initial development in the Solomon Islands. GCSL was coordinated by the Institute of Education (IOE) at the University of the South Pacific (USP). GCSL was seen as a relevant and appropriate training programme for school leaders in the RMI as part of an Asia Development Bank (ADB) funded programme which aimed at “Improving Quality Basic Education” (IQBE) in parts of the northern Pacific. GCSL was managed on Majuro, RMI’s main island, by the director at the time Dr Irene Taafaki, coordinator Yolanda McKay, and administrators at the University of the South Pacific’s (USP) RMI campus. Through the provision of GCSL, as school leaders we were encouraged to re-think and draw-from our own cultural repository and connect to our ancestral knowledge that have always provided strength for us. This kind of thinking and practice was encouraged by our educational leaders (Heine, 2002). We argue that a culturally-affirming and culturally-contextual framework that reflects the lived experiences of Marshallese people is much needed and enables the disruption of inherent colonial processes left behind by Western and Eastern administrations which have influenced our education system in the RMI (Heine, 2002). Kanne Lobal, an approach utilising a traditional navigation has warranted its need to provide solutions for today’s educational challenges for us in the RMI. Education in the Pacific Education in the Pacific cannot be understood without contextualising it in its history and culture. It is the same for us in the RMI (Heine, 2002; Walsh et al., 2012). The RMI is located in the Pacific Ocean and is part of Micronesia. It was named after a British captain, John Marshall in the 1700s. The atolls in the RMI were explored by the Spanish in the 16th century. Germany unsuccessfully attempted to colonize the islands in 1885. Japan took control in 1914, but after several battles during World War II, the US seized the RMI from them. In 1947, the United Nations made the island group, along with the Mariana and Caroline archipelagos, a U.S. trust territory (Walsh et al, 2012). Education in the RMI reflects the colonial administrations of Germany, Japan, and now the US. Before the turn of the century, formal education in the Pacific reflected western values, practices, and standards. Prior to that, education was informal and not binded to formal learning institutions (Thaman, 1997) and oral traditions was used as the medium for transmitting learning about customs and practices living with parents, grandparents, great grandparents. As alluded to by Jiba B. Kabua (2004), any “discussion about education is necessarily a discussion of culture, and any policy on education is also a policy of culture” (p. 181). It is impossible to promote one without the other, and it is not logical to understand one without the other. Re-thinking how education should look like, the pedagogical strategies that are relevant in our classrooms, the ways to engage with our parents and communities - such re-thinking sits within our cultural approaches and frameworks. Our collective attempts to provide a cultural framework that is relevant and appropriate for education in our context, sits within the political endeavour to decolonize. This means that what we are providing will not only be useful, but it can be used as a tool to question and identify whether things in place restrict and prevent our culture or whether they promote and foreground cultural ideas and concepts, a significant discussion of culture linked to education (Kabua, 2004). Donor funded development aid programmes were provided to support the challenges within education systems. Concerned with the persistent low educational outcomes of Pacific students, despite the prevalence of aid programmes in the region, in 2000 Pacific educators and leaders with support from New Zealand Aid (NZ Aid) decided to intervene (Heine, 2002; Taufe’ulungaki, 2014). In April 2001, a group of Pacific educators and leaders across the region were invited to a colloquium funded by the New Zealand Overseas Development Agency held in Suva Fiji at the University of the South Pacific. The main purpose of the colloquium was to enable “Pacific educators to re-think the values, assumptions and beliefs underlying [formal] schooling in Oceania” (Benson, 2002). Leadership, in general, is a valued practice in the RMI (Heine, 2002). Despite education leadership being identified as a significant factor in school improvement (Sanga & Chu, 2009), the limited formal training opportunities of school principals in the region was a persistent concern. As part of an Asia Development Bank (ADB) funded project, the Improve Quality Basic Education (IQBE) intervention was developed and implemented in the RMI in 2017. Mentoring is a process associated with the continuity and sustainability of leadership knowledge and practices (Sanga & Chu, 2009). It is a key aspect of building capacity and capabilities within human resources in education (ibid). Indigenous knowledges and education research According to Hilda Heine, the relationship between education and leadership is about understanding Marshallese history and culture (cited in Walsh et al., 2012). It is about sharing indigenous knowledge and histories that “details for future generations a story of survival and resilience and the pride we possess as a people” (Heine, cited in Walsh et al., 2012, p. v). This paper is fuelled by postcolonial aspirations yet is grounded in Pacific indigenous research. This means that our intentions are driven by postcolonial pursuits and discourses linked to challenging the colonial systems and schooling in the Pacific region that privileges western knowledge and learning and marginalises the education practices and processes of local people (Thiong’o, 1986). A point of difference and orientation from postcolonialism is a desire to foreground indigenous Pacific language, specifically Majin Majol, through Marshallese concepts. Our collective bwebwenato and conversation honours and values kautiej (respect), jouj eo mour eo (reciprocity), and jouj (kindness) (Taafaki & Fowler, 2019). Pacific leaders developed the Rethinking Pacific Education Initiative for and by Pacific People (RPEIPP) in 2002 to take control of the ways in which education research was conducted by donor funded organisations (Taufe’ulungaki, 2014). Our former president, Dr Hilda Heine was part of the group of leaders who sought to counter the ways in which our educational and leadership stories were controlled and told by non-Marshallese (Heine, 2002). As a former minister of education in the RMI, Hilda Heine continues to inspire and encourage the next generation of educators, school leaders, and researchers to re-think and de-construct the way learning and education is conceptualised for Marshallese people. The conceptualisation of Kanne Lobal acknowledges its origin, grounded in Marshallese navigation knowledge and practice. Our decision to unpack and deconstruct Kanne Lobal within the context of formal education and leadership responds to the need to not only draw from indigenous Marshallese ideas and practice but to consider that the next generation will continue to be educated using western processes and initiatives particularly from the US where we get a lot of our funding from. According to indigenous researchers Dawn Bessarab and Bridget Ng’andu (2010), doing research that considers “culturally appropriate processes to engage with indigenous groups and individuals is particularly pertinent in today’s research environment” (p. 37). Pacific indigenous educators and researchers have turned to their own ancestral knowledge and practices for inspiration and empowerment. Within western research contexts, the often stringent ideals and processes are not always encouraging of indigenous methods and practices. However, many were able to ground and articulate their use of indigenous methods as being relevant and appropriate to capturing the realities of their communities (Nabobo-Baba, 2008; Sualii-Sauni & Fulu-Aiolupotea, 2014; Thaman, 1997). At the same time, utilising Pacific indigenous methods and approaches enabled research engagement with their communities that honoured and respected them and their communities. For example, Tongan, Samoan, and Fijian researchers used the talanoa method as a way to capture the stories, lived realities, and worldviews of their communities within education in the diaspora (Fa’avae, Jones, & Manu’atu, 2016; Nabobo-Baba, 2008; Sualii-Sauni & Aiolupotea, 2014; Vaioleti, 2005). Tok stori was used by Solomon Islander educators and school leaders to highlight the unique circles of conversational practice and storytelling that leads to more positive engagement with their community members, capturing rich and meaningful narratives as a result (Sanga & Houma, 2004). The Indigenous Aborigine in Australia utilise yarning as a “relaxed discussion through which both the researcher and participant journey together visiting places and topics of interest relevant” (Bessarab & Ng’andu, 2010, p. 38). Despite the diverse forms of discussions and storytelling by indigenous peoples, of significance are the cultural protocols, ethics, and language for conducting and guiding the engagement (Bessarab & Ng’andu, 2010; Nabobo-Baba, 2008; Sualii-Sauni & Aiolupotea, 2014). Through the ethics, values, protocols, and language, these are what makes indigenous methods or frameworks unique compared to western methods like in-depth interviews or semi-structured interviews. This is why it is important for us as Marshallese educators to frame, ground, and articulate how our own methods and frameworks of learning could be realised in western education (Heine, 2002; Jetnil-Kijiner, 2014). In this paper, we utilise bwebwenato as an appropriate method linked to “talk story”, capturing our collective stories and experiences during GCSL and how we sought to build partnerships and collaboration with each other, our communities, and the PSS. Bwebwenato and drawing from Kajin Majel Legends and stories that reflect Marshallese society and its cultural values have survived through our oral traditions. The practice of weaving also holds knowledge about our “valuable and earliest sources of knowledge” (Taafaki & Fowler, 2019, p. 2). The skilful navigation of Marshallese wayfarers on the walap (large canoes) in the ocean is testament of their leadership and the value they place on ensuring the survival and continuity of Marshallese people (Taafaki & Fowler, 2019; Walsh et al., 2012). During her graduate