How Can 1984 Be Read and Interpreted Differently?

How can a text be read and interpreted differently by two different readers? 1984  by George Orwell (1949) is a political novel written with the purpose of warning readers of the dangers of totalitarian government. The book can be read and interpreted very differently by two different readers, especially when they were born in a different time. In this essay the viewpoint of two Western readers, one from 1950 and the other from 2012 will be compared to look at the possible difference they could experience in interpreting the story.First of all, the fear of being watched and controlled is more recognizable for a reader in 1950. During World War II, the media was controlled by the Nazi’s. Radio’s for example, only transmitted positive news for Germany. In order to ensure nobody secretly listened to something else, houses were checked regularly. That was not only to see if people listened to an illegal radio-channel but also to see if they were hiding Jews. When they wer e founded guilty, they were send to a concentration camp immediately. In the book this is compared with Thought Crime and the Ministry of Love.P 21: theyll shoot me in the back of the neck i dont care down with big brother they always should you in the back of the neck i dont care down with big brother This is a quote from Winstons’ diary. Even writing something in his own private diary, in his own house is a crime since he didn’t obey Big Brother, the Party’s leader. The fact that he scribbled it down so quickly and full of mistakes shows the fear being caught and watched. Second of all, the concern of totalitarian governments was more relevant immediately after World War II.The reader in 1950 could easily recognize the similarities between the totalitarian government of Hitler and the totalitarian government described in 1984. Before World War II Germany was in an economic downturn. Hitler was a magnificent speaker who offered a reason for this occurring; he b lamed the Jews. No one wants to hear that the problem with their country are their own so the German accepted this as an answer. In Oceana the same happened: P 13: â€Å"The hate had started. As usual, the face of Emmanuel Goldstein, the enemy of the people, had flashed onto the screen. The leaders of The Party use the same way to gain power as Hitler did, so readers from 1950 are likely to . For readers in 1950 this is all fresh and easily recognizable and therefore more relevant than for readers from 2012. Lastly, the fear of being spied on and eavesdropped by telescreens and secret microphones was more realistic to a reader from 1950. That is because around 1950 more and more people started to own a television and therefore it became a real possibility that everybody’s house would have a telescreen one day. Nowadays this fear has become a reality, only in a different way.The government is able to control and check a lot of things through cameras and social media and there is little privacy. But to a reader from 2012 this is not strange or frightening, it is absolutely normal. For this reason you could say the actual fear is not realistic because a reader from 2012 doesn’t have to fear it anymore. To conclude, the fear a reader could experience while reading the book in 1950 is more realistic, more relevant and easier recognizable than the fear possibly experienced by a reader in 2012. Therefore, 1984 can be read and interpreted differently by two different readers who were born in a different time.

