Domestic violence is a continual stressor that motivates its victim to react. The way a woman deals with her husband’s violence determine the consequence of the violent relationship. In the present study, a qualitative approach was employed to investigate women’s reactions to and ways of coping with domestic violence.Semi-structured interviews were conducted in 2014 with 18 women who experienced domestic violence in an attempt to explain how women deal with domestic violence. After the interviews were transcribed word by word, they were explored in the form of meaningful units and encoded as subcategories and categories through inductive content analysis. The reliability and validity of the interviews were measured by an external supervisor.Two categories of reaction and coping were identified through content analysis: passive and non-normative measures and active measures. Passive and non-normative measures included the subcategories of harmful behaviors, retaliation, tolerance, and silence. Active measures included seeking help and advice, legal measures, leaving the spouse, positive and health promoting measures.In the present study, ways of coping with a husband’s violence among women experiencing domestic violence were divided into two categories: passive and non-normative measures and active measures. These categories confirmed the models of coping with stress in previous studies. Adopting an appropriate approach to dealing with domestic violence is affected by a woman’s capacity and beliefs, the dominant culture, intensity of the violence, available social and legal supports, and effectiveness of evaluation measures. To generalize service provision to victimized women, the type of coping and the reason for adopting the chosen approach need to be taken into account. For more than 2 decades, research in the fields of health, social problems, family, and jurisdiction has focused on domestic violence . A pivotapproach and avoidance, i.e. behavioral versus cognitive strategies.Domestic violence is a continuous stressor that motivates the victim to react . The wayapproach is adopting active behavior to reduce stress and its consequences. Behavioral strategy refers to measures that are observable and/or external. On the opposite side, avoidance and cognitive strategies refer to a lack of action or change in thinking in such a way that stressors can be avoided, such as denying the presence of violence or thinking a violent relation is the norm in order to better tolerate a violent life . The duration of the interviews varied between 20–50 minutes. All interviews were recorded and then transcribed. All transcribed texts and notes were considered by the researchers. Data was analyzed during data collection. The Graneheim and Lundman method was employed to conduct content analyses . This meEthical considerations in this study included obtaining either written or oral consent from participants, ensuring them of confidentiality, and allowing them to freely participate in the research. Furthermore, sampling was done after permission was obtained from the Research and Ethics Committee of the School of Nursing and Midwifery, Isfahan University of Medical Sciences.The current study was conducted on 18 women from Isfahan and Shiraz who experienced domestic violence. A summary of the demographic information of female victims is presented in Two main categories, non-normative and passive measures and active measures, were extracted as a result of content analyses of the interviews. Non-normative and passive measures included harmful behaviors, retaliation, tolerance, and silence, and active measures included seeking help and advice, legal measures, leaving the spouse, and positive and promoting measures; they are presented in This category included measures that had no consequences other than harming the victim of violence. Emotional reactions, inability to cope with violence, lack of support, and frequency of violence resulted in a wrong orientation in dealing with the violence. Subcategories of this category included harmful behaviors, retaliation, tolerance, and silence.While encountering a husband’s violence, measures related to threats to the individual’s health that could have been involved with early or late damages included suicide attempts or threats. Suicide attempts originated from despair and depression over continuing the violent life or attracting the husband’s attention or support. Participant #3, 40 years old, who experienced her husband’s physical and emotional violence said, “I’m frustrated. I even took a handful of drugs a while ago to kill myself, but unfortunately I failed. Only my liver was damaged.” Participant #2, 28 years old, who was experiencing her husband’s emotional violence and negligence stated, “I’ve been so severely stressed by the atmosphere at home that I’d like to commit suicide; I can even take 10 to 20 pills.” Some participants referred to beginning tobacco consumption as a response to violent measures of their husband. “Sometimes I’m so tired of my husband’s behavior that I resort to smoking cigarettes or hookah,” said Participant #2, 28 years old.Retaliatory measures were another adopted non-normative measure for dealing with a husband’s violence. Establishing a sexual relationship with a stranger to compensate for a lack of affection in the marital life was another measure that potentially exposed the individual to social, emotional, and physical damages by sexually transmitted diseases. “I’ve had affairs with 15 men so far. My husband’s apathy is the reason. Last night he cursed me a lot,” said Participant #3, 21 years old. She continued, “Others love me; that is why I have affairs with them.”Since the sexual behavior of women compared with that of men is formed with mental and emotional motivation, sexual ignorance was named by the participants as a retaliatory behavior against a husband’s violence or an unconscious reaction. Because of feelings of humiliation, oppression, and mistrust of their husbands, female victims are reluctant to have a sexual relationship or they use sexual ignorance as a means of retaliating against their husbands’ violence. Participant #7, 48 years old, reacting to her husband’s controlling behaviors, stating, “It does no good if I pay sexual attention to him; his behavior won’t change. I’m sick of him. Above all, he expects me to caress him.”One behavior for coping with a husband’s violence noted in the present study was tolerance and silence in order to maintain peace in the family and for the children. The participants declared that by practicing passive treatment, they consciously decide to prevent their children from experiencing damage from the domestic violence.Participant #6, 46 years old, commented on coping with her husband’s behavior of not recognizing women’s right to use television or electricity at their will stating, “He tells me not to turn up the light, so I turn it off or leave the room. Just for the sake of the kids and to keep peace in the family, I forget all about it and do not argue with him.”“I decided not to talk to him, because it was quite in vain. Let him say whatever he likes; I nod at him pretentiously just to prevent quarrels and tension in the house. Just for the sake of the kids, I didn’t want to continue the argument and quarrel,” said Participant #5, 45 years old. She continued, “I’m not important at all. I just want to do something to prevent my husband from making quarrels and arguments so my kids can be safe.”In the present study, active measures referred to behaviors that, although they might not be effective in reducing violence or removing the victim from the violent situation, at least the victim had a correct orientation, and, in some cases, these measures resulted in empowering female victims and changing their beliefs, knowledge, and awareness.This category refers to the individual’s attempt to seek help, awareness, and knowledge to improve their relationship or reduce the mental drain. This measure was carried out by referring to family counseling or legal centers or by talking about the domestic violence with family members and friends to gain their support. In some cases, this measure had no obvious results. One reason for this is the lack of the husband’s interaction with his wife or the thought that the domestic violence was deeply rooted.“A while ago I referred to a counseling center. They told me to begin from myself and to try to take my husband with me, too. My only problem is that I don’t know how to take him to the center.” Said participant #8, 30 years oldParticipant #7, 48 years old, responding to her husband’s paranoid behavior, and said, “I’ve even told him that he is sick and he should seek treatment. We referred to a psychologist and a psychiatrist, but no results were gained. He told me that I got him sleeping pills so he would fall asleep and I could go hang out.” In some cases, seeking help and advice led to thinking and understanding the situations or in enabling the individuals through gathering awareness and knowledge.“I went to a consultant. I don’t know; I didn’t feel I could do anything that time. He told me that I deserved more than this life. This left a great influence on me. I came to my senses and tried to change my life and value myself,” said Participant #5, 45 years old.In some cases, talking with another individual was mentioned as a major need of female victims of domestic abuse for mental drain. “I just need someone to listen to me,” reported Participant #11, 24 years old.While the first measure adopted by most women against their husband’s violence was silence and tolerance, some attempted to leave their marriage temporarily and/or divorce when they got exhausted and frustrated of improving their relationship. “I think it’s impossible. A tooth that aches should be pulled out and thrown away when you cannot restore it. You need to separate from him so you can reach spiritual peace and calmness. I also want to get separated,” said Participant #3, 47 years old.By taking their concerns to legal centers, some women tried to stop their husbands’ violence; however, most of them failed. Participant #3, experiencing her husband’s violence, said, “Once after I was hit by him, I went to the court and lodged a complaint, but it led to nothing. They took him to the police station, and then his family bailed him out. The only result was that he became more violent against me.”Some violence victims continue married life because they lack social support, family support, or financial resources, or because they believe legal measures are futile, or because of cultural issues, like viewing divorce as a shame or believing in biting the bullet.Some of the participants of the current study referred to their husbands’ violence as an opportunity to adopt positive measures. Focusing on positive behaviors, they tried to reduce the pressure of domestic violence. Positive