study in 2014, Kathy Jetnil-Kijiner conceptualised bwebwenato as being the most “well-known form of Marshallese orality” (p. 38). The Marshallese-English dictionary defined bwebwenato as talk, conversation, story, history, article, episode, lore, myth, or tale (cited in Jetnil Kijiner, 2014). Three years later in 2017, bwebwenato was utilised in a doctoral project by Natalie Nimmer as a research method to gather “talk stories” about the experiences of 10 Marshallese experts in knowledge and skills ranging from sewing to linguistics, canoe-making and business. Our collective bwebwenato in this paper centres on Marshallese ideas and language. The philosophy of Marshallese knowledge is rooted in our “Kajin Majel”, or Marshallese language and is shared and transmitted through our oral traditions. For instance, through our historical stories and myths. Marshallese philosophy, that is, the knowledge systems inherent in our beliefs, values, customs, and practices are shared. They are inherently relational, meaning that knowledge systems and philosophies within our world are connected, in mind, body, and spirit (Jetnil-Kijiner, 2014; Nimmer, 2017). Although some Marshallese believe that our knowledge is disappearing as more and more elders pass away, it is therefore important work together, and learn from each other about the knowledges shared not only by the living but through their lamentations and stories of those who are no longer with us (Jetnil-Kijiner, 2014). As a Marshallese practice, weaving has been passed-down from generation to generation. Although the art of weaving is no longer as common as it used to be, the artefacts such as the “jaki-ed” (clothing mats) continue to embody significant Marshallese values and traditions. For our weavers, the jouj (check spelling) is the centre of the mat and it is where the weaving starts. When the jouj is correct and weaved well, the remainder and every other part of the mat will be right. The jouj is symbolic of the “heart” and if the heart is prepared well, trained well, then life or all other parts of the body will be well (Taafaki & Fowler, 2019). In that light, we have applied the same to this paper. Conceptualising and drawing from cultural practices that are close and dear to our hearts embodies a significant ontological attempt to prioritize our own knowledge and language, a sense of endearment to who we are and what we believe education to be like for us and the next generation. The application of the phrase “Majolizing '' was used by the Ministry of Education when Hilda Heine was minister, to weave cultural ideas and language into the way that teachers understand the curriculum, develop lesson plans and execute them in the classroom. Despite this, there were still concerns with the embedded colonized practices where teachers defaulted to eurocentric methods of doing things, like the strategies provided in the textbooks given to us. In some ways, our education was slow to adjust to the “Majolizing '' intention by our former minister. In this paper, we provide Kanne Lobal as a way to contribute to the “Majolizing intention” and perhaps speed up yet still be collectively responsible to all involved in education. Kajin Wa and Kanne Lobal “Wa” is the Marshallese concept for canoe. Kajin wa, as in canoe language, has a lot of symbolic meaning linked to deeply-held Marshallese values and practices. The canoe was the foundational practice that supported the livelihood of harsh atoll island living which reflects the Marshallese social world. The experts of Kajin wa often refer to “wa” as being the vessel of life, a means and source of sustaining life (Kelen, 2009, cited in Miller, 2010). “Jouj” means kindness and is the lower part of the main hull of the canoe. It is often referred to by some canoe builders in the RMI as the heart of the canoe and is linked to love. The jouj is one of the first parts of the canoe that is built and is “used to do all other measurements, and then the rest of the canoe is built on top of it” (Miller, 2010, p. 67). The significance of the jouj is that when the canoe is in the water, the jouj is the part of the hull that is underwater and ensures that all the cargo and passengers are safe. For Marshallese, jouj or kindness is what living is about and is associated with selflessly carrying the responsibility of keeping the family and community safe. The parts of the canoe reflect Marshallese culture, legend, family, lineage, and kinship. They embody social responsibilities that guide, direct, and sustain Marshallese families’ wellbeing, from atoll to atoll. For example, the rojak (boom), rojak maan (upper boom), rojak kōrā (lower boom), and they support the edges of the ujelā/ujele (sail) (see figure 1). The literal meaning of rojak maan is male boom and rojak kōrā means female boom which together strengthens the sail and ensures the canoe propels forward in a strong yet safe way. Figuratively, the rojak maan and rojak kōrā symbolise the mother and father relationship which when strong, through the jouj (kindness and love), it can strengthen families and sustain them into the future. Figure 1. Parts of the canoe Source: https://www.canoesmarshallislands.com/2014/09/names-of-canoe-parts/ From a socio-cultural, communal, and leadership view, the canoe (wa) provides understanding of the relationships required to inspire and sustain Marshallese peoples’ education and learning. We draw from Kajin wa because they provide cultural ideas and practices that enable understanding of education and leadership necessary for sustaining Marshallese people and realities in Oceania. When building a canoe, the women are tasked with the weaving of the ujelā/ujele (sail) and to ensure that it is strong enough to withstand long journeys and the fierce winds and waters of the ocean. The Kanne Lobal relates to the front part of the ujelā/ujele (sail) where the rojak maan and rojak kōrā meet and connect (see the red lines in figure 1). Kanne Lobal is linked to the strategic use of the ujelā/ujele by navigators, when there is no wind north wind to propel them forward, to find ways to capture the winds so that their journey can continue. As a proverbial saying, Kanne Lobal is used to ignite thinking and inspire and transform practice particularly when the journey is rough and tough. In this paper we draw from Kanne Lobal to ignite, inspire, and transform our educational and leadership practices, a move to explore what has always been meaningful to Marshallese people when we are faced with challenges. The Kanne Lobal utilises our language, and cultural practices and values by sourcing from the concepts of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity). A key Marshallese proverb, “Enra bwe jen lale rara”, is the cultural practice where families enact compassion through the sharing of food in all occurrences. The term “enra” is a small basket weaved from the coconut leaves, and often used by Marshallese as a plate to share and distribute food amongst each other. Bwe-jen-lale-rara is about noticing and providing for the needs of others, and “enra” the basket will help support and provide for all that are in need. “Enra-bwe-jen-lale-rara” is symbolic of cultural exchange and reciprocity and the cultural values associated with building and maintaining relationships, and constantly honouring each other. As a Marshallese practice, in this article we share our understanding and knowledge about the challenges as well as possible solutions for education concerns in our nation. In addition, we highlight another proverb, “wa kuk wa jimor”, which relates to having one canoe, and despite its capacity to feed and provide for the individual, but within the canoe all people can benefit from what it can provide. In the same way, we provide in this paper a cultural framework that will enable all educators to benefit from. It is a framework that is far-reaching and relevant to the lived realities of Marshallese people today. Kumit relates to people united to build strength, all co-operating and working together, living in peace, harmony, and good health. Kanne Lobal: conceptual framework for education and leadership An education framework is a conceptual structure that can be used to capture ideas and thinking related to aspects of learning. Kanne Lobal is conceptualised and framed in this paper as an educational framework. Kanne Lobal highlights the significance of education as a collective partnership whereby leadership is an important aspect. Kanne Lobal draws-from indigenous Marshallese concepts like kautiej (respect), jouj eo mour eo (reciprocity), and jouj (kindness, heart). The role of a leader, including an education leader, is to prioritise collective learning and partnerships that benefits Marshallese people and the continuity and survival of the next generation (Heine, 2002; Thaman, 1995). As described by Ejnar Aerōk, an expert canoe builder in the RMI, he stated: “jerbal ippān doon bwe en maron maan wa e” (cited in Miller, 2010, p. 69). His description emphasises the significance of partnerships and working together when navigating and journeying together in order to move the canoe forward. The kubaak, the outrigger of the wa (canoe) is about “partnerships”. For us as elementary school leaders on Majuro, kubaak encourages us to value collaborative partnerships with each other as well as our communities, PSS, and other stakeholders. Partnerships is an important part of the Kanne Lobal education and leadership framework. It requires ongoing bwebwenato – the inspiring as well as confronting and challenging conversations that should be mediated and negotiated if we and our education stakeholders are to journey together to ensure that the educational services we provide benefits our next generation of young people in the RMI. Navigating ahead the partnerships, mediation, and negotiation are the core values of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity). As an organic conceptual framework grounded in indigenous values, inspired through our lived experiences, Kanne Lobal provides ideas and concepts for re-thinking education and leadership practices that are conducive to learning and teaching in the schooling context in the RMI. By no means does it provide the solution to the education ills in our nation. However, we argue that Kanne Lobal is a more relevant approach which is much needed for the negatively stigmatised system as a consequence of the various colonial administrations that have and continue to shape and reframe our ideas about what education