Greece: A Country with a Rich Cultural

Greece is a country characterized by a remarkable history and a rich cultural heritage.   In ancient times, Greece played a crucial role in early civilization that proved to be monumental in shaping both European and world history.   At present, it successfully maintains its distinct culture in the dynamic modern society.Greece is a country with the land area of 131, 957 square kilometers (â€Å"Countries† 302).  Ã‚  Ã‚   Its capital is Athens, which is also one of its major cities (â€Å"Countries† 302).   Other major cities include Thessaloniki, Piraeus, Patras, Iraklion and Larissa (U.S. Department of State).   In 2005, the Greek population was estimated at 11,104,000, ten percent of which consists of immigrants (U.S. Department of State).   Three million of the said population is situated in Greater Athens (U.S. Department of State).In terms of religion, the majority of the Greek citizens are members of the Greek Orthodox Church (â€Å"Countries† 302).   Other religions present in Greek society include Islam, Roman Catholicism and Protestantism (â€Å"Countries† 302).   Greece is characterized by an interesting and diverse culture which is established on customs and traditions, religion, food and wine, and music.   Religion and traditions are closely linked, since the latter is usually based and anchored on the former.   Ironically, the Greeks also believe in superstitions.One of the Greek traditions still honored today at is the name day celebration (Greeka).   The Greeks give more importance to name days than birthdays; those who share a name with a celebrated saint also celebrate in a particular day of the year.   During a certain person's â€Å"name day,† family and friends visit to give wishes and gifts.   At the house, the hostess provides food for the guests (Greeka).Another Greek tradition is the Carnival or the â€Å"Apokries† (Greeka).  Ã‚   This feast occurs within a two week p eriod; it starts on Sunday of Meat Fare and ends on â€Å"Clean Monday† or Kathari Deutera (Greeka). â€Å"Clean Monday† or Kathari Deutera is the first day of Lent; at this time, families usually gather for a picnic and kite flying.   The Carnival is believed to have originated from paganism, and is derived from the merrymaking associated with the god Dionysus (Greeka).   This tradition is characterized by people in costumes partying in the streets.   A Carnival parade is held in Patra, where the festivities take place from day until night (Greeka).Easter is also significant for the Greeks.   In fact, it is considered more important than Christmas (Greeka).   Easter is a celebration that brings Greek families together.   Greek women are tasked to color the eggs red using dye; Godparents also give the children new things, such as shoes and clothes (Greeka).   Even the houses and streets are prepared for this occasion, as both are whitewashed for Easter.   In addition, the Greek family gathers for a feast of roasted lamb, wine and appetizers (Greeka).Music also plays a crucial role in Greek culture.   Music in Greece began as early as Antiquity, as it was an essential part of Greek civilization (Greeka).   The best example would be that of Greek tragedy, in which music was one of its key elements.   The demise of Ancient Greece also resulted in the decline of Greek music.   Fortunately, Greek music reemerged in the 19th century (Greeka).Folk songs also play a large role in Greek history.   The folk songs originated from ancient times (Greeka).   These songs are categorized into two: akritic and klephtic styles of music.   The former originated in 9th century AD. This kind of music conveyed the experiences and hardships of the â€Å"akrites,† or the Byzantine Empire guards (Greeka).   The latter was produced by â€Å"kleftes† or those who fought against the Ottoman Empire.Even though music is an express ion of the gruesome period in Greek history, it also included love songs.   This style of music was believed to have originated between the latter part of the Byzantine era and the early part of the Greek Revolution (Greeka).   Instruments that accompanied the folk songs include the bagpipe, tambourine and lute, just to name a few.   Other important elements of the Greek musical tradition are cantadha, nisiotika and rebetiko (Greeka).Food and wine are also significant in Greek culture (Greeka).   Greece is known for their appetizers and wines.   Mezedes, or Greek appetizers, are crucial in Mediterranean culture, as it promotes friendship through the sharing of food.   Some of the recognized Greek appetizers include the Greek salad or Horiatiki Salata, Tiropitakia, Htapodi and Feta cheese.Greece also produces wines. It is therefore no surprise that Greek alcohol such as Tsipouro and Ouzo are a main component in Greek culture.   Also, meat is almost always present in Gre ek main dishes, while their soups are very much preferred during the winter season.   The Greeks are also famous for the herbs and spices used in their dishes (Greeka).The history of Greece is extensive and thorough.   Greek culture began in the classical era, and proved to be a crucial element in the development of civilization in general (Pounds 326).   The Greek island of Crete was the location for the Minoan civilization, the earliest in Europe (â€Å"Countries† 303).   Greece is also home to the city-states, whose prosperity brought the development of culture in aspects such as philosophy, literature, politics, architecture and art (â€Å"Countries† 303-304).   Greek civilization was at its peak under the control of Philip II of Macedonia and his son, Alexander the Great.   However, the Greek civilization declined when the Roman civilization emerged (â€Å"Countries† 304).Greek history also includes several wars. Civil War erupted following the occupation of German forces from 1941 to 1944 (â€Å"Countries† 304).   Then, under the leadership of Prime Minister Eleutherios Venizelos, Greece officially became a part of World War I in 1917 (Pounds 328).The history of Greece was also marked by the constant change in form of government.   From 1925 to 1935, Greece was a republic (Pounds 328).   Then, Greece became a constitutional monarchy (Pounds 328).   In 1967, the monarchy was deposed by a military coup (â€Å"Countries† 304).   The republic was restored in 1973, which lasted for only a year.   In 1975, democratic elections were held once again.   Six years later, Andreas Papandreou became the first socialist Prime Minister of Greece.   Then, in 1990, a Democratic Party member named Constantine Mitsotakis was elected at the same post (â€Å"Countries† 304).With its extensive historical background, Greece remains a crucial part of world civilization.   With its customs and traditions, Gr eece keeps its diverse and unique culture in modern day society.   Indeed, Greece remains relevant at present through its history and culture.Works CitedBateham, Graham, and Victoria Egan, eds. Illustrated Guide to Countries of the World. Australia: RD Press, 1996.Greeka. 17 March 2008 ;http://www.greeka.com/greece-culture/;.Pounds, Norman J.G. â€Å"Greece.† Lexicon Universal Encyclopedia. 21 vols. New York: Lexicon Publications, Inc., 1992.U.S. Department of State.   17 March 2008 ;https://www.state.gov/r/pa/ei/bgn/3395.htm;.