behaviors included education, employment, and further attention to self-care behaviors, like paying attention to physical health, playing sports, paying more attention to diet, losing weight, paying more attention to appearance, and trying to reduce tobacco consumption. “My main reason for attending university was to be away from home. While I’m at university, I’m free from thoughts of how my husband acts toward me,” said Participant #11, 25 years old.Although pursuing positive behaviors was not aimed at reducing violence, according to the participants, it did result in improving their lives. After behaving positively, the victimized women felt a sense of empowerment which led to further hope for the future. Participant #11 said, “The reason that I tolerate my husband is that I think about life after him. I feel I can manage my life then.”In the present study, content analysis was carried out on measures taken by female victims of domestic violence to deal with their husbands’ violence. Content analysis led to the recognition of passive and non-normative behaviors that included the subcategories of harmful behaviors, retaliation, tolerance, and silence, which are classified as cognitive coping and/or avoidance or, according to Lazarus and Folkman, emotion-centered copings. The other category recognized was active measures, which included subcategories of seeking help and advice, legal measures, leaving the spouse, and positive and promoting measures which can be classified as approach or behavioral coping and/or problem-based coping . The catAnother subcategory of passive measures was silence and tolerance toward a husband’s violence. Silence is more common coping strategy to husband’s violence . AlthougAnother coping method was seeking help and advice. This measure has been known as an active approach in most studies . The effLeaving the relationship and taking legal measures against a husband’s violence can occur in a violent relationship. Adopting this measure depends on the intensity of the violence, access to legal support, and the rate of dependence or independence in economic, emotional, and social regards. Avoiding leaving the husband and adopting legal measures can be due to the belief that such measures are futile in the legal and social context  or becauBehaviors like pursuing studies, earning money, exercising, and focusing more on health and appearance were also classified as subcategories of positive coping and empowerment gain. Such behaviors result in remarkable changes in adopting and changing the type of coping with or even reducing violence by creating internal satisfaction, empowerment, and hope and enhancing the quality of life . Women wIn the present study, reacting to and coping with a husband’s violence fell under two categories: passive and non-normative measures and active measures. These categories support the models of coping with stress in previous studies. Passive and non-normative measures included the subcategories of harmful behaviors, retaliation, tolerance, and silence. Active measures included measures of seeking help and advice, legal measures, leaving the spouse, positive and health-promoting measures. Adopting an appropriate approach for dealing with domestic violence is affected by women’s empowerment and beliefs, the dominant culture, intensity of the violence, availability of social and legal supports, and effectiveness of evaluation measures. In order to generalize service provision to victimized women, the type of coping and the reason for adopting such approach need to be taken into account.Due to the limited number of participants who were purposefully selected and because each of the participants had her own special cultural, educational, and social characteristics, the results and findings of the present study cannot be generalized to other populations or samples.


Partner notification (PN) is an essential case-finding tool in the management of sexually transmitted infections (STIs). Yet, data on the effectiveness and factors impacting implementation of PN in the Netherlands are lacking. With the aim of further exploring and improving the PN process, the current study assessed perceived barriers and facilitators among health care professionals in the STI clinical setting. In particular, we explored the management of PN in young heterosexual patients diagnosed with Chlamydia trachomatis (Ct).We conducted semi-structured interviews among 22 health care professionals (response rate 52%) from 5 of the 8 national STI clinics in the Netherlands. We carried out qualitative content analysis using a framework approach. All participants were nurses, aged mid 20’s to late 50’s, and all but one were female.All health care professionals felt comfortable discussing PN. Other perceived facilitators for PN included: time, one-on-one consultations, interviewing skills  and a proactive helping style. Important barriers were identified as: sub-optimal guidelines, inaccurate sexual history, a lack of feedback regarding the motivational strategies that were used, and the lack of feedback regarding overall PN effectiveness. The health care professionals placed an emphasis on the care and treatment of the individual index patient rather than on discussion of PN, or on motivating and helping patients to engage in PN.Health care professionals identified several barriers that need to be overcome, and facilitators which need to be maintained. Future efforts should concentrate on introducing PN protocols, providing feedback on both the effectiveness of strategies used by health care professionals, and on the PN process as a whole, and educating health care professionals about Motivational Interviewing strategies. Moreover, the possible implementation of an Internet-based PN system should be explored. Partner notification (PN) has an essential role to play in the management of sexually transmitted infections (STIs), both for the individual (i.e. in terms of the prevention of re-infection and complications) and the community (i.e. in terms of transmission interruption) ,2. The PWhen all 4 PN steps are carried out successfully, PN is an extremely effective tool in STI prevention, as it enables a high-risk population to be targeted, tested and treated. However, barriers at the health care professional, patient and organisational levels can disrupt the process at every step . Data abIn the Netherlands, public health STI clinics are responsible for approximately 30% of STI care and the large majority of PN . The orgChlamydia trachomatis (Ct) who had visited an STI clinic for treatment. In the Netherlands, PN is not mandatory or enforceable by health care professionals. The role of the health care professional is to motivate and help Ct positive patients to identify and notify their sex partners. PN can be initiated when a STI test is performed, when a patient is informed about a positive test result by telephone, or when a patient visits the STI clinic for treatment. In cases where a patient agrees that the health care professional may notify his or her sex partner(s), the health care professional will telephone or send a text message. Other tasks performed by STI clinic health care professionals include sexual health consultations, STI testing, treatment, and education. Their professional role description  includes the protection of the community as a whole (i.e. sex partners). In the current study, we focused on Ct because it is the most common STI in patients younger than 25 years old, with an estimated prevalence of 17% in 2013 in the Netherlands  is really the patient’s own responsibility, although I do work at a Public Health Care Service, whose job it is to identity and treat as many people as possible”.“For me, the patient and his questions come first, because he is sitting in front of me, he is top of the list”.Health care professionals primarily mentioned barriers in steps 2 and 3 of PN, i.e., the process of identifying and notifying sex partners. Some participants indicated awareness of the PN-related goal of public health care, that is, the prevention of STIs in the community. However, nearly all health care professionals expressed a bigger commitment to curing the (index) patient rather than interviewing the patient about PN and helping him/her to notify (by themselves or with a staff member) sex partners of their exposure to an STI.“The community is important, but you should not scare the patients away from public health care”.Health care professionals felt that placing too much pressure on PN could drive current patients away from future testing, in which case access to a high risk population would be lost.“My task is to convince and to inform, the actual notification is the client’s responsibility”.Moreover, client referral, as opposed to provider referral, was preferred by almost all health care professionals. They viewed the notification of sex partners as the responsibility of the patient.“… it [PN] is important, because girls could become infertile. To be honest, because of this, I take a more active attitude with girls, as they may suffer more serious consequences than men”.Some of the health care professionals were more committed to protecting female partners than male partners of patients, as females have a higher disease burden.“I think this [discussing PN] is a task that belongs to us. I do not have any problems with discussing it [PN].“I try to see all my patients one-on-one without the presence of a partner… so you know they will provide you with complete information… it will be easier to ask more in-depth questions about their sex partners from the past 6 months”.All of the health care professionals felt comfortable assessing sexual history and discussing PN (i.e. PN step 1). Generally, PN was practised one-on-one, and the process was not disrupted by the presence of third parties.Interviewer: “How often do you apply Motivational Interviewing techniques during a conversation?”Health care professional: “Sometimes, because you do not need to apply it every time…when I have many doubts about someone’s willingness to comply. In such moments it will help you to determine what someone thinks of it [Partner Notification], and it will indicate how far you can go with this person”.Furthermore, all health care professionals had been trained in Motivational Interviewing, which they felt to be an advantage at moments in which a patient’s willingness to identify sex partners was low. When a patient appeared reluctant to notify their partners themselves, for instance because they were afraid to do so , health care professionals contacted his/her partner(s). However, this happened only occasionally, because patients often indicated that they preferred to notify their sex partner(s) themselves.Health care professional; “When I started working here, I felt it [PN] was the client’s responsibility. Meanwhile I think it is entirely our [health care professional and public health care] job to convince people to notify their partners”.Interviewer: “Is it only about informing partners, or is it more?”Health care professional:” Of course informing -- that was also the case when I started here. But I mean more. I mean estimating whether you should take control in the interview and use a more directive style”Interviewer: “How many people request that you notify their partners, and how many people do it themselves?Health care professional: “I try my best to achieve 50 per cent, but so far this has proven impossible. No, I think 40 per cent request me to take over a big part. I convince them in an early phase, the best way in current practice”.The scope of public health care is to protect the community as a whole (i.e. sex partners) and not merely focus on the treatment of individuals. In line with this scope, it is notable that one health care professional mentioned that her professional role was to convince people to notify their partners and to use a more proactive helping style towards patients. As a result, she was often asked by patients to notify sex partners on their behalf.