should be like for us in the RMI. Moreover, Kannel Lobal is our attempt to decolonize the framing of education and leadership, moving our bwebwenato to re-framing conversations of teaching and learning so that our cultural knowledge and values are foregrounded, appreciated, and realised within our education system. Bwebwenato: sharing our stories In this section, we use bwebwenato as a method of gathering and capturing our stories as data. Below we capture our stories and ongoing conversations about the richness in Marshallese cultural knowledge in the outer islands and on Majuro and the potentialities in Kanne Lobal. Danny Jim When I was in third grade (9-10 years of age), during my grandfather’s speech in Arno, an atoll near Majuro, during a time when a wa (canoe) was being blessed and ready to put the canoe into the ocean. My grandfather told me the canoe was a blessing for the family. “Without a canoe, a family cannot provide for them”, he said. The canoe allows for travelling between places to gather food and other sources to provide for the family. My grandfather’s stories about people’s roles within the canoe reminded me that everyone within the family has a responsibility to each other. Our women, mothers and daughters too have a significant responsibility in the journey, in fact, they hold us, care for us, and given strength to their husbands, brothers, and sons. The wise man or elder sits in the middle of the canoe, directing the young man who help to steer. The young man, he does all the work, directed by the older man. They take advice and seek the wisdom of the elder. In front of the canoe, a young boy is placed there and because of his strong and youthful vision, he is able to help the elder as well as the young man on the canoe. The story can be linked to the roles that school leaders, teachers, and students have in schooling. Without each person knowing intricately their role and responsibility, the sight and vision ahead for the collective aspirations of the school and the community is difficult to comprehend. For me, the canoe is symbolic of our educational journey within our education system. As the school leader, a central, trusted, and respected figure in the school, they provide support for teachers who are at the helm, pedagogically striving to provide for their students. For without strong direction from the school leaders and teachers at the helm, the students, like the young boy, cannot foresee their futures, or envisage how education can benefit them. This is why Kanne Lobal is a significant framework for us in the Marshall Islands because within the practice we are able to take heed and empower each other so that all benefit from the process. Kanne Lobal is linked to our culture, an essential part of who we are. We must rely on our own local approaches, rather than relying on others that are not relevant to what we know and how we live in today’s society. One of the things I can tell is that in Majuro, compared to the outer islands, it’s different. In the outer islands, parents bring children together and tell them legends and stories. The elders tell them about the legends and stories – the bwebwenato. Children from outer islands know a lot more about Marshallese legends compared to children from the Majuro atoll. They usually stay close to their parents, observe how to prepare food and all types of Marshallese skills. Loretta Joseph Case There is little Western influence in the outer islands. They grow up learning their own culture with their parents, not having tv. They are closely knit, making their own food, learning to weave. They use fire for cooking food. They are more connected because there are few of them, doing their own culture. For example, if they’re building a house, the ladies will come together and make food to take to the males that are building the house, encouraging them to keep on working - “jemjem maal” (sharpening tools i.e. axe, like encouraging workers to empower them). It’s when they bring food and entertainment. Rubon Rubon Togetherness, work together, sharing of food, these are important practices as a school leader. Jemjem maal – the whole village works together, men working and the women encourage them with food and entertainment. All the young children are involved in all of the cultural practices, cultural transmission is consistently part of their everyday life. These are stronger in the outer islands. Kanne Lobal has the potential to provide solutions using our own knowledge and practices. Connie Joel When new teachers become a teacher, they learn more about their culture in teaching. Teaching raises the question, who are we? A popular saying amongst our people, “Aelon kein ad ej aelon in manit”, means that “Our islands are cultural islands”. Therefore, when we are teaching, and managing the school, we must do this culturally. When we live and breathe, we must do this culturally. There is more socialising with family and extended family. Respect the elderly. When they’re doing things the ladies all get together, in groups and do it. Cut the breadfruit, and preserve the breadfruit and pandanus. They come together and do it. Same as fishing, building houses, building canoes. They use and speak the language often spoken by the older people. There are words that people in the outer islands use and understand language regularly applied by the elderly. Respect elderly and leaders more i.e., chiefs (iroj), commoners (alap), and the workers on the land (ri-jerbal) (social layer under the commoners). All the kids, they gather with their families, and go and visit the chiefs and alap, and take gifts from their land, first produce/food from the plantation (eojōk). Tommy Almet The people are more connected to the culture in the outer islands because they help one another. They don’t have to always buy things by themselves, everyone contributes to the occasion. For instance, for birthdays, boys go fishing, others contribute and all share with everyone. Kanne Lobal is a practice that can bring people together – leaders, teachers, stakeholders. We want our colleagues to keep strong and work together to fix problems like students and teachers’ absenteeism which is a big problem for us in schools. Demetria Malachi The culture in the outer islands are more accessible and exposed to children. In Majuro, there is a mixedness of cultures and knowledges, influenced by Western thinking and practices. Kanne Lobal is an idea that can enhance quality educational purposes for the RMI. We, the school leaders who did GCSL, we want to merge and use this idea because it will help benefit students’ learning and teachers’ teaching. Kanne Lobal will help students to learn and teachers to teach though traditional skills and knowledge. We want to revitalize our ways of life through teaching because it is slowly fading away. Also, we want to have our own Marshallese learning process because it is in our own language making it easier to use and understand. Essentially, we want to proudly use our own ways of teaching from our ancestors showing the appreciation and blessings given to us. Way Forward To think of ways forward is about reflecting on the past and current learnings. Instead of a traditional discussion within a research publication, we have opted to continue our bwebwenato by sharing what we have learnt through the Graduate Certificate in School Leadership (GCSL) programme. Our bwebwenato does not end in this article and this opportunity to collaborate and partner together in this piece of writing has been a meaningful experience to conceptualise and unpack the Kanne Lobal framework. Our collaborative bwebwenato has enabled us to dig deep into our own wise knowledges for guidance through mediating and negotiating the challenges in education and leadership (Sanga & Houma, 2004). For example, bwe-jen-lale-rara reminds us to inquire, pay attention, and focus on supporting the needs of others. Through enra-bwe-jen-lale-rara, it reminds us to value cultural exchange and reciprocity which will strengthen the development and maintaining of relationships based on ways we continue to honour each other (Nimmer, 2017). We not only continue to support each other, but also help mentor the next generation of school leaders within our education system (Heine, 2002). Education and leadership are all about collaborative partnerships (Sanga & Chu, 2009; Thaman, 1997). Developing partnerships through the GCSL was useful learning for us. It encouraged us to work together, share knowledge, respect each other, and be kind. The values of jouj (kindness, love), kautiej (respect), and jouj eo mour eo (reciprocity) are meaningful in being and becoming and educational leader in the RMI (Jetnil-Kijiner, 2014; Miller, 2010; Nimmer, 2017). These values are meaningful for us practice particularly given the drive by PSS for schools to become accredited. The workshops and meetings delivered during the GCSL in the RMI from 2018 to 2019 about Kanne Lobal has given us strength to share our stories and experiences from the meeting with the stakeholders. But before we met with the stakeholders, we were encouraged to share and speak in our language within our courses: EDP05 (Professional Development and Learning), EDP06 (School Leadership), EDP07 (School Management), EDP08 (Teaching and Learning), and EDP09 (Community Partnerships). In groups, we shared our presentations with our peers, the 15 school leaders in the GCSL programme. We also invited USP RMI staff. They liked the way we presented Kannel Lobal. They provided us with feedback, for example: how the use of the sail on the canoe, the parts and their functions can be conceptualised in education and how they are related to the way that we teach our own young people. Engaging stakeholders in the conceptualisation and design stages of Kanne Lobal strengthened our understanding of leadership and collaborative partnerships. Based on various meetings with the RMI Pacific Resources for Education and Learning (PREL) team, PSS general assembly, teachers from the outer islands, and the PSS executive committee, we were able to share and receive feedback on the Kanne Lobal framework. The coordinators of the PREL programme in the RMI were excited by the possibilities around using Kanne Lobal, as a way to teach culture in an inspirational way to Marshallese students. Our Marshallese knowledge, particularly through the proverbial meaning of Kanne Lobal provided so much inspiration and insight for the groups during the presentation which gave us hope and