Political Systems in U.K and U.S Essay

What are the similarities and differences between the political systems in U. K and U. S? When the U. S. Constitution was being drafted, its writers had the British Parliamentary system to base on. The British system was the system they were used to and had learnt since childhood. However, because the monarchy was one of the main things that the former colonists had rebelled against, any form of monarchy and most forms of concentrated power were avoided. The most fundamental difference between the political system in the U. K and the U. S is the constitution. The United States has a written constitution which is very difficult to change. The UK does not have a single document called the constitution but instead its constitutional provisions are scattered over various Acts of Parliament, any of which can be changed by a simple majority in the Parliament. Similarities Both the U. S. and British political systems have a head of state, a court system and an upper and lower house. The U. S political system has a constitution which lays out the rules for government and the rights of the people, however, the U. K has documents with constitutional provisions which lay out the same rules. Both systems are democratic in nature, as governments are put in place and removed from power by the will of the people and both have systems of checks and balances to limit the power of any one branch. Head of State In the U. S. political system, the president is the official head of state. The president is elected under the electoral college system. In the U. K. , although the prime minister usually has the spotlight on political matters and is the official head of government, the queen or king is the official head of state. The queen officially signs off on acts of parliament and, just as the U. S. president delivers the State of the Union Address every year, the queen reads the â€Å"Speech from the Throne,† which is written by the prime minister. In U. K, the monarch is more of a ceremonial figurehead and it is unusual for any member of the royal family to directly interfere with the political process. The Upper House The United States has a Senate as the upper house of the legislative branch and the U. K. has the House of Lords. Under the U. S. ystem, each state, regardless of size, has two senators. Originally, senators were appointed by the governor of the state they represented but they are now elected to serve six-year terms. The House of Lords is very different. Members of the House of Lords are not elected. The 792 members of the House of Lords are members by inheritance, appointment or their rank in the Church of England; they are not elected and cannot be removed byvote. This part of t he political system in the U. K is not democratic. Otherwise the House of Lords serve the same purpose as the U. S. Senate. They discuss, debate and vote on legislation passed by the lower house of the legislative branch. The Lower House The U. S. House of Representatives and the British House of Commons have a great deal in common. Each house is made up of representatives elected by the people. In both systems control of the lower house goes to the party that has the most seats. Under the U. K. system, the leader of the party with the most seats becomes the Prime Minister and the official head of the government. Under the U. S. system this person would be the Speaker of the House. One other key difference is elections. Under the parliamentary system, the prime minister can go to the crown at any point and ask to dissolve Parliament. If this is done an election is called. An election can also be called if the prime minister loses â€Å"the confidence of the house. † This means that the prime minister lost a vote in Parliament on a matter of confidence. Matters of confidence are usually over budgetary matters. If the prime minister loses a vote of confidence, the end result is an election Other political differences. The American general electionlasts almost two years, starting with the declaration of candidates for the primaries. The British general election lasts around four weeks. In the United States, no Cabinet member is allowed to be a member of the Congress because of the strict theory of the separation of the powers. In Britain, every Government Minister must be a member of one of the two Houses of Parliament and, if he or she is not already in the Parliament, he or she is made a peer. The constitutional system in the UK involves a lot of custom and practice, and much more flexibility than the US system. For example, the timing of US presidential elections is fixed. In the UK, it is essentially the Prime Minister’s choice as to when elections are to be held, up to the 5 year limit. The resignation of a president in the US would have to lead either to an election or to his vice president taking up the office. In the UK, the resignation of a prime minister will lead to the party choosing a new leader, but there is no technically requiring this, the Queen is technically free to choose whoever she wishes.

People, Power, and Politics in Canada Essay Example | Topics and Well Written Essays - 1250 words

People, Power, and Politics in Canada - Essay Example McRobert profoundly disagrees with Trudeau, who offered to get rid of the villagers in Canada outside Quebec. In the process, they left the poor and the local people in the worst and most pathetic conditions. McRobert disagrees stating that before Trudeau came into the lime light, there was a veritable ambiguity about the Canadian deal. He says Trudeau never improved the asymmetrical arrangements for the Quebec in any way. He claims that Trudeau ruined Quebec social economic status. Democracy Reforms Democracy is a fundamental aspect in every state. The people defined it as the rule for the people and with the people. The perception that ordinary citizens have about the government and those who are in should substantially change (Robert & Doreen, 2009). With these reforms in place, various parties will conduct themselves in a good manner. It will also provide an opportunity for people to select their preferred leaders. In most cases, people often evade engaging in the government-initiated processes like elections since they believe that it is a waste of time. Therefore, the basic advantage of these reforms will be to enable different citizens to exercise their legal rights. Common citizens will also be free to compete for various political posts in the government. Whether these are federal, senate, or other elective posts, democracy is a very crucial aspect and warrants priority. The electoral reforms are also necessary as they determine the mode of carrying out elections. This implies that people competing for various positions need to have guidelines to aid them. The electoral body should be selected wisely and democratically to ensure free and fair elections. The political parties also need to have policies governing the manner by which campaigns are done. The reforms of elections also need to touch on areas like setting the exact date for the elections as well as appointing watchdogs to oversee the entire process (Robert & Doreen, 2009). The electoral body should also train and enlighten individuals as for the importance of carrying out elections. The electoral reforms should touch on various aspects like the number of women to be elected to the Senate seats. This will ensure fairness in the state elections and the members elected

