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These obstacles are investigated below. Even though health insurance would cover the direct costs of treatment and admissions, highland caregivers e. Distance and time was also a constraint for highland caregivers from poor families without means of transportation, who would have to spend half or a full day if walking to the CHS.
Caregivers acknowledged that this was too time consuming if a child was seriously sick. In focus group discussion and interviews, caregivers all said that they would borrow or spend their money to pay for transport to get to the CHS in time, despite having very low incomes.
The cost of petrol or renting a motorbike driver for a round-trip from a highland village and the CHS wasVietnamese Dong, equalling several days of work for a highland farmer. Gender roles as a constraint for accessing health services Observations in households conducted during fieldwork in and interviews with caregivers confirmed that all four groups of ethnic minorities live according to patriarchal gender roles, with the oldest men taking all major decisions and the youngest women being the main domestic labour force.
In the highland, six out of 19 caregivers of children during sickness were grandmothers, and mothers and grandmothers indicated that elders were the primary persons in the household in charge of deciding, preparing and administering the treatment for a sick child. A group of highland men explained: Highland women also had very few opportunities of accessing information in the community on health care options and preventive measures compared with women in the lowland.
TVs and radios were only accessible in few households and not broadcasted in local languages, making it difficult for most women to understand the provided information since they had short or no education and therefore did not speak much Kinh. Village meetings were mostly attended by male heads of households and women's groups were not established in the highland communities.
Furthermore, VHWs were not consulted much elaborated later.
In comparison, many lowland family units were smaller and less influenced by the older generations. They all stressed that they took decisions on their own about staying home from work to tend the child, going to the CHSs or buying drugs in town.
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Most lowland women also attended Women's Union meetings in their communities regularly, watched TV on daily basis, and could understand the radio and loudspeaker announcements broadcasted in Kinh language. Reluctance towards government health services Despite the fact that all caregivers, from highland as well as lowland communities, highly appreciated access to Government health services and drugs free of charge, many caregivers sought these services with some apprehension.
None of the interviewed caregivers sought the advice or were visited regularly by the VHWs working in their villages. Caregivers said they normally only had contact with the VHWs when attending child vaccinations or child nutrition surveillance on a monthly or bi-monthly basis, which were also perceived to be the main tasks of a VHW; "He just weighs the small children once per month.
Health Station staff, on the other hand, were perceived to be qualified to diagnose diseases and prescribe drugs. Their illiteracy and 'backward' lifestyles were often commented on negatively by different types of health staff. Thirteen caregivers told stories of being scolded, ignored, or blamed for seeking treatment too late or too often. A caregiver from the highland explained; "Most of the people here are scolded by the doctors.
Doctors often blame people for not taking good care of their children [ It is really hard to live in a place like this" Dao woman. A young lowland mother added: Language barriers were also mentioned by caregivers during observations and in all interviews with highland women.
They felt they could not communicate accurately in Kinh language with staff at the CHS. Health staff also expressed frustration about not being able to communicate with patients. They therefore used very simple language or, in rare cases, used other waiting patients as translators or asked patients to have someone in their own community read and explain the prescriptions to them from a prescription book.
To avoid being misunderstood or perceived as backwards, caregivers uniformly said that they never shared ideas about causes of diseases, asked clarifying questions about the prescribed drugs or told any health staff including VHWs, about the home-made treatments they had used before coming to the CHS.
This was verified during observations at the CHS. Here, no caregivers were observed to share any information on the child disease or ask about prescriptions, diagnose, or the guidelines given by health staff. Staffs were observed to only ask few direct questions on disease symptoms and personal details.
Explanatory model for treatment seeking: A highland mother added: Because sometimes doing 'mo' will make him recover, sometimes going to ask for drugs at the health clinic will" highland mother.
A lowland mother added: Referral to a hospital was also generally agreed as a necessary action if treatment with western drugs did not stop the diarrhoea. This was also acknowledged among older caregivers from highland communities with longer distances to the CHS; "When he kept being very sick, we couldn't let him stay at home.
We went down to the health clinic to ask for drugs He was sick at home for two-three days and it was getting too serious The longer we stay at home, the more serious it gets" Dao Grandparents.
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Nevertheless, a total of six children four from the highland had been sick with diarrhoea for several weeks and were seriously weakened before being taken to the CHS and admitted up to 12 days at the inter-communal clinic or the district hospitals receiving frequent intravenous sodium glucose solution and drugs. Compatibility turned out to be a central and complex concept, functioning at various levels and having implications on all aspects of diarrhoea management, including the perceived cause, the chosen treatment and evaluations of its outcome.