confidence to develop the framework. Kanne Lobal is an organic and indigenous approach, grounded in Marshallese ways of doing things (Heine, 2002; Taafaki & Fowler, 2019). Given the persistent presence of colonial processes within the education system and the constant reference to practices and initiatives from the US, Kanne Lobal for us provides a refreshing yet fulfilling experience and makes us feel warm inside because it is something that belongs to all Marshallese people. Conclusion Marshallese indigenous knowledge and practices provide meaningful educational and leadership understanding and learnings. They ignite, inspire, and transform thinking and practice. The Kanne Lobal conceptual framework emphasises key concepts and values necessary for collaborative partnerships within education and leadership practices in the RMI. The bwebwenato or talk stories have been insightful and have highlighted the strengths and benefits that our Marshallese ideas and practices possess when looking for appropriate and relevant ways to understand education and leadership. Acknowledgements We want to acknowledge our GCSL cohort of school leaders who have supported us in the development of Kanne Lobal as a conceptual framework. A huge kommol tata to our friends: Joana, Rosana, Loretta, Jellan, Alvin, Ellice, Rolando, Stephen, and Alan. References Benson, C. (2002). Preface. In F. Pene, A. M. Taufe’ulungaki, & C. Benson (Eds.), Tree of Opportunity: re-thinking Pacific Education (p. iv). Suva, Fiji: University of the South Pacific, Institute of Education. Bessarab, D., Ng’andu, B. (2010). Yarning about yarning as a legitimate method in indigenous research. International Journal of Critical Indigenous Studies, 3(1), 37-50. Fa’avae, D., Jones, A., & Manu’atu, L. (2016). Talanoa’i ‘a e talanoa - talking about talanoa: Some dilemmas of a novice researcher. AlterNative: An Indigenous Journal of Indigenous Peoples,12(2),138-150. Heine, H. C. (2002). A Marshall Islands perspective. In F. Pene, A. M. Taufe’ulungaki, & C. 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In my postgraduate formation during the last years of the 80’s, we had close to thirty hospital beds in a pavilion called “sépticas” (1). In Colombia, where abortion was completely penalized, the pavilion was mostly filled with women with insecure, complicated abortions. The focus we received was technical: management of intensive care; performance of hysterectomies, colostomies, bowel resection, etc. In those times, some nurses were nuns and limited themselves to interrogating the patients to get them to “confess” what they had done to themselves in order to abort. It always disturbed me that the women who left alive, left without any advice or contraceptive method. Having asked a professor of mine, he responded with disdain: “This is a third level hospital, those things are done by nurses of the first level”. Seeing so much pain and death, I decided to talk to patients, and I began to understand their decision. I still remember so many deaths with sadness, but one case in particular pains me: it was a woman close to being fifty who arrived with a uterine perforation in a state of advanced sepsis. Despite the surgery and the intensive care, she passed away. I had talked to her, and she told me she was a widow, had two adult kids and had aborted because of “embarrassment towards them” because they were going to find out that she had an active sexual life. A few days after her passing, the pathology professor called me, surprised, to tell me that the uterus we had sent for pathological examination showed no pregnancy. She was a woman in a perimenopausal state with a pregnancy exam that gave a false positive due to the high levels of FSH/LH typical of her age. SHE WAS NOT PREGNANT!!! She didn’t have menstruation because she was premenopausal and a false positive led her to an unsafe abortion. Of course, the injuries caused in the attempted abortion caused the fatal conclusion, but the real underlying cause was the social taboo in respect to sexuality. I had to watch many adolescents and young women leave the hospital alive, but without a uterus, sometime without ovaries and with colostomies, to be looked down on by a society that blamed them for deciding to not be mothers. I had to see situation of women that arrived with their intestines protruding from their vaginas because of unsafe abortions. I saw women, who in their despair, self-inflicted injuries attempting to abort with elements such as stick, branches, onion wedges, alum bars and clothing hooks among others. Among so many deaths, it was hard not having at least one woman per day in the morgue due to an unsafe abortion. During those time, healthcare was not handled from the biopsychosocial, but only from the technical (2); nonetheless, in the academic evaluations that were performed, when asked about the definition of health, we had to recite the text from the International Organization of Health that included these three aspects. How contradictory! To give response to the health need of women and guarantee their right when I was already a professor, I began an obstetric contraceptive service in that third level hospital. There was resistance from the directors, but fortunately I was able to acquire international donations for the institution, which facilitated its acceptance. I decided to undertake a teaching career with the hope of being able to sensitize health professionals towards an integral focus of health and illness. When the International Conference of Population and Development (ICPD) was held in Cairo in 1994, I had already spent various years in teaching, and when I read their Action Program, I found a name for what I was working on: Sexual and Reproductive Rights. I began to incorporate the tools given by this document into my professional and teaching life. I was able to sensitize people at my countries Health Ministry, and we worked together moving it to an approach of human rights in areas of sexual and reproductive health (SRH). This new viewpoint, in addition to being integral, sought to give answers to old problems like maternal mortality, adolescent pregnancy, low contraceptive prevalence, unplanned or unwanted pregnancy or violence against women. With other sensitized people, we began with these SRH issues to permeate the Colombian Society of Obstetrics and Gynecology, some universities, and university hospitals. We are still fighting in a country that despite many difficulties has improved its indicators of SRH. With the experience of having labored in all sphere of these topics, we manage to create, with a handful of colleagues and friend at the Universidad El Bosque, a Master’s Program in Sexual and Reproductive Health, open to all professions, in which we broke several paradigms. A program was initiated in which the qualitative and quantitative investigation had the same weight, and some alumni of the program are now in positions of leadership in governmental and international institutions, replicating integral models. In the Latin American Federation of Obstetrics and Gynecology (FLASOG, English acronym) and in the International Federation of Obstetrics and Gynecology (FIGO), I was able to apply my experience for many years in the SRH committees of these association to benefit women and girls in the regional and global environments. When I think of who has inspired me in these fights, I should highlight the great feminist who have taught me and been with me in so many fights. I cannot mention them all, but I have admired the story of the life of Margaret Sanger with her persistence and visionary outlook. She fought throughout her whole life to help the women of the 20th century to be able to obtain the right to decide when and whether or not they wanted to have children (3). Of current feminist, I have had the privilege of sharing experiences with Carmen Barroso, Giselle Carino, Debora Diniz and Alejandra Meglioli, leaders of the International Planned Parenthood Federation – Western Hemisphere Region (IPPF-RHO). From my country, I want to mention my countrywoman Florence Thomas, psychologist, columnist, writer and Colombo-French feminist. She is one of the most influential and important voices in the movement for women rights in Colombia and the region. She arrived from France in the 1960’s, in the years of counterculture, the Beatles, hippies, Simone de Beauvoir, and Jean-Paul Sartre, a time in which capitalism and consumer culture began to be criticized (4). It was then when they began to talk about the female body, female sexuality and when the contraceptive pill arrived like a total revolution for women. Upon its arrival in 1967, she experimented a shock because she had just assisted in a revolution and only found a country of mothers, not women (5). That was the only destiny for a woman, to be quiet and submissive. Then she realized that this could not continue, speaking of “revolutionary vanguards” in such a patriarchal environment. In 1986 with the North American and European feminism waves and with her academic team, they created the group “Mujer y Sociedad de la Universidad Nacional de Colombia”, incubator of great initiatives and achievements for the country (6). She has led great changes with her courage, the strength of her arguments, and a simultaneously passionate and agreeable discourse. Among her multiple books, I highlight “Conversaciones con Violeta” (7), motivated by the disdain towards feminism of some young women. She writes it as a dialogue with an imaginary daughter in which, in an intimate manner, she reconstructs the history of women throughout the centuries and gives new light of the fundamental role of feminism in the life of modern women. Another book that shows her bravery is “Había que decirlo” (8), in which she narrates the experience of her own abortion at age twenty-two in sixty’s France. My work experience in the IPPF-RHO has allowed me to meet leaders of all ages in diverse countries of the region, who with great mysticism and dedication, voluntarily, work to achieve a more equal and just society. I have been particularly impressed by the appropriation of the concept of sexual and reproductive rights by young people, and this has given me great hope for the future of the planet. We continue to have an incomplete agenda of the action plan of the ICPD of Cairo but seeing how the youth bravely confront the challenges motivates me to continue ahead and give my years of experience in an intergenerational work. In their policies and programs, the