“… When a patient has tested positive for Chlamydia and refuses to return for treatment. That is, those patients who consider returning for treatment a nuisance…They just want a prescription, that’s it. It really annoys me, because I will have to discuss PN over the phone and make it quick at that”.Some health care professionals mentioned that PN can be hindered when opportunities to discuss PN (PN step 1) are inadequate, especially when face-to-face contact is not possible.“It is difficult when a client in front of you does not feel any commitment towards the person they have to notify -- for example, because their partner was unfaithful and got infected with Chlamydia. This is an obstacle we face during Partner Notification”.Even though health care professionals felt comfortable discussing PN, they were sometimes confronted with a lack of commitment among patients towards sex partners when discussing a Ct diagnosis. Reasons for this lack of commitment mentioned by the health care professionals included feelings of anger, fear and embarrassment among patients towards their sex partners.“Basically, a sexual history is unreliable. People pimp up their stories to appear more flattering”. So, I always assume that they have more contacts than they reveal.“It [dealing with socially desirable answers] is sometimes even harder than trying to persuade someone who frankly says ’I won’t notify’, because with the latter I can at least start the conversation”.In addition, health care professionals took into account that sexual history may be unreliable due to patients providing socially desirable answers. Health care professionals indicated that in such cases it is challenging to find opportunities to discuss PN optimally.“Sometimes, it [PN] is impossible, because people had a one night stand or visited a disco and do not have a telephone number; in such instances, there is simply no room for PN”.An additional barrier to PN included patients not having their partners’ contact information.“When they [Chlamydia positive patients] visit us for treatment, they quite often indicate that they have already notified their partners.Some health care professionals mentioned that, at the time of treatment, index patients often claim to have already notified their partners. Health care professionals stated this is often the case when patients have high feelings of responsibility toward their sex partners .“When someone brings along a partner to a treatment consultation, both of them will be treated”.Some health care professionals said that patients occasionally visit the STI clinic with a sex partner during a treatment consultation. In current practice, both the patient and the sex partner will receive treatment .“Often young people want to notify their partners themselves, and of course we do not have any idea whether they actually do so, or if they actually manage to get in touch. This makes the process difficult. Actually, you would like to count who [sex partners] is visiting you and if they are tested”.“To be honest, I do not know, never measured this…. I have never received feedback on it [Partner notification]”.“Whether it [PN] works or not, we do not know. We do not monitor whether a sex partner has been notified or has actually been tested.“There are many factors that play a role; my contribution [in the notification of partners] is only a small one”.Health care professionals are not obliged to register the PN process in the Electronic Patient Record, and therefore no feedback on the effectiveness of PN outcomes and PN techniques used was available. The majority of the health care professionals did not know whether their PN techniques were effective, and some felt that their own contribution in PN was limited. In addition to this, health care professionals were unaware of whether patients’ sex partners were subsequently tested, treated, and educated (PN step 4).“The recall period of sex partners is stated on paper, but the way you should do this [PN] is not. Everyone applies Motivational Interviewing their own way”.“We do not strictly follow the national guidelines as stated during PN. We ask young people if they know who infected them… If they don’t know, we ask them to recall sex partners from the past 6 months”.Health care professionals also stated that current guidelines do not specify in detail which motivational strategies to use, which PN procedure to follow, or which referral strategy is preferred; the guidelines only include a recommended recall period for tracing back sex partners. However, the health care professionals also mentioned variation in the use of these recall periods, suggesting that some staff members did not adhere to the guidelines.“There is sufficient time! Sometimes you need 5 minutes and on other occasions you need half an hour”.Almost all health care professionals reported that their STI clinics provide them with sufficient time to conduct and discuss PN (PN step 1).The semi-structured interviews we carried out among health care professionals in national public health STI clinics in The Netherlands revealed several barriers at the health care professional, patient, and organisational levels. These barriers may hinder the PN process (in which PN is discussed with the patient and sex partner(s) are subsequently identified, notified, tested, treated and educated). Important barriers were identified as: no-shows at the treatment stage (which was the most important moment to discuss PN), a focus on curing patients, less of a perceived need to conduct PN in male sex partners, a perceived lack of commitment among patients towards sex partners, missing contact data of partner(s), unreliable sexual history, a lack of feedback on the effectiveness of the PN process and on the strategies used by health care professionals, and sub-optimal guidelines. In addition to these barriers, important facilitators of PN were identified as: feelings of being comfortable discussing sexual history and PN, one-on-one consultation, sufficient consultation time, a proactive helping style, being experienced in Motivational Interviewing, patient commitment towards sex partner(s), and having sex partners attend the clinic together with the patientsWhile barriers among GPs concentrated on the discussion of PN (i.e. step 1 in the PN process), barriers among STI clinic professionals were mostly related to steps 2 and 3  has previously been identified as a barrier in the PN process . Health The results of this study underline the fact that national and international guidelines about PN contain only general recommendations ,24. GuidA different approach towards partner management, called Expedited Partner Therapy (EPT), has recently gained attention in the literature . In thisSince the results of this study became clear, discussions have taken place among health care professionals about their emphasis on patient care rather than public health, and also about the absence of outcome measures to determine effectiveness. Nationally, there is an ongoing public debate about these issues, and the professional community has been informed. Currently, national PN protocols are being re-written and regional PN reporting systems have been developed, taking into account the findings presented in this study.It is important to use, improve, and maintain current facilitators of PN. On the other hand, perceived barriers to PN should be tackled . To minimize the difference between the verbal and non-verbal communication of the interviewers, a protocol was used for each of the interviews. Data showed that there were no notable differences in the themes raised by the interviewees across the face-to-face or telephone interviews. Second, to minimize the possibility of receiving only socially desirable answers, the interviewers emphasized the confidentiality of data before and during the interview. Third, barriers and facilitators as perceived by health care professionals were studied only in relation to PN in young heterosexual people infected with Ct . Therefore, it is unknown whether results can be extrapolated to other target groups  and other STIs (e.g. Syphilis or HIV). Fourth, the experience that a health worker has (i.e. number of years working in a clinic) may play a role in the PN process. Positive and/or negative experiences over time could influence the attitudes and self-efficacy of health care professionals towards PN. Although we did not have exact data relating to employment years, all participants in the present study had at least six months PN experience in an STI clinic setting. Finally, the results of this study were not presented to the participants for confirmation. Nevertheless, at the end of each interview, participants were given the opportunity to ask questions and/or give comments concerning the interview.The results of this study carried out among Dutch STI clinics provides insight into the challenges and facilitators at the health care professional, patient, and organisational levels. These applied mainly to steps 2 and 3 of PN, i.e., the identification and notification of sex partner(s). In order to overcome these barriers and maintain facilitators --and thereby optimize PN -- efforts should be made to focus more on the public health care goals of STI clinical practice, especially on the aim of protecting the community. Examples of ways in which these goals can be reached include: introducing PN protocols, providing feedback on the effectiveness of strategies used by health care professionals, and on the PN process as a whole, education in the use of Motivational Interviewing strategies, and the possible implementation of an Internet-based PN system.The Medical Ethics Committee of Maastricht University reviewed and approved this study (reference number 13-4-054).