Compatibility and causal factors Reflections about the possible causes of a diarrhoeal episode were important for the choice of treatment.
In all four groups of EMGs, a local cosmology of keeping the body of mother and child well-balanced and un-exposed to certain 'un-suitable' elements in the environments or 'in-compatible foods and drugs', dominated the explanations of diarrhoea. As described in case 2, the suitable treatment for exposure to these factors was to re-balance the body by restricting the behaviour not going out in the sun etc.
All breastfeeding mothers also said they had continued breastfeeding during diarrhoea unless they were forced to go to work. Compatibility and treatment testing The process of testing and establishing the 'compatibility' of a treatment was crucial for disease management. In general, caregivers perceived a treatment to be compatible, if they saw the diarrhoea lessening or stopping within a short time.
This was perceived a compatible treatment for children affected by angry ghosts, a spell or a discontent ancestor, since such factors had to be eliminated first in order to make the child susceptible to biomedical treatment: Compatibility and choice of medication All types of medication were also evaluated according to whether it was perceived compatible with the specific person or the specific disease.
A lowland father explained the choice of herbal medicines: A lowland mother similarly explained the effect of western medicines: A group of highland fathers explained how they also had to consider the compatibility of a disease with a drug: As already mentioned, shifts from herbal medicines to western drugs were related to perceptions of severity of disease.
Antibiotics were perceived as particularly powerful. Six caregivers described them as 'too hard', 'too strong', and 'too sweet' for a sick child. In order to limit the intake and harm from western drugs, many caregivers said they gave smaller daily doses of the drugs than prescribed. Or they decided to give only some of the drugs and shifted from one drug to another if recovery did not take place quickly.
These perceptions also had implications for the use of ORS. Others perceived it as any other drug, did not understand the principle of rehydration and did not believe that the child could tolerate the large quantities of powder mixed with water or the unpleasant taste of it. A highland mother explained: I had to mix with a little bit of water for him to drink it.
Then it was sweet and the child liked to drink. Some caregivers also expressed suspicion and doubts about the quality and effectiveness of the free western drugs handed out at the CHS:: Therefore, despite having very low incomes or living in remote areas, some caregivers occasionally bought drugs at private pharmacies in town instead expecting higher quality drugs: Hence, the expectations to the effectiveness of western medicines and the easy access to drugs provided by commercial providers seemed to sometimes override concerns of cost, distance and harmfulness of drugs.
Summing up Findings suggest that logistical and social barriers exist for accessing the CHSs. In addition, two guiding principles constitute a local explanatory model for managing childhood diarrhoea among ethnic minority caregivers in this area. Simultaneous resort to multiple treatments or "praying in all four directions" is the leading strategy, relying on the two core concepts of 'severity' and 'compatibility'.
Reflections of compatibility were drawing on local cosmologies of balancing the body, as well as testing and determining effectiveness of various therapies and drugs. Discussion This study describes how logistic constraints, gender roles, local treatment seeking strategies and reluctance towards government health workers together constitute a suboptimal use of free government health services among ethnic minority caregivers in two rural communes in northern rural Vietnam.
These constraints are discussed in the following to suggest ways of improving the quality and use of government health services. Economic and logistical constraints when choosing health provider Low usage of government health providers among EMGs compared to Kinh have previously been ascribed to failures in insurance coverage [ 19 ] and logistical constraints to access health services from the highlands [ 1928 ]. But as pointed out by London [ 8 ], health service fee exemptions only cover one component of health service costs, while indirect costs may present bigger challenges for the poor.
This was also expressed by highland caregivers in this study, who worried a lot about the substantial related costs of admittance, which potentially delayed seeking treatment for seriously sick children. Interestingly, despite having insurance with access to free treatment for their children at government CHSs, higher costs and longer distances, this and one other study [ 19 ] have identified a willingness among ethnic minority caregivers to buy drugs from private drug stores.
The common practice among the rural population of Vietnam of seeking private health services and buying over-the counter drugs for self-medication [ 57 ] apparently extend to poor EMGs. The study also showed that VHWs, who are the closest health providers, were not considered qualified by caregivers, who instead bypassed VHWs and travelled long distances to access private or public health facilities.