IPPF-RHO evidences great commitment for the rights and the SRH of adolescent, that are consistent with what the organization promotes, for example, 20% of the places for decision making are in hands of the young. Member organizations, that base their labor on volunteers, are true incubators of youth that will make that unassailable and necessary change of generations. In contrast to what many of us experienced, working in this complicated agenda of sexual and reproductive health without theoretical bases, today we see committed people with a solid formation to replace us. In the college of medicine at the Universidad Nacional de Colombia and the College of Nursing at the Universidad El Bosque, the new generations are more motivated and empowered, with great desire to change the strict underlying structures. Our great worry is the onslaught of the ultra-right, a lot of times better organized than us who do support rights, that supports anti-rights group and are truly pro-life (9). Faced with this scenario, we should organize ourselves better, giving battle to guarantee the rights of women in the local, regional, and global level, aggregating the efforts of all pro-right organizations. We are now committed to the Objectives of Sustainable Development (10), understood as those that satisfy the necessities of the current generation without jeopardizing the capacity of future generations to satisfy their own necessities. This new agenda is based on: - The unfinished work of the Millennium Development Goals - Pending commitments (international environmental conventions) - The emergent topics of the three dimensions of sustainable development: social, economic, and environmental. We now have 17 objectives of sustainable development and 169 goals (11). These goals mention “universal access to reproductive health” many times. In objective 3 of this list is included guaranteeing, before the year 2030, “universal access to sexual and reproductive health services, including those of family planning, information, and education.” Likewise, objective 5, “obtain gender equality and empower all women and girls”, establishes the goal of “assuring the universal access to sexual and reproductive health and reproductive rights in conformity with the action program of the International Conference on Population and Development, the Action Platform of Beijing”. It cannot be forgotten that the term universal access to sexual and reproductive health includes universal access to abortion and contraception. Currently, 830 women die every day through preventable maternal causes; of these deaths, 99% occur in developing countries, more than half in fragile environments and in humanitarian contexts (12). 216 million women cannot access modern contraception methods and the majority live in the nine poorest countries in the world and in a cultural environment proper to the decades of the seventies (13). This number only includes women from 15 to 49 years in any marital state, that is to say, the number that takes all women into account is much greater. Achieving the proposed objectives would entail preventing 67 million unwanted pregnancies and reducing maternal deaths by two thirds. We currently have a high, unsatisfied demand for modern contraceptives, with extremely low use of reversible, long term methods (intrauterine devices and subdermal implants) which are the most effect ones with best adherence (14). There is not a single objective among the 17 Objectives of Sustainable Development where contraception does not have a prominent role: from the first one that refers to ending poverty, going through the fifth one about gender equality, the tenth of inequality reduction among countries and within the same country, until the sixteenth related with peace and justice. If we want to change the world, we should procure universal access to contraception without myths or barriers. We have the moral obligation of achieving the irradiation of extreme poverty and advancing the construction of more equal, just, and happy societies. In emergency contraception (EC), we are very far from reaching expectations. If in reversible, long-term methods we have low prevalence, in EC the situation gets worse. Not all faculties in the region look at this topic, and where it is looked at, there is no homogeneity in content, not even within the same country. There are still myths about their real action mechanisms. There are countries, like Honduras, where it is prohibited and there is no specific medicine, the same case as in Haiti. Where it is available, access is dismal, particularly among girls, adolescents, youth, migrants, afro-descendent, and indigenous. The multiple barriers for the effective use of emergency contraceptives must be knocked down, and to work toward that we have to destroy myths and erroneous perceptions, taboos and cultural norms; achieve changes in laws and restrictive rules within countries, achieve access without barriers to the EC; work in union with other sectors; train health personnel and the community. It is necessary to transform the attitude of health personal to a service above personal opinion. Reflecting on what has occurred after the ICPD in Cairo, their Action Program changed how we look at the dynamics of population from an emphasis on demographics to a focus on the people and human rights. The governments agreed that, in this new focus, success was the empowerment of women and the possibility of choice through expanded access to education, health, services, and employment among others. Nonetheless, there have been unequal advances and inequality persists in our region, all the goals were not met, the sexual and reproductive goals continue beyond the reach of many women (15). There is a long road ahead until women and girls of the world can claim their rights and liberty of deciding. Globally, maternal deaths have been reduced, there is more qualified assistance of births, more contraception prevalence, integral sexuality education, and access to SRH services for adolescents are now recognized rights with great advances, and additionally there have been concrete gains in terms of more favorable legal frameworks, particularly in our region; nonetheless, although it’s true that the access condition have improved, the restrictive laws of the region expose the most vulnerable women to insecure abortions. There are great challenges for governments to recognize SRH and the DSR as integral parts of health systems, there is an ample agenda against women. In that sense, access to SRH is threatened and oppressed, it requires multi-sector mobilization and litigation strategies, investigation and support for the support of women’s rights as a multi-sector agenda. Looking forward, we must make an effort to work more with youth to advance not only the Action Program of the ICPD, but also all social movements. They are one of the most vulnerable groups, and the biggest catalyzers for change. The young population still faces many challenges, especially women and girls; young girls are in particularly high risk due to lack of friendly and confidential services related with sexual and reproductive health, gender violence, and lack of access to services. In addition, access to abortion must be improved; it is the responsibility of states to guarantee the quality and security of this access. In our region there still exist countries with completely restrictive frameworks. New technologies facilitate self-care (16), which will allow expansion of universal access, but governments cannot detach themselves from their responsibility. Self-care is expanding in the world and can be strategic for reaching the most vulnerable populations. There are new challenges for the same problems, that require a re-interpretation of the measures necessary to guaranty the DSR of all people, in particular women, girls, and in general, marginalized and vulnerable populations. It is necessary to take into account migrations, climate change, the impact of digital media, the resurgence of hate discourse, oppression, violence, xenophobia, homo/transphobia, and other emergent problems, as SRH should be seen within a framework of justice, not isolated. We should demand accountability of the 179 governments that participate in the ICPD 25 years ago and the 193 countries that signed the Sustainable Development Objectives. They should reaffirm their commitments and expand their agenda to topics not considered at that time. Our region has given the world an example with the Agreement of Montevideo, that becomes a blueprint for achieving the action plan of the CIPD and we should not allow retreat. This agreement puts people at the center, especially women, and includes the topic of abortion, inviting the state to consider the possibility of legalizing it, which opens the doors for all governments of the world to recognize that women have the right to choose on maternity. This agreement is much more inclusive: Considering that the gaps in health continue to abound in the region and the average statistics hide the high levels of maternal mortality, of sexually transmitted diseases, of infection by HIV/AIDS, and the unsatisfied demand for contraception in the population that lives in poverty and rural areas, among indigenous communities, and afro-descendants and groups in conditions of vulnerability like women, adolescents and incapacitated people, it is agreed: 33- To promote, protect, and guarantee the health and the sexual and reproductive rights that contribute to the complete fulfillment of people and social justice in a society free of any form of discrimination and violence. 37- Guarantee universal access to quality sexual and reproductive health services, taking into consideration the specific needs of men and women, adolescents and young, LGBT people, older people and people with incapacity, paying particular attention to people in a condition of vulnerability and people who live in rural and remote zone, promoting citizen participation in the completing of these commitments. 42- To guarantee, in cases in which abortion is legal or decriminalized in the national legislation, the existence of safe and quality abortion for non-desired or non-accepted pregnancies and instigate the other States to consider the possibility of modifying public laws, norms, strategies, and public policy on the voluntary interruption of pregnancy to save the life and health of pregnant adolescent women, improving their quality of life and decreasing the number of abortions (17).