Mirror neurons, firing when an action is performed but also when the same action is perceived, have been the source of both excitement and controversy since their discovery (Di Pellegrino et al., perception may require mirror neuron areas (Saygin, language appears to require the basal ganglia, rather than somatotopically organized motor areas: Ibáñez et al., perception, but little to support their involvement in a higher-level process of “action understanding” (see also Mikulan et al., Data on the contribution of mirror neurons—or mirror neuron brain areas, in particular premotor cortex—to a psychological process that might possibly correspond to “action understanding” are relatively sparse. Some, but not all, patient data indicate that action Therefore, Michael et al.  addresseand the ability to match an action to its goal object. Finally, the “complex” task tested action perception, the ability to match an action to its goal object, and the ability to select a context-appropriate goal object. It is apparent that the simple task requires only action perception, not action understanding, whereas the other tasks involve higher-level processes in addition to action perception. If premotor cortex is involved in higher-level processes of action understanding then the intermediate and/or complex tasks should be more impaired by TMS than the simple task.More interestingly, however, Michael et al. measured the processing of others' actions in three different ways. In all three tasks, participants saw a contextual cue, then watched a video of an action of the hand or mouth. Their task was to judge which of three subsequent probe items matched the action video they had observed. The “simple” task tested action perception: participants had only to perceive the action video and make a delayed match to sample judgment. The “intermediate” task tested both action perception not in higher-level processes such as matching an action to its goal object or selecting the relevant object for that action in a given context, but instead in a lower-level process of action perception. Michael et al. describe their results as demonstrating the role of mirror neuron areas in “action understanding”; instead, however, these data support the claim that premotor cortex may contribute to the perception of others' actions.TMS to premotor cortex impaired participants' performance, in a body-part specific way, on all three tasks, but crucially, there were no significant differences between tasks. Recall that all three tasks required action perception: since performance on all three tasks was impaired, these data suggest that mirror neuron areas are involved, It does not appear, therefore, that these data are in contradiction with what Michael et al. term a “deflationary” account of mirror neuron properties: the suggestion that mirror neuron responses during action observation are the result of sensorimotor associations. If mirror neurons are the result of bidirectional associations between sensory and motor representations of actions Heyes, , 2010, tunderstanding must therefore control for premotor contributions to action perception, as well as providing a clearer definition of what is meant by “action understanding.”In conclusion, these data do not convincingly support the claim that mirror neurons are involved in high-level “action understanding”; if anything, they contradict this claim. However, they do demonstrate that premotor cortex may, in some circumstances, contribute to action perception. Future studies testing mirror neuron contributions to action The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


I would like to highlight 3 of our patients, a 14-year-old boy and females of 4 and 41 years old  with acqTwo of our 3 patients with acquired hemophilia B, which is rarer than acquired hemophilia A, improved most likely due to corticosteroid administration in at least one case and without any intervention in the others. We have shown antibodies against factor VIII in more than 20% of patients with X-linked hemophilia A and extremely rarely in normal people in low titers [On this occasion I would rather use the term ‘hereditary’ instead of ‘congenital’ hemophilia, which was used by Bilgin et al., since inheritance is not involved in most congenital disorders, such as congenital tuberculosis, syphilis, CMV, rubella infection, etc. May I also indicate that methyl prednisolone at 1 mg/kg/day may not be effective as an immunosuppressive, but 30 mg/kg/day seems to be more effective?Conflict of Interest StatementThe authors of this paper have no conflicts of interest, including specific financial interests, relationships, and/or affiliations relevant to the subject matter or materials included.I would like to thank you for your comment and interest in my article. Firstly you are right about this subject; hemophilia is a genetic disorder. However, congenital hemophilia is a term that can be used in literature. Secondly high dose of steroid was not preferred for this patient because of his age and comorbid disease.Aynur UĞUR BİLGİN


The increased emphasis on standards-based school accountability since the passage of the no child left behind act of 2001 is focusing critical attention on the professional development of school principals and their ability to meet the challenges of improving the student outcomes. Due to this subject, the current study examined professional development needs of Shiraz high schools principals. The statistical population consisted of 343 principals of Shiraz high schools, of whom 250 subjects were selected using Krejcie and Morgan (1978) sample size determination table. To collect the data, a questionnaire developed by Salazar (2007) was administered. This questionnaire was designed for professional development in the leadership skills/competencies and consisted of 25 items in each leadership performance domain using five-point Likert-type scales. The content validity of the questionnaire was confirmed and the Cronbach’s Alpha coefficient was (a=0.78). To analyze the data, descriptive statistics and Paired-Samples t-test were used. Also, the data was analyzed through SPSS14 software. The findings showed that principals’ “Importance” ratings were always higher than their “Actual proficiency” ratings. The mean score of the difference between “Importance” and “Actual proficiency” pair on “Organizing resources” was 2.11, making it the highest “need” area. The lowest need area was “Managing the organization and operational procedures” at 0.81. Also, the results showed that there was a statistically significant difference between the means of the “Importance” and the corresponding means on the “Actual proficiency” .Based on the obtained results, the most important professional development needs of the principals included organizing resources, resolving complex problems, understanding student development and learning, developing the vision and the mission, building team commitment, understanding measurements, evaluation and assessment strategies, facilitating the change process, solving problems and making decisions. In other words, the principals had statistically significant professional development needs in all areas of the educational leadership. Also, the results suggested that today’s school principals need to grow and learn throughout their careers by ongoing professional development. As we move into the new millennium, education and schools are facing many challenges . In thisGiven the important and determining role of today’s school leaders, many have taken it for granted that the job of school principal has become more challenging and important than ever , 10. It Today’s school principals need to grow and learn throughout their careers to adapt to the changing needs of students and schools. The technical, conceptual and public skills demanded of educational leaders have increased dramatically over the last decade. With the widespread acceptance of the need for schools to improve, it is impossible to ignore the critical needs of school leaders to be more effective at their work. They must receive professional development aiming at helping them to be more effective, knowledgeable and qualified to facilitate continuous improvement .Though leadership development is a recent phenomenon , studiesIn these studies, development of those principals is recommended as one of the ways of solving those problems. This will enable them to get the skills, knowledge and attributes to run schools in a professional and effective manner to ensure good teaching and learning practices , 12-15. Allen (2003) in his study discovered that all principals, regardless of their length of service (novice/experienced) or school context (urban/non-urban), had significant professional development needs related to educational technology in all areas .Salazar (2007) in a study entitled “the professional development needs of rural high school principals” reported that most important professional development needs of principals were promoting team commitment, creating a learning organization, sustaining and motivating for continuous improvement, setting instructional direction and communicating effectively .Bichsel (2008) in his study reported that the top five professional development needs of secondary principals in the southwestern Pennsylvania region include analyzing data, communicating effectively, using research and “best practices”, building team commitment, developing information and data collection strategies .As a result, it is suggested that the professional development needs of principals should be enquired continuously in order to determine the form and content of a curriculum for leadership development. Thus, the aim of this study was to determine the professional development needs of Shiraz high schools principals. The survey method was applied. The statistical population consisted of 343 principals of Shiraz high schools, of whom 250 persons were selected using