Problems of distance to health services might therefore be lessened by upgrading services at community level, either by increasing skills and competences of VHWs in remote communities to perform effective health promotion and basic treatment, or by increasing the frequency of outreach visits by CHS staff to remote communities. Balancing between a local explanatory model of disease management and government health services The study also identified a local explanatory model of disease management among ethnic minority caregivers, clearly differing from a bio-medical treatment system.
Simultaneous resort, local medical cosmologies of obtaining bodily balances, concepts of compatibility of treatment and humoral qualities of medicines e. However, our study also found that health staff ascribed such health seeking patterns as 'ethnic' and 'backwards', and that government health services are not always the first and most well-liked choice of health service for ethnic minority caregivers. Health is a key objective of state policies and governance in Vietnam and health sciences in modern Vietnam have become symbolically associated with socialist modernity, rationality, and progress [ 832 ].
Further, ethnic minorities have commonly been described as 'marginal' and 'developmental backwards' and therefore targeted by the socialist state to 'assimilate' to mainstream developmental standards [ 3334 ] - while also being encouraged by the state to preserve cultural traditions not posing any threats to progress of the socialist state [ 3335 ].
Hence our study provide further evidence that ethnic minorities seem to balance between practicing, to them, meaningful health rituals, while also interacting with a modern government health system. This might explain why ethnic minority caregivers do not reveal local explanatory models of disease to health staff and opt for drugs from the private sector, where they are not met with demands to change health behaviours.
At the main pier. Yorktown Road, after the ship by that name and where Lord Cornwallis surrendered British forces in The former US Naval Annex remains a desolate out-of-bounds peninsula. Unfortunately, it has been off limits to all visitors and locals since May 30, Part of the legacy is the pollution caused during its previous use. The cost of cleaning up the site so that it can once more be safely used by the public is a matter of debate.
It is the last remaining large development opportunity for an integrated resort and commercial complex in Bermuda. It has spectacular views across the Great Sound with 5, meters of waterfront. The mainland area is acres, with 60 acres on the peninsular joined by a causeway.
The peninsular projects into the Great Sound and is all flat land. Remnants of old buildings and equipment at former US Navy Base Andy Burrows, chief investment officer of the Bermuda Tourism Authority and Nancy Duperreault, wife of board chairman Brian Duperreault, have replaced them as directors.
David Burt, the Premier and Minister of Finance, said: The resort and residential project owner looks forward to the successful completion of this unique Bermudian destination resort and residential project at Caroline Bay. As a Government, we will keep their livelihoods at the forefront of our discussions and we will do all that we can to minimize the impact of this necessary action on them and by extension their families.
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Most construction will now focus primarily on completion of the first residential building. Construction will include that building plus the utility infrastructure for it, the road access from Middle Road down to the residential site area, landscaping, parking, and beach. About construction staff were affected by the decision.
Construction will, however, continue on residential units at the resort, which is being built on the brownfield site of the old US Naval Annex in Southampton. Charles Dunstan, president of the Construction Association of Bermuda, said: We heard this morning that work needs to be suspended by the end of the day. These people have families. Usually if they stall, it happens in the initial phases. Mr Dunstan, who is also managing director of construction firm Kaissa, said: For one to stop like this is not good.
According to a spokeswoman, the marina team were able to cater to a range of visitors during the international event, including Artemis Racing. The Swedish team operated out of the property for the past two years, erecting their home base on the end of the peninsula.
Construction is set to continue with the first set of 14 Ritz-Carlton-branded luxury homes to be completed in December. Those interested in the housing units or a berth at the marina should visit carolinebay. Upmarket hotel company Ritz-Carlton is to launch a luxury yacht and cruise line targeted on smaller ports and glamour destinations. But the firm, which is due to open a Ritz-Carlton Reserve property at Caroline Bay next year, yesterday declined to say whether Bermuda would figure in its cruise plans.
The Ritz-Carlton Yacht Collection will feature three luxury cruising yachts, with the first going into service in the last quarter of The first ship will measure metres and carry up to passengers in suites, each with a private balcony, as well as two square metre penthouse suites. We have assembled a team of professionals that is looking forward to serving our clients, some already en route to Bermuda. The completion of phase one of the marina development included the construction of the berths and mooring spaces.
Structural completion includes installation of the all the docks, including piles, pontoons, fingers and electrical components. Completion was celebrated with a dock wetting yesterday, attended by Cabinet Minister Craig Cannonier.