“I suppose in reality not a leaf goes yellow in autumn without ceasing to care about its sap and making the parent tree very uncomfortable by long growling and grumbling - but surely nature might find some less irritating way of carrying on business if she would give her mind to it. Why should the generations overlap one another at all? Samuel Butler, The Way of All Flesh1 Millenials or Generation Y physicians (born 1977/1980-1995) today form the majority of medical personnel, from medical students and residents in their early twenties and thirties to young attending physicians hitting forty; practicing side-by-side with Generation X (1965-1976/1980) in their late thirties to early fifties; Baby Boomers (1946-1964) in their mid-fifties, sixties and early seventies; and the last of the Silent Generation or Traditionalists (1925-1945) in their mid-seventies, eighties and nineties.2,3 Among 734 Fellows of the Philippine Society of Otolaryngology – Head and Neck Surgery alone, there are currently 18 Traditionalists, 192 Boomers, 360 Generation X, and 164 Millenials. Assuming the 862 board-certified Diplomates waiting to become full-fledged Fellows and 182 Residents-in-Training are also Millenials, there are a total of 1,208 Millenials in the field of Otolaryngology Head and Neck Surgery in the Philippines. With four distinct generations simultaneously in the workforce, it is not unusual to hear older physicians gripe about “these Millenials,” and how different they are from previous generations. The so-called generation gap has been used to characterize inter-generational relations, wherein the preceding generation historically puts down the younger, and the succeeding generation usually complains about the older one. I posit that central to this conflict is a clash between tradition -- the way things should be done (as perceived by the older generation) -- and disruption, the way things can be done differently (from the perspective of the younger generation). In particular (meaning no offense to the “in-between” Generation X, and at risk of being overly simplistic), this is highlighted by the supposed looming showdown between Baby Boomers who are not yet ready to leave and Millenials who can hardly wait to take over.4 Tradition, a “statement, belief or practice handed down from generation to generation” comes from the Old French tradicion “transmission, presentation, handing over” and directly from the Latin traditionem “delivery, surrender, a handing down, a giving up,” from tradere “deliver, hand over,” derived from trans – “over” + dare “to give.”5 Although older generations may like to think they uphold tradition (giving them the right and duty to pass it on to succeeding ones), a large part of what defines each generation in the first place is their departure from the statements, beliefs or practices of their predecessors. Such a transition may have been gradual or sudden, and more pronounced in some generations than in others. Our post-war Boomer generation grew up in a world where face-to-face communication was supplemented by the written (handwritten, typewritten, typeset or telegraphed) and spoken (rotary-dial telephone) word. In medicine and medical education, history and physical examination were taught through lectures (with overhead and opaque projectors, slides on carousels and filmstrips) and live demonstrations on patients and on one another. The advent of word processing and advances in telecommunications and technology that became available to Generation X (who in the Philippines include “martial law babies” oblivious to our “wonder years” of the sixties) gradually changed the landscape of medical education and practice, but it would take the digital and internet revolution to finally, drastically change the world-- and Millenials were the primary beneficiaries of this change. Disruption, from the Latin disruptionem “a breaking asunder,” which comes from disrumpere “break apart, split, shatter, break to pieces,” from dis- “apart” + rumpere “to break”6 perhaps best describes the Baby Boomer generation’s experience of the technological revolution that Millenials grew up with. Suddenly, everything could be had in a split-second and the world was connected in real time. No longer did one have to master penmanship, typing and speed-reading, and homes no longer displayed dictionaries and encyclopedias. Even the library card catalogue and periodicals index became obsolete, as most anything became instantly available and accessible – including information, fast food and relationships. Millenials grew up with this transition, and readily mastered the rapidly changing technology. The locus of socialization was no longer face-to-face interaction within the family, but the worldwide web and social media. In medical education, lectures gave way to podcasts and webinars; heavy textbooks gave way to electronic references; and even dissection gave way to 3D virtual human anatomy. The Millenials’ expertise in, and dependence on, technology can both be their boon and bane – as I often note when residents and students automatically search their peripheral brains (a.k.a. mobile devices) to answer a ward round question. But they are also as quick to intuitively master the diagnostic and therapeutic tools that did not exist when their older colleagues were in residency.7 The early access that Millenials and Generation X had to computer resources in childhood certainly laid “a critical foundation for use of these systems later in life,” compared to Baby Boomers and Traditionalists whose “lack of early experience may limit their enthusiasm” for such tools.3 As Cole puts it, “Baby Boomers don't react well to a 20-something coming in and disrupting the way things have ‘always been’ while Millennials don't react well when they're told to shoot for the moon and ‘do big things,’ and then when they walk in the door with new ideas ready to disrupt age-old models, get told to know their place.”8 Thus, older generations of physicians may question how the stock knowledge and clinical eye of Millenials can compare to theirs, who learned medicine without these tools, and wonder how Millenials would fare in conflict and catastrophic situations when technology fails, or in low- and middle-income rural settings where technology is scarce. Conversely, Millenials wonder why Boomers insist on their old ways and just don’t get it! Perhaps we can learn from Mohr et al.3 about bridging generational issues in medical and surgical education—for instance, between the Socratic Method whereby Boomers may appear to intimidate learners9 versus the Millenial expectation that presentation of information be tailored to their needs, individually or via available technology.10 It could be helpful for Millenials who are “outcomes-oriented and value doing more than knowing”11 “to realize that Traditionalists and Boomers ‘know how to do’ and are ready and able to teach.”3 On the other hand, “when instructing Boomers in new technology or information,” the Millenial teacher “should recognize that this role reversal is uncomfortable to older generations” and “mitigate discomfort … by focus(ing) on the relevance of the information and creat(ing) an environment in which it is ‘safe’ to ask questions and challenge the teacher.”3 Indeed, if inter-generational differences could be surmounted, there is much that Boomers can learn from Millenials, and vice versa. If as Cole observes, “this great debate is hauntingly similar to a parent/child argument,”8 it is because Boomers and Millennials are “also each other’s children and parents, bound together in an intricate web of love, support, anxiety, resentment, and interdependence.”4 Perhaps by involving Generation X in bridging the great divide, and fostering an environment that allows for inter-generational differences in teaching and learning styles, non-disruptive disruption of tradition can take place. Each generation must have the humility (as opposed to intellectual arrogance) to accept that they can learn from other generations – younger or older—for truly meaningful medical progress to take place. We cannot do otherwise, for Generation Z (born after 1995, and about to enter Medical School) is already poised to join the fray. References Butler S. The Way of All Flesh. New York: Dover Publications, 2004. 315 pages. The Center for Generational Kinetics. How to determine generational birth years. November 28, 2016 ©2016 [cited 2017 Nov 2.] Available from: http://genhq.com/generational_birth_years/ Mohr NM, Moreno-Walton L, Mills AM, Brunett PH, Promes SB. Generational Influences in Academic Emergency Medicine: Teaching and Learning, Mentoring, and Technology (Part I). Acad Emerg Med. 2011 Feb;18(2):190-199. DOI: 10.1111/j.1553-2712.2010.00985.x PMID: 21314779 PMCID: PMC3076332 Taylor P, Pew Research Center. The Next America: Boomers, Millenials, and the Looming Generational Showdown. New York: PublicAffairs, 2016. 384 pages. Harper D. Online Etymology Dictionary © 2001-2017 [Cited 2017 November 2.] Available from: https://www.etymonline.com/word/tradition Harper D. Online Etymology Dictionary © 2001-2017 [Cited 2017 November 2.] Available from: https://www.etymonline.com/word/disruption Sopher M. How Millenial Doctors Will Shape the Future of Health Care. Blog on the Internet, Baltimore: Rendia, 2016 October 26. [Cited 2017 November 2.] Available from: https://blog.rendia.com/millennials/ Cole N. The Real Reason Baby Boomers and Millenials Don’t See Eye to Eye (Written by a Millenial). Southeast Asia. 2017 Jan 20 [Cited 2017 November 2] Available from: https://www.inc.com/nicolas-cole/the-real-reason-baby-boomers-and-millennials-dont-see-eye-to-eye-written-by-a-mi.html Seabrook M. Intimidation in medical education: students' and teachers' perspectives. Studies Higher Educ. 2004;29(1):59–74. http://dx.doi.org/10.1080/1234567032000164877 Feiertag J, Berge ZL. Training generation N: How educators should approach the Net Generation. Education and Training. 2008 September;50(6):457–64. DOI: 10.1108/00400910810901782 Mangold K. Educating a new generation: teaching baby boomer faculty about millennial students. Nurse Educ. 2007 Jan-Feb;32(1):21-23. PMID: 17220763

1. Introduction This Special Issue (Part 2) expands upon the theme “Building Local Capacity for Long-term Disaster Resilience” presented in Special Issue Part 1 (JDR Volume 5, Number 2, April 2010) by examining the evolving concept of disaster resilience and providing additional reflections upon various aspects of its meaning. Part 1 provided a mixed set of examples of resiliency efforts, ranging from administrative challenges of integrating resilience into recovery to the analysis of hazard mitigation plans directed toward guiding local capability for developing resiliency. Resilience was broadly defined in the opening editorial of Special Issue Part 1 as “the capacity of a community to: 1) survive a major disaster, 2) retain essential structure and functions, and 3) adapt to post-disaster opportunities for transforming community structure and functions to meet new challenges.” In this editorial essay we first explore in Section 2 the history of resilience and then locate it within current academic and policy debates. Section 3 presents summaries of the papers in this issue. 