Krejcie and Morgan (1978) sample size determination table. Also, the participants were selected by simple random sampling from different high schools of Shiraz.In order to determine what professional development learning opportunities were needed, a needs assessment was conducted using a questionnaire. The Principal Professional Development Needs Assessment questionnaire was used to obtain information concerning a principal’s self-perception of his/her need (or lack of) for professional development in the leadership skills/competencies to facilitate a comprehensive school improvement. This questionnaire consists of 25 items used to identify the leadership domains which are viewed as critical for success in the principal ship. So in this research we used the Salazar questionnaire . SalazarAll descriptive statistics and inferential statistics were performed using SPSS 14. To analyze the data, we measured the principals’ "Actual Proficiently and importance on those similar 25 items related to leadership performance domains, using Mean and SD. Deviation. Also, Paired-Samples t-test was performed to investigate the difference (or gaps) between "Importance" and "Actual Proficiently” of the principals in leadership performance domains. According to descriptive indicators, 44% and 56% were female and male, respectively. Also 0.4% of the sample had a diploma degree, 21.6% associate degree, 56.8% bachelor degree and 21.2% master degree.The difference between “Importance” and “Actual proficiency” on the instrument represented the professional development needs of principals. As noted in the previous section, in every case, principals’ “Importance” ratings were always higher than their “Actual proficiency” ratings. This difference, for the purposes of the study, constituted their professional development needs in the area of leadership performance domains. To test the significance of these differences, a paired sample t-test was used. In this instance, the t-test was used to determine if there were significant differences among the means of the “Importance” and “Actual proficiency” of the instrument. The results showed that there was a statistically significant difference between the means of the “Importance” and the corresponding means on the “Actual proficiency”  .1. Principals highly value all of the expected areas of performance as indicated by their ratings on the “Importance” domains of the Educational leadership for Principals Survey. It was concluded that principals highly value each of the standards.2. Principals’ responses to “Actual proficiency “on all of the survey items were always rated lower than their responses to the corresponding “Importance” on the items. Also the results showed that there was a statistically significant difference between the means of the “Importance” and the corresponding means on the “Actual Proficiency”. This difference suggests that principals have a need for professional development on each standard. These structures highlighted the fact that professional development activities should be unique to the individual principal. Depending on whether a principal is novice or experienced, elementary or secondary, serving in a suburb or in an urban district, it is clear that the focus must be on the unique needs of individual principals. The rationale for conducting a needs assessment was the final section of the background and related literature. Part of the reason for the minimal attention on the topic of professional development for principals has been a lack of understanding of what principals should know and be able to do in this area.The results of this study revealed that the principals are concerned about the leadership needed for school improvement. They stated they needed more professional development in order to meet the new expectations of their role. A large proportion of the principals perceived that they lacked the skills to build the collaborative learning organization that is so critical to successful school improvement. Clearly, principals must be provided with quality professional development if schools are going to successfully serve every student , 8, 16.Good leadership is not innate . The maiThe findings show that the principals are in a poor condition with regard to all key areas. To explore why it is so, we can return to the literature demonstrating that the leaders aren’t appropriately trained to take on the job of school principalship and that they are ill-prepared for the existing challenges. Also, leaders have frequently stated that trainings provided by universities don’t get them ready for school leadership. In addition, many scholars are dubious about the appropriateness of conventional programs for getting the principals equipped. Pashiard and Brauckmann argued that principals, in some regions, are assigned based on inappropriate criteria, such as teaching experience rather than leadership skills, experience and irrelevant academic qualifications, and even favoritism. In many cases, teachers are also assigned principals without having adequate training. It can be, therefore, stated these factors altogether have caused principals to feel incapable in their new positions; hence, as mentioned earlier, professional development through needs assessment provides the principals with knowledge, attitude, and adequate competencies so as they will effectively and professionally lead their schools which, subsequently, help to realize education goals and purposes.


In Japan, there is a shortage of young physicians in various specialties; the present situation of general medicine or family medicine (GM/FM) in particular is risky. The factors influencing the career choice of Japanese medical students are poorly understood. This study aims to identify factors related to choosing GM/FM as a career.The study was designed as a cross-sectional survey. Students at one medical school in Japan filled out a questionnaire. Students were asked to state their intended medical specialty, and they rated the importance of specific individual and occupational aspects using a 4-point likert scale. Factor analysis was performed on the variables. Reliability of the factor scores was estimated using Cronbach‘s alpha coefficients; biserial correlations between the factors and career choices were calculated. Furthermore, multiple linear regression analysis was performed using career choice (GM/FM vs. others) as the criterion variable and the factors plus demographic characteristics as confounding variables.P=0.001), ‘Student preparing for the entrance exam’ , ‘Intent for rural practice’ , and ‘Work–life balance’ . While significant variables that were negatively associated with choosing GM/FM were ‘Presence of medical relatives’  and ‘Scientific orientation’ .Factor analysis produced six factors that explained future career plans. Medical students in this study had a positive and realistic idea about GM/FM, but only 18.8% of them chose GM/FM first as a career. The significant variables associated with choosing GM/FM first as a career were: ‘Admission from hometown’ (β=0.189, Strategies have been suggested, such as recruiting medical students with significant variables that were associated with choosing GM/FM first as a career. By engaging students early in their choice of career, we may be able to increase enthusiasm for this specialty. In Japan, there have been absolute and relative deficiencies in the number of physicians, and the number of those belongs to the lowest group in the Organisation for Economic Co-operation and Development (OECD) . There aIn the misdistribution and shortage of physicians, communities need doctors who can cater flexibly to the demands from the health care and welfare systems, as is the case for general medicine (GM) in Europe and family medicine (FM) in North America. In 2007, Japan's Ministry of Education, Culture, Sports, Science, and Technology revised the model core curriculum by adopting a clinical training program in communities . Thus, cThus, it is important to know the expectations of future physicians as they play a role in their choice of career. There are many studies on career choice of medical students in Western countries. Wright et al. , 6 demonOn the contrary, there are few studies that demonstrate the background factors associated with GM/FM as a career choice among Japanese medical students . Ohtaki N=450) from one Japanese regional university school of medicine. A 5-page entry questionnaire was handed out in class within the first 4 weeks of the start of medical school. The study was approved by the ethics committee of the Ehime University Graduate School of Medicine, and informed consent was obtained from all subjects.The study was designed as a cross-sectional survey. We conducted a survey of 1st to 5th year medical students (chiiki-waku in Japanese), student preparing for the entrance exam, presence of medical relatives, and growing up in a rural area were included. Moreover, the participants were asked whether they were willing to work in a rural area.We used a modified questionnaire enquiring about their specialty preference and to what extent their decision was influenced by a set of given criteria that were developed by Takeda et al. . SociodeParticipants were asked to specify which of the following 14 medical specialties they intended to pursue: GM/FM, internal medicine subspecialty, surgery, pediatrics, obstetrics/gynecology, psychiatry, anesthesiology, emergency medicine, dermatology, orthopedics, ophthalmology, otolaryngology, urology and radiology, or ‘other’. They were instructed to choose the specialty most preferable to them and also other specialties ‘under consideration’ with no restriction in the number. When ‘other’ was chosen for a non-listed specialty, respondents were asked to specify which discipline they were choosing. They then indicated the degree to which 30 items influenced their choice . The subχ2-test for categorical variables. Finally, stepwise