2. Why is Resilience a Contemporary Theme? There is growing scholarly and policy interest in disaster resilience. In recent years, engineers [1], sociologists [2], geographers [3], economists [4], public policy analysts [5, 6], urban planners [7], hazards researchers [8], governments [9], and international organizations [10] have all contributed to the literature about this concept. Some authors view resilience as a mechanism for mitigating disaster impacts, with framework objectives such as resistance, absorption, and restoration [5]. Others, who focus on resiliency indicators, see it as an early warning system to assess community resiliency status [3, 8]. Recently, it has emerged as a component of social risk management that seeks to minimize social welfare loss from catastrophic disasters [6]. Manyena [11] traces scholarly exploration of resilience as an operational concept back at least five decades. Interest in resilience began in the 1940s with studies of children and trauma in the family and in the 1970s in the ecology literature as a useful framework to examine and measure the impact of assault or trauma on a defined eco-system component [12]. This led to modeling resilience measures for a variety of components within a defined ecosystem, leading to the realization that the systems approach to resiliency is attractive as a cross-disciplinary construct. The ecosystem analogy however, has limits when applied to disaster studies in that, historically, all catastrophic events have changed the place in which they occurred and a “return to normalcy” does not occur. This is true for modern urban societies as well as traditional agrarian societies. The adoption of “The Hyogo Framework for Action 2005-2015” (also known as The Hyogo Declaration) provides a global linkage and follows the United Nations 1990s International Decade for Natural Disaster Reduction effort. The 2005 Hyogo Declaration’s definition of resilience is: “The capacity of a system, community or society potentially exposed to hazards to adapt by resisting or changing in order to reach and maintain an acceptable level of functioning and structure.” The proposed measurement of resilience in the Hyogo Declaration is determined by “the degree to which the social system is capable of organizing itself to increase this capacity for learning from past disasters for better future protection and to improve risk reduction measures.” While very broad, this definition contains two key concepts: 1) adaptation, and 2) maintaining acceptable levels of functioning and structure. While adaptation requires certain capacities, maintaining acceptable levels of functioning and structure requires resources, forethought, and normative action. Some of these attributes are now reflected in the 2010 National Disaster Recovery Framework published by the U.S. Federal Emergency Management Agency (FEMA) [13]. With the emergence of this new thinking on resilience related to disasters, it is now a good time to reflect on the concept and assess what has recently been said in the literature. Bruneau et al. [1] offer an engineering sciences definition for community seismic resilience: “The ability of social units (e.g., organizations, communities) to mitigate hazards, contain the effects of disasters when they occur, and carry out recovery activities in ways that minimize social disruption and mitigate the effects of future earthquakes.” Rose [4] writes that resiliency is the ability of a system to recover from a severe shock. He distinguishes two types of resilience: (1) inherent – ability under normal circumstances and (2) adaptive – ability in crisis situations due to ingenuity or extra effort. By opening up resilience to categorization he provides a pathway to establish multi-disciplinary approaches, something that is presently lacking in practice. Rose is most concerned with business disruption which can take extensive periods of time to correct. In order to make resource decisions that lower overall societal costs (economic, social, governmental and physical), Rose calls for the establishment of measurements that function as resource decision allocation guides. This has been done in part through risk transfer tools such as private insurance. However, it has not been well-adopted by governments in deciding how to allocate mitigation resources. We need to ask why the interest in resilience has grown? Manyena [11] argues that the concept of resilience has gained currency without obtaining clarity of understanding, definition, substance, philosophical dimensions, or applicability to disaster management and sustainable development theory and practice. It is evident that the “emergency management model” does not itself provide sufficient guidance for policymakers since it is too command-and-control-oriented and does not adequately address mitigation and recovery. Also, large disasters are increasingly viewed as major disruptions of the economic and social conditions of a country, state/province, or city. Lowering post-disaster costs (human life, property loss, economic advancement and government disruption) is being taken more seriously by government and civil society. The lessening of costs is not something the traditional “preparedness” stage of emergency management has concerned itself with; this is an existing void in meeting the expanding interests of government and civil society. The concept of resilience helps further clarify the relationship between risk and vulnerability. If risk is defined as “the probability of an event or condition occurring [14]#8221; then it can be reduced through physical, social, governmental, or economic means, thereby reducing the likelihood of damage and loss. Nothing can be done to stop an earthquake, volcanic eruption, cyclone, hurricane, or other natural event, but the probability of damage and loss from natural and technological hazards can be addressed through structural and non-structural strategies. Vulnerability is the absence of capacity to resist or absorb a disaster impact. Changes in vulnerability can then be achieved by changes in these capacities. In this regard, Franco and Siembieda describe in this issue how coastal cities in Chile had low resilience and high vulnerability to the tsunami generated by the February 2010 earthquake, whereas modern buildings had high resilience and, therefore, were much less vulnerable to the powerful earthquake. We also see how the framework for policy development can change through differing perspectives. Eisner discusses in this issue how local non-governmental social service agencies are building their resilience capabilities to serve target populations after a disaster occurs, becoming self-renewing social organizations and demonstrating what Leonard and Howett [6] term “social resilience.” All of the contributions to this issue illustrate the lowering of disaster impacts and strengthening of capacity (at the household, community or governmental level) for what Alesch [15] terms “post-event viability” – a term reflecting how well a person, business, community, or government functions after a disaster in addition to what they might do prior to a disaster to lessen its impact. Viability might become the definition of recovery if it can be measured or agreed upon. 3. Contents of This Issue The insights provided by the papers in this issue contribute greater clarity to an understanding of resilience, together with its applicability to disaster management. In these papers we find tools and methods, process strategies, and planning approaches. There are five papers focused on local experiences, three on state (prefecture) experiences, and two on national experiences. The papers in this issue reinforce the concept of resilience as a process, not a product, because it is the sum of many actions. The resiliency outcome is the result of multiple inputs from the level of the individual and, at times, continuing up to the national or international organizational level. Through this exploration we see that the “resiliency” concept accepts that people will come into conflict with natural or anthropogenic hazards. The policy question then becomes how to lower the impact(s) of the conflict through “hard or soft” measures (see the Special Issue Part 1 editorial for a discussion of “hard” vs. “soft” resilience). Local level Go Urakawa and Haruo Hayashi illustrate how post-disaster operations for public utilities can be problematic because many practitioners have no direct experience in such operations, noting that the formats and methods normally used in recovery depend on personal skills and effort. They describe how these problems are addressed by creating manuals on measures for effectively implementing post-disaster operations. They develop a method to extract priority operations using business impact analysis (BIA) and project management based business flow diagrams (BFD). Their article effectively illustrates the practical aspects of strengthening the resiliency of public organizations. Richard Eisner presents the framework used to initiate the development and implementation of a process to create disaster resilience in faith-based and community-based organizations that provide services to vulnerable populations in San Francisco, California. A major project outcome is the Disaster Resilience Standard for Community- and Faith-Based Service Providers. This “standard” has general applicability for use by social service agencies in the public and non-profit sectors. Alejandro Linayo addresses the growing issue of technological risk in cities. He argues for the need to understand an inherent conflict between how we occupy urban space and the technological risks created by hazardous chemicals, radiation, oil and gas, and other hazardous materials storage and movement. The paper points out that information and procedural gaps exist in terms of citizen knowledge (the right to know) and local administrative knowledge (missing expertise). Advances and experience accumulated by the Venezuela Disaster Risk Management Research Center in identifying and integrating technological risk treatment for the city of Merida, Venezuela, are highlighted as a way to move forward. L. Teresa Guevara-Perez presents the case that certain urban zoning requirements in contemporary cities encourage and, in some cases, enforce the use of building configurations that have been long recognized by earthquake engineering as seismically vulnerable. Using Western Europe and the Modernist architectural movement, she develops the historical case for understanding discrepancies between urban zoning regulations and seismic codes that have led to vulnerable modern building configurations, and traces the international dissemination of architectural and urban planning concepts that have generated vulnerability in contemporary cities around the world. Jung Eun Kang, Walter Gillis Peacock, and Rahmawati Husein discuss an assessment protocol for Hazard Mitigation Plans applied to 12 coastal hazard zone plans in the state of Texas in the U.S. The components of these plans are systematically examined in order to highlight their respective strengths and weaknesses. The authors describe an assessment tool, the plan quality score (PQS), composed of seven primary components (vision statement, planning process, fact basis, goals and objectives, inter-organizational coordination, policies & actions, and implementation), as well as a component quality score (CQS). State (Prefecture) level Charles Real presents the Natural Hazard Zonation Policies for Land Use Planning and Development in California in the U.S. California has established state-level policies that utilize knowledge of where natural hazards are more likely to occur to enhance the effectiveness of land use planning as a tool for risk mitigation. Experience in California demonstrates that a combination of education, outreach, and mutually supporting policies that are linked to state-designated natural hazard zones can form an effective framework for enhancing the role of land use planning in reducing future losses from natural disasters. Norio Maki, Keiko Tamura, and Haruo Hayashi present a method for local government stakeholders involved in pre-disaster plan making to describe performance measures through the formulation of desired outcomes. Through a case study approach, Nara and Kyoto Prefectures’ separate experiences demonstrate how to conduct Strategic Earthquake Disaster Reduction Plans and Action Plans that have deep stakeholder buy-in and outcome measurability. Nara’s plan was prepared from 2,015 stakeholder ideas and Kyoto’s plan was prepared from 1,613 stakeholder ideas. Having a quantitative target for individual objectives ensures the measurability of plan progress. Both jurisdictions have undertaken evaluations of plan outcomes. Sandy Meyer, Eugene Henry, Roy E. Wright and Cynthia A. Palmer present the State of Florida in the U.S. and its experience with pre-disaster planning for post-disaster redevelopment. Drawing upon the lessons learned from the impacts of the 2004 and 2005 hurricane seasons, local governments and state leaders in Florida sought to find a way to encourage behavior that would create greater community resiliency in 2006. The paper presents initial efforts to develop a post-disaster redevelopment plan (PDRP), including the experience of a pilot county. National level Bo-Yao Lee provides a national perspective: New Zealand’s approach to emergency management, where all hazard risks are addressed through devolved accountability. This contemporary approach advocates collaboration and coordination, aiming to address all hazard risks through the “4Rs” – reduction, readiness, response, and recovery. Lee presents the impact of the Resource Management Act (1991), the Civil Defence Emergency Management Act (2002), and the Building Act (2004) that comprise the key legislation influencing and promoting integrated management for environment and hazard risk management. Guillermo Franco and William Siembieda provide a field assessment of the February 27, 2010, M8.8 earthquake and tsunami event in Chile. The papers present an initial damage and life-loss review and assessment of seismic building resiliency and the country’s rapid updating of building codes that have undergone continuous improvement over the past 60 years. The country’s land use planning system and its emergency management system are also described. The role of insurance coverage reveals problems in seismic coverage for homeowners. The unique role of the Catholic Church in providing temporary shelter and the central government’s five-point housing recovery plan are presented. A weakness in the government’s emergency management system’s early tsunami response system is noted. Acknowledgements The Editorial Committee extends its sincere appreciation to both the contributors and the JDR staff for their patience and determination in making Part 2 of this special issue possible. Thanks also to the reviewers for their insightful analytic comments and suggestions. Finally, the Committee wishes to again thank Bayete Henderson for his keen and thorough editorial assistance and copy editing support.