multiple linear regression analysis was performed in order to derive confounding factors associated with level of interest in choosing GM/FM as a career. A p-value<0.05 was considered significant.Statistical analysis was performed using IBM SPSS Statistics Version 21 . Data are presented as the mean±standard deviation (SD) unless otherwise specified, and in the cases of parameters with non-normal distributions, the data were log-transformed for analysis. The factor analysis was conducted in IBM SPSS using a maximum likelihood method and promax rotation. For each item, we calculated the mean±SD, and items showing ceiling effect (≥3.2) or floor effect (<1.2) were excluded from the analysis. In order to decide the number of factors, a scree plot, which shows the eigenvalues on the y-axis and the number of factors on the x-axis, was generated, and a cutoff of eigenvalue was set to be greater than 1. Item retention was based on coefficient values (factor loadings ≥ 0.35) or showing a similar factor loading in more than two factors were excluded, and then the factor analysis was repeated. We calculated the Cronbach's alpha coefficient for each factor to determine its scale reliability and calculated a mean score and SD. Differences in the subscales by level of interest in choosing GM/FM as a career were examined using ANOVA for continuing variables and Of 417 students, 368 completed the survey giving an 88.2% response rate. In The results of the factor analysis including the factor loadings of the items and the internal consistency of the factors  are shown in In The purpose of this study was to determine factors that are associated with level of interest in choosing GM/FM as a career among Japanese medical students. Some factors found to be important for making this choice in previous studies were also found important in this study. Students highly influenced by the factors of ‘Academic year’, ‘Admission from hometown’, ‘Public high school graduation’, ‘Student preparing for the entrance exam’, ‘Admission by a special policy’, ‘Intent for rural practice’, and ‘Work–life balance’ were more likely to choose GM/FM as a career. Both ‘Presence of medical relatives’ and ‘Scientific orientation’ did not influence the choice of GM/FM as a career. These findings suggest that students’ characteristics may be strongly associated with choosing GM/FM as a career, and more research is needed to examine the effectiveness of specific educational interventions in promoting GM/FM as a career choice.In our study, some positive and negative factors that were significantly and independently associated with the choice of GM/FM as a career were similar to those in the Western reports. Medical students in a higher academic year of training are more likely to choose the GM/FM career. In Japan, all medical schools including ours provide education on community-based medicine during the 3rd to 4th academic year. Senf et al.  demonstrIn the present study, ‘Public school graduation’ and ‘Admission from hometown’ were significantly associated with the choice of GM/FM as a career. In Japan, ‘Private high school graduation’, ‘Combined junior high and high school graduation’ and ‘Presence of medical relatives’ are related to a higher socioeconomic status. There are some studies showing that the higher socioeconomic status of parents relates negatively to the choice of FM , 23. Med‘Intent for rural practice’ is important for choice of FM/GM as a career. Medical students understand that career choice of FM/GM is necessary for rural practice which is expected to cover a broad range of conditions. Rabinowitz et al.  demonstrIn our study, the factor of ‘Work–life balance’, which consists not only of ‘Working hours’ and ‘Attainable lifestyle’ but also ‘Risk of my malpractice law suits’ was also significantly and independently associated with choosing GM/FM first as a career. Newton et al. demonstrated that lifestyle as well as income has become more important to medical students in their career choice . StudentScientific orientation is a background characteristic that was negatively associated with choice of GM/FM as a career. ‘Interest in the surgical procedures or technologies’, ‘Mastering the specialty’, and ‘Interest in an organ specialty’ which identify with ‘Scientific orientation’ are strongly related to organ-specific specialty and not important for students selecting GM/FM. Medical students with less interest in research or scientific aspects do not plan a research career. This tendency is consistent with that of previous studies in Western countries, and for that reason, it is possible that, compared with other specialties of physicians, many family physicians do not serve as good research role models . Then, sSome limitations of this study must be considered. First, our cross-sectional study design does not eliminate potential causal relationships between characteristics of medical students and career choice. Second, this study was on a limited number of students who belong to one local university. Therefore, the students were more likely to choose GM/FM than students from other universities. Third, our study measured students’ interest in the GM/FM career, but not their actual choice of practice because students’ intent was measured prior to their residency. Fourth, as we used a self-administered questionnaire developed for 1st to 5th year medical students, some of the characteristics examined appeared to be suitable for upper grade students  but not for lower grade students. Future research using longitudinal data collection will enable us to monitor the relationship between early stated interest and actual behavior.The present study showed that medical students have a positive and realistic picture of what general practice is all about; however, only 18.8% of students in the study ranked GM/FM as their first choice career. They highlighted that the important factors considered when choosing a future career were: ‘Intent for rural practice’ and ‘Fulfilling lifestyle’, while ‘Presence of medical relatives’ and ‘Scientific orientation’ did not seem to be of much importance. Strategies have been suggested, such as redesigning the curriculum to give students more exposure to the diversity of general practice. By engaging students early in their career, we may be able to increase their enthusiasm for this specialty.


Georgia has limited tobacco control policies, particularly in the area of smoke-free public policies, which may influence the adoption of smoke-free home rules. We qualitatively examined knowledge about and reactions to public and personal smoke-free policies among Tbilisi residents. In Spring 2014, we conducted six focus groups among 47 total participants—two among male smokers, one among male nonsmokers, two among female smokers, and one among female nonsmokers. Our sample was 48.9% male and 70.2% past 30-day smokers. Most believed that SHS was dangerous, with particular concern regarding the impact of SHS on children and pregnant women. Many had misconceptions about how to protect others from SHS and the effectiveness of some approaches. Many indicated that they had some type of home rules, but few reported a complete ban on smoking in the home. Even when some restrictions were in place, they rarely were effective or enforced. Common concerns about the partial smoke-free public policy in Georgia included its economic impact, perceived discrimination among smokers, and the policy being against the Georgian culture. These concerns were heightened when participants were asked about the possible implementation of a complete smoke-free policy. Educational programs are needed to promote smoke-free policies in Georgia. Cigarette smoking is a major global public health issue, with roughly 31.1% of men and 6.2% of women being daily smokers globally [One high-risk region for tobacco use is the area of the former Soviet Union . A studyMoreover, secondhand smoke exposure (SHS) is a major global public health problem. A recent study  found thGlobal health disparities related to tobacco use and SHS exposure are largely due to differences in tobacco control policy implementation, particularly in LMICs . The WorDespite the ratification of the FCTC in December 2005, Georgia lags in terms of its adoption of all tobacco control policies mandated by the FCTC, including smoke-free public policies. Currently, there is no comprehensive policy in place and exceptions are made in almost every setting with the exclusions of healthcare facilities and universities. Even in settings where smoking is restricted or banned, the level of enforcement of these rules has not been documented. In efforts to progress in their level of smoke-free policies, in 2008, Georgia implemented a partial smoke-free policy applied to restaurants and bars.Outside the context of smoke-free policies in public places, the home is a significant source of SHS exposure . Smoke-fGiven the aforementioned literature, we conducted a qualitative focus group study using Grounded Theory  to examiThis study was approved by the Institutional Review Boards of Emory University and the National Centers for Disease Control and Public Health in Georgia. In Spring 2014, we conducted six focus groups among a total of 47 participants—two among male smokers, one among male nonsmokers, two among female smokers, and one among female nonsmokers in Tbilisi.Focus groups are well-suited to explore individual subjective experiences and attitudes, particularly related to concepts or phenomenon that have not been well explored previously ,21,22,23Participants were recruited through fliers and posters posted throughout Tbilisi, the capitol city of Georgia. Interested individuals called the research staff and were confirmed for eligibility. Eligibility criteria included: (1) between the ages of 18 and 65 years old; and (2) spoke Georgian. If individuals were deemed eligible, they were asked if they currently smoke tobacco on a daily basis, less