Rapid urbanization rates impact significantly on the nature of Land Cover patterns of the environment, which has been evident in the depletion of vegetal reserves and in general modifying the human climatic systems (Henderson, et al., 2017; Kumar, Masago, Mishra, & Fukushi, 2018; Luo and Lau, 2017). This study explores remote sensing classification technique and other auxiliary data to determine LULCC for a period of 50 years (1967-2016). The LULCC types identified were quantitatively evaluated using the change detection approach from results of maximum likelihood classification algorithm in GIS. Accuracy assessment results were evaluated and found to be between 56 to 98 percent of the LULC classification. The change detection analysis revealed change in the LULC types in Minna from 1976 to 2016. Built-up area increases from 74.82ha in 1976 to 116.58ha in 2016. Farmlands increased from 2.23 ha to 46.45ha and bared surface increases from 120.00ha to 161.31ha between 1976 to 2016 resulting to decline in vegetation, water body, and wetlands. The Decade of rapid urbanization was found to coincide with the period of increased Public Private Partnership Agreement (PPPA). Increase in farmlands was due to the adoption of urban agriculture which has influence on food security and the environmental sustainability. The observed increase in built up areas, farmlands and bare surfaces has substantially led to reduction in vegetation and water bodies. The oscillatory nature of water bodies LULCC which was not particularly consistent with the rates of urbanization also suggests that beyond the urbanization process, other factors may influence the LULCC of water bodies in urban settlements. Keywords: Minna, Niger State, Remote Sensing, Land Surface Characteristics References Akinrinmade, A., Ibrahim, K., & Abdurrahman, A. (2012). Geological Investigation of Tagwai Dams using Remote Sensing Technique, Minna Niger State, Nigeria. Journal of Environment, 1(01), pp. 26-32. Amadi, A., & Olasehinde, P. (2010). Application of remote sensing techniques in hydrogeological mapping of parts of Bosso Area, Minna, North-Central Nigeria. International Journal of Physical Sciences, 5(9), pp. 1465-1474. Aplin, P., & Smith, G. (2008). Advances in object-based image classification. The International Archives of the Photogrammetry, Remote Sensing and Spatial Information Sciences, 37(B7), pp. 725-728. Ayele, G. T., Tebeje, A. K., Demissie, S. S., Belete, M. A., Jemberrie, M. A., Teshome, W. M., . . . Teshale, E. Z. (2018). Time Series Land Cover Mapping and Change Detection Analysis Using Geographic Information System and Remote Sensing, Northern Ethiopia. Air, Soil and Water Research, 11, p 1178622117751603. Azevedo, J. A., Chapman, L., & Muller, C. L. (2016). Quantifying the daytime and night-time urban heat island in Birmingham, UK: a comparison of satellite derived land surface temperature and high resolution air temperature observations. Remote Sensing, 8(2), p 153. Blaschke, T., Hay, G. J., Kelly, M., Lang, S., Hofmann, P., Addink, E., . . . van Coillie, F. (2014). Geographic object-based image analysis–towards a new paradigm. ISPRS Journal of Photogrammetry and Remote Sensing, 87, pp. 180-191. Bukata, R. P., Jerome, J. H., Kondratyev, A. S., & Pozdnyakov, D. V. (2018). Optical properties and remote sensing of inland and coastal waters: CRC press. Camps-Valls, G., Tuia, D., Bruzzone, L., & Benediktsson, J. A. (2014). Advances in hyperspectral image classification: Earth monitoring with statistical learning methods. IEEE signal processing magazine, 31(1), pp. 45-54. Chen, J., Chen, J., Liao, A., Cao, X., Chen, L., Chen, X., . . . Lu, M. (2015). Global land cover mapping at 30 m resolution: A POK-based operational approach. 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AbstractWith an increasing older population in Germany and the need for polypharmacy to treat multimorbid patients computer-assisted decision making on an individual level is increasingly important to reduce prescription errors and adverse drug reactions. While current systems focus on guidelines and prescribing information, molecular information is equally important for explanation and discovery of drug-related problems. Based on the existing KALIS system and newer projects like PIMBase, a new concept for the KALIS-2 system is presented. Improvements to the modularisation of components enable future extension and greater maintainability. Interoperability with available electronic health records standards and protocols allows the integration and communication with existing workflows for healthcare professionals. Finally, new visualisation modes empower the user to explore and analyze the patient situation in an individual patient subgraph. For offline use and dialogue between patient and general practitioner, the results can be printed out using a new reporting tool. The adherence to findings from previous decision support systems and reasons for their failed adoption is an important task in the development of KALIS-2.

Abstract Background Rare Diseases (RDs) are difficult to diagnose. Clinical Decision Support Systems (CDSS) could support the diagnosis for RDs. The Medical Informatics in Research and Medicine (MIRACUM) consortium developed a CDSS for RDs based on distributed clinical data from eight German university hospitals. To support the diagnosis for difficult patient cases, the CDSS uses data from the different hospitals to perform a patient similarity analysis to obtain an indication of a diagnosis. To optimize our CDSS, we conducted a qualitative study to investigate usability and functionality of our designed CDSS. Methods We performed a Thinking Aloud Test (TA-Test) with RDs experts working in Rare Diseases Centers (RDCs) at MIRACUM locations which are specialized in diagnosis and treatment of RDs. An instruction sheet with tasks was prepared that the participants should perform with the CDSS during the study. The TA-Test was recorded on audio and video, whereas the resulting transcripts were analysed with a qualitative content analysis, as a ruled-guided fixed procedure to analyse text-based data. Furthermore, a questionnaire was handed out at the end of the study including the System Usability Scale (SUS). Results A total of eight experts from eight MIRACUM locations with an established RDC were included in the study. Results indicate that more detailed information about patients, such as descriptive attributes or findings, can help the system perform better. The system was rated positively in terms of functionality, such as functions that enable the user to obtain an overview of similar patients or medical history of a patient. However, there is a lack of transparency in the results of the CDSS patient similarity analysis. The study participants often stated that the system should present the user with an overview of exact symptoms, diagnosis, and other characteristics that define two patients as similar. In the usability section, the CDSS received a score of 73.21 points, which is ranked as good usability. Conclusions This qualitative study investigated the usability and functionality of a CDSS of RDs. Despite positive feedback about functionality of system, the CDSS still requires some revisions and improvement in transparency of the patient similarity analysis.

Abstract With continued global market growth and an increasingly competitive environment, manufacturing industry is facing challenges and desires to seek continuous improvement. This effect is forcing manufacturers to squeeze every asset for maximum value and thereby calls for high-equipment effectiveness, and at the same time flexible and resilient manufacturing systems. Maintenance operations are essential to modern manufacturing systems in terms of minimizing unplanned down time, assuring product quality, reducing customer dissatisfaction, and maintaining advantages and competitiveness edge in the market. It has a long history that manufacturers struggle to find balanced maintenance strategies without significantly compromising system reliability or productivity. Intelligent maintenance systems (IMS) are designed to provide decision support tools to optimize maintenance operations. Intelligent prognostic and health management tools are imperative to identify effective, reliable, and cost-saving maintenance strategies to ensure consistent production with minimized unplanned downtime. This article aims to present a comprehensive review of the recent efforts and advances in prominent methods for maintenance in manufacturing industries over the last decades, identifying the existing research challenges, and outlining directions for future research.