than daily, or not at all. Those that reported daily smoking or less than daily smoking were categorized as current smokers . ParticiFocus groups were conducted in conference rooms at the National Centers for Disease Control and Public Health in Tbilisi. Prior to the focus group discussion, participants completed the informed statement of consent and a brief survey. Each participant was compensated with a top-up mobile balance worth 10 Georgian Lari for participation. The focus groups were designed based on methods proposed by Morgan and Krueger . Two modSemi-structured Interview Guide. The semi-structured focus group interview guide was developed by the research team and was pilot tested through mock interviews among research staff members. It explored perceptions of SHS, experiences with and reactions to public smoke-free policies, and personal practices regarding smoking in homes and cars. Example questions regarding SHS included: “How harmful do you think SHS is? Do you believe that SHS can cause health problems for nonsmokers? For children? What kind of health problems?” Questions regarding restrictions in personal settings included: “What rules do you have in your home and car about smoking cigarettes? How have public restrictions impacted the rules in your home and car? How did you decide to implement restrictions in your home or car? How strictly do you adhere to these rules? How do others respond to your rules?” Questions regarding experiences with public smoke-free policies included: “What do you know about the policy in Georgia regarding smoke-free areas in restaurants and bars that went to effect in 2008? What do you think of the policy that went into effect? What reasons might you have for opposing the policy? What reasons might you have for supporting the policy? How effective do you think no-smoking areas in protecting people from the harms of SHS? To what extent do you think this policy has actually been enforced?” Quantitative Assessment. A short questionnaire was used to assess sociodemographics and tobacco use behaviors. Participants were asked to report their age, gender, number of years of education, their monthly income in Lari, their employment status , their relationship status , and the number of people in the home [the home .In terms of tobacco use characteristics, participants were asked if they used tobacco in their lifetime and if they currently smoke tobacco on a daily basis, less than daily, or not at all. Those that reported daily smoking or less than daily smoking were categorized as current smokers . Currenti.e., major topics explored) and secondary codes  were then clearly defined in a codebook that was used to independently code each transcript. Coders resolved any discrepancies through discussions. Intra-class correlations for context were 0.92. Themes were then identified and agreed upon between the PI and the coders, and representative quotes were selected and identified by group .Focus group interviews were transcribed verbatim by a professional transcription service, and text files were imported into qualitative analysis software. NVivo 10.0  was used for text coding and to facilitate the organization, retrieval, and systematic comparison of data. The research team was guided by the COREQ checklist when conducting and analyzing interview data . TranscrDescriptive statistics from the short questionnaire were computed using means and standard deviations for continuous variables and frequency and percentage for categorical variables. Bivariate analyses were computed using t-tests for continuous variables and Chi-squared tests for categorical variables. Quantitative data were analyzed using SPSS 19.0 .p = 0.032), there were no differences in sociodemographics between the smoker and nonsmoker participants.Most participants believed that SHS was dangerous. There was particular concern regarding the impact of SHS on children and pregnant women. For example, one female smoker (FG1) said, “I have heard and read that it’s far more dangerous for children than for smokers themselves”. Along the same lines, one male smoker said, “One should not smoke at home, in the presence of a pregnant woman and of a child”.Interestingly, a couple of participants felt that protecting children from SHS was impractical. For instance, one female smoker (FG1) said, “Honestly, I believe that it’s ok to smoke in front of children, as they have to get used to it, as smoking is an everyday activity”.There were misconceptions about how to protect others from SHS and the effectiveness of some approaches to do so. For example, one female smoker (FG2) said, “I ask a non-smoker if the smoke bothers him/her. If he/she tells me that it bothers, for example if we are in the car, I will either roll down the window or act in a way that smoke does not get in his/her face”. These misconceptions were reflected in discussions regarding smoke-free policies or rules regarding smoking in private residences and personal vehicles.Lack of Home Policies or Exceptions to Policies. In terms of voluntary policies in homes, many indicated that they had some type of rules, but few reported a complete ban on smoking in the home. Among those that said that “smoking wasn’t allowed in their home”, they frequently commented on places where smoking was allowed in the home, with common places including kitchens or bathrooms. One female smoker (FG2) said, “It is forbidden to smoke in my home, so I go to the toilet and smoke”.Another female smoker (FG1) indicated, “At my place, no one is allowed to smoke. I’m a smoker and so is my husband, but for smoking, you either go to the balcony or use the kitchen”.While many participants reported that they restricted smoking particularly when children were present, they commonly reported that they made exceptions when they had guests in their home. One female smoker (FG2) said, “People don’t smoke at my place, but whenever a guest is visiting, I don’t prohibit smoking. We respect the guests, and I do not prohibit them to smoke. I know that it is bad, but I can’t prohibit it”.In addition, even when some sort of restrictions were in place for guests, they rarely were effective. Reflecting an ineffective attempt to reduce SHS exposure, one female smoker (FG2) said, “When a guest is visiting I make him/her sit at the window; he/she will be disturbed but he/she won’t smoke for the second time”.Highlighting the difficulties of enforcing restrictions when guests visit, one female nonsmoker (FG5) said, “Some people ask if they should go out on a balcony, and at the same time they are already hold a lit up cigarette. At that point, you can’t chase them outside”.Impact of Others’ Rules Regarding Smoking in the Home. In terms of reactions to others’ rules about smoking in their home, several participants who were smokers indicated that they avoided going to those places. For example, one female smoker (FG2) said, “Yes, it bothers me . I never go to those places where I cannot smoke. There are some families where no one smokes, and I don’t like to go to their homes. In my family, we smoke, and our guests can smoke as well, but not in the room where our child sleeps”.Another female smoker (FG2) said, “I regularly find myself in those kind of situations (where I cannot smoke), for example at my friend’s place, or at my relative’s place, or at my mother in law’s place. And since I can’t smoke in those places, I don’t go there that often. I always argue regarding this with the taxi drivers, if he/she tells me that he/she does not smoke and asks me not to smoke as well”. This participant and several other smokers indicated that they resisted requests not to smoke in both personal and public settings.Participants also indicated that going to homes where smoking commonly takes place increased the likelihood that they would smoke as well. For example, one female smoker (FG2) said, “I have a friend. Both mother and daughter smoke. And at their place there is an atmosphere in which I somehow have to smoke. There is no other way there. I don’t feel comfortable there otherwise”.Concerns about and Opposition to Public Smoke-free Policies. Themes that emerged regarding concerns about partial smoke-free public policy reported by participants included the economic impact of the policy, the discriminatory nature against smokers of such policies, and the policy being against the culture of Georgians. These concerns were heightened when participants were asked about the possible implementation of a complete smoke-free policy.Reflecting one concern highlighted by several participants regarding the impact of smoke-free policies on the economy, one female smoker (FG1) stated, “A 100% ban will damage restaurant owners in terms of economy and the government, too, as owners bring money. If you don’t want to lose clients it should be 50%–50% among smoking and nonsmoking areas. This percentage shows how probable it is to ban smoking in Georgia”.versus benefits of smoke-free policies, one female smoker (FG1) said, “If smoking is banned, it’ll damage the economy but the health condition will improve”.Weighing the costs Many participants also indicated that having expansive smoke-free policies in Georgia is impossible due to the culture and smoking prevalence of the country. One female smoker (FG1) said, “The country’s psychology should be considered. The rate of smoker women in Georgia is one of the highest, at the same time Georgia is one of the most conservative countries”.One female smoker (FG1) said, “I like a lot the idea of dividing cafes and bars into smoking and nonsmoking areas, but in Georgia, I’m afraid, it’s impossible in Georgia”.Reflecting the same concern, one female smoker (FG1) said, “I think it’s unrealistic to think about smoking areas outside in Georgia due to the mentality that is here. Nobody will go out to smoke during winter, put on coats and then take them off again and return to a bar or a restaurant”.Another theme that emerged was feeling as though smoke-free policies discriminated against smokers, with a few participants indicating such a concern. One female smoker (FG1) stated, “Well, we can go out and defend our rights like LGBT. In a way, it’s discriminatory, and I don’t like it”.Support for Public Smoke-free Policies. Despite these concerns, many participants—both nonsmokers and smokers—were in favor of the partial smoke-free policy. They highlighted the importance of protecting people from SHS, the pleasure of being in public without being exposed, the impact such policies will have on population health, and the impact it could have on social norms regarding smoking. One female nonsmoker (FG5) said, “There are some places where there are designated areas for nonsmokers, and this is very pleasant. One gets the feeling that, besides smokers, the owners also start caring about nonsmokers…. At the same time this will be a good impetus for smokers to smoke less and maybe stop smoking all at once”.Another female smoker (FG2) said, “Certain organizations have limitations, and I like it, since this helps to develop a certain culture and teaches one to abide the laws. There are separate places in the cafes as well, where smokers and non-smokers sit separately”.One female nonsmoker (FG5) said, “(A public smoke-free policy) will work for sure. Many people will feel lazy to go out, and they won’t smoke”.There were several smokers who indicated that they liked the impact it made on their smoking. One female smoker (FG2) said, “If one cannot smoke, I won’t smoke either. I ask where it is possible to smoke. If it is impossible to smoke, I will go outside or not smoke at all”.Ineffective Enforcement and Measures to Reduce SHS Exposure. A major theme that emerged was that measures being used in the context of the partial ban were not effective in protecting nonsmokers from SHS. One male smoker (FG4) said, “I remember a new restaurant opened, and when I went there. I was asked if I preferred smokers’ or nonsmokers’ part. When I looked, it was one same hall divided into two parts. I once sat with nonsmokers, but the smell came to our area, too”.A different male smoker (FG3) reported, “When I was in the mall, there was a place for nonsmokers as well as the place for smokers. I was sitting there, a smoker, and beside me there was a non-smoker, so this is not following the rules. We should be separated properly. When I enter a place, I should have a feeling of controlling myself regarding where I smoke”.Another major theme that emerged was lack of enforcement. Most participants reported having violated smoke-free policies at work, in public transportation, or other public settings, or witnessing the rules being broken. For example, one male nonsmoker (FG6) said, “There are restaurants who have separate places for smokers and nonsmokers; only in some places is this law respected”.Participants were forthcoming in telling about situations in which they would violate smoke-free policies. For example, one female nonsmoker (FG2) said, “When I was working, there was a bar under the office where I would go to, and we girls would drink coffee there and smoke. But when we would not go there, we still managed to smoke at work, and we were taking a risk because smoking could have been the reason for us to lose our jobs”.Further compounding the issue of enforcement, many participants indicated that they would not say anything in situations where they were being exposed to SHS, even in the context of a nonsmoking area or vehicle . One female smoker (FG2) said, “Whenever I sit in a café, in a non-smoking area, and I feel that someone has smoked near me, I won’t take offense personally. And I won’t offend anyone because I think that this kind of person is ill, who needs a cigarette and can’t do without it”.A female nonsmoker (FG5) said, “When you are in a taxi you can tolerate for 5–10 min, but when you travel on a long distance and the Marshutka (minibus) driver smokes, as well as people sitting next to him and the smoke gets into the back cabin, and plus it is winter and everything is closed, then this becomes very hard. And I become very angry. But nobody pays attention and everyone is silent. But in reality many have the feeling of protest”.Overall, current findings indicate that cigarette smoking and SHS exposure are critical public health problems in Georgia. One major finding was a lack of empowerment to protect oneself from SHS. A recent national survey on Georgian adults  indicateMoreover, prior research has found that four-tenths of Georgian adults are exposed to SHS in their home daily, and in fact, only 14.3% indicated that smoking was never allowed in their home . It is lThis prior study  also docSome of the common concerns about the partial smoke-free policy included concerns about the economic impact of the policy, the perceived discriminatory nature of the policy, and the difficulties in consolidating such a policy with the culture of Georgia, which includes a high smoking prevalence. In relation to the former, evidence suggests that smoke-free policies do not have an adverse economic impact on businesses and may have a positive impact in some contexts . HoweverOne of the major overarching findings in the current study involved measures being taken to reduce harm, both in private and in public settings, that are ineffective. In relation to the home, participants frequently reported limiting smoking to certain rooms or using windows or fans to circulate smoky air in order to reduce the impact of SHS exposure. While the public health goal is complete smoke-free home policies, partial bans have been found to decrease SHS exposure ,34. As sMoreover, the lack of enforcement of policies that do exist also suggests high levels of SHS exposure in spite of any policies that are implemented. Given the limited smoke-free policies in place in Georgia and the difficulties enforcing those in place, there are two major concerns. First, the level of SHS exposure and related morbidity and mortality is an obvious concern. Second, the challenges facing the culture of Georgia in terms of shifting social norms regarding smoking are surmounted by these policies being unenforced.Current findings have important implications for research and practice. First, research must change the way in which they assess smoke-free home policies. It is clear that asking individuals if they allow smoking in the home is limited, as people may indicate that they do but have multiple exceptions, particularly in contexts like Georgia where cultural norms are conducive to smoking. In addition, future research should examine the processes that impede the voluntary adoption of such policies in personal settings and adoption of comprehensive public smoke-free policies in Georgia. For public health practitioners, our findings suggest that Georgians are largely in support of public smoke-free policies and the inefficiency of measures taken in the context of partial smoke-free policies. Thus, this empirical evidence should be leveraged toward garnering political will to implement such policies, particularly within the context of the significant public health costs of SHS-related morbidity and mortality in Georgia. Moreover, practitioners must educate the general public about the limitations of certain harm reduction measures in protecting nonsmokers and children from the harms of SHS. Collectively, these findings provide a foundation to inform the activities of public health practitioners to further the agenda of public smoke-free policy adoption.vs. 14.6% in Georgia in 2013 when recruitment began [This study has some limitations. First, while participants were recruited for focus groups to represent each gender and both smokers and nonsmokers, findings from this small sample may not generalize to other Georgian adults. In particular, it is important to note that our sample was younger than the general Georgian adult population and had a higher rate of unemployment (nt began ). Also, In Georgia, efforts must promote smoke-free policies, particularly among male smokers, in order to reduce SHS exposure, smoking rates, and ultimately the related morbidities and mortality. Georgians are experiencing high levels of exposure to SHS both in public and private settings. While they are in support of adopting more rigorous public smoke-free policies, legislation has yet to adopt such policy. Moreover, the limited voluntary implementation of smoke-free policies in homes and cars warrants intervention efforts.


There has been mounting concern among social scientists that conclusions from studies conducted on highly educated populations from affluent European cultures may have limited applicability to human behavior in general . When reading researchers today seek enlightenment on the subject of writing systems they refer to Gelb—the founding father of the field of “grammatology”  was embraced by almost all reading researchers, despite its repudiation by subsequent scholarship in the field of writing systems research … Rayner et al.  to describe and label the functional architecture  of reading  for both consonants and vowels under the motto “consonants as in English, vowels as in Italian.” Gleason, .But are alphabets optimal? Well, we really don't know. There is, however, evidence suggesting that it cannot be assumed that alphabets are inherently superior and therefore the default choice of script. There are at least four lines of counterevidence converging on the conclusion that syllable-based writing systems are, in many cases, superior to alphabets.Psychoacoustically, syllables are more “real” than phonemes  more easily than phonemically/alphabetically  as well as morpheme constancy (<soft/soften>) are crucial for rapid silent reading  from slow, deliberate, step-by-step, unskilled performance to rapid, automatic, one-step  skilled processing. And because this broader dualism applies to The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.