ERP Systems For Small And Medium Size Companies Research Paper - 1

ERP Systems For Small And Medium Size Companies - Research Paper Example Additionally, because of globalization an e-commerce arrangement bringing changes rapidly, and small and medium size businesses as well refurbish their industry. Since the sizes of corporations are growing with the passage of time. In this scenario, the traditional business practices would not be helpful for the organizations to adopt these changes as well as the disharmony among business and information systems in their corporation can happen. Thus, at the present, majority of businesses utilize of Enterprise Resource Planning (ERP) systems for improving business performance (Park & Lee, 2006) and (Turban, Leidner, McLean, & Wetherbe, 2005). This paper presents a comprehensive analysis of some of the important aspects of Enterprise Resource Planning (ERP) technology based platforms for the small and large size business organizations. In this prospect, this research will cover the analysis of various major ERP technologies, their corporate implementation and possible advantages and d isadvantages. This paper will discuss SAP business by design, SAP business One and SAP All-In-One, Oracle’s PeopleSoft and Microsoft ERP system. ERP systems for Small and Medium Size Companies Without adopting ERP technology based arrangements and systems large size corporations cannot survive in today’s ever-increasing competitive world. In fact, ERP technology based systems allow the large scale organizations to work as an enabler instead of a differentiator. Additionally, this difference is apparent in the fraction of big businesses making use of the ERP systems. In view of the fact that in only United States more than 90 % organizations make use of Oracle to manage their business functions. Thus, given the diffusion of ERP marketplace for large scale corporations, adequate client growth in the huge firm marketplace turns out to be minimal for ERP vendors. In this scenario, ERP software suppliers and their business partners are able to generate and uphold revenues b y offering support and upgrades however actual growth is possible by expanding their business into new marketplaces. In addition, with the implementation of ERP software into the business, corporate expansion requires, more and more efficient computing and networking facilities, rising significance of information usage inside companies, and continuously technically trained employees, however, the current ERP systems suppliers are currently focusing sales expansion on the small and middle sized business (SMB) marketplace. On the other hand, at the present, more and more small and middle sized businesses are gaining a competitive and information edge over their competitors by implementing latest ERP systems. Therefore, business sectors suggested by SMB’s have to now recognize the importance of ERP systems as their marketplace landscapes turn out to be growing competitive (Crumley, Fain, & McFadden, 2010). SAP Business One Application The SAP Business One system puts together th e entire fundamental business purposes across the business; comprising sales, financials, inventory, customer relationship management and processes

Freud and his view of psychology based on Creative Writers and Research Paper

Freud and his view of psychology based on Creative Writers and Daydreaming - Research Paper Example While this is obvious in some creative art movements like â€Å"Surrealism†, to a certain extent, this holds true for every art form though often not very obvious. The subconscious mind, in its wandering day-dreaming form, allows the artist to touch such deep rooted emotions which normally are restrained by social consciousness and social appropriateness. The drifting mind creates a world of its own in the deep alleys of the subconscious, allowing the mind to roam in this unreal play world and create images and imagery. This becomes the basis for many a creative endeavor. Sigmund Freud, the famous psychoanalyst and the originator of modern psychoanalysis, in his theories had subscribed to some form of this theory. This is hardly surprising as the Freudian theory is based on bringing out the subconscious thoughts of a person into consciousness and thereby making the person free from the agonies of repression and consequent distortion. As Sigmund Freud once said, â€Å"there ar e no indications of reality in the unconscious, so that one cannot distinguish between the truth and fiction that has been cathected with affect† (as cited in Steiner, 5). Sigmund Freud was born in Austria on 6th May 1856 to Jewish parents. He came from a very impoverished family but worked his way up through sheer hard work, intelligence and talent. Though he started his research work related to medical studies on the life history of eels, failure in this line made him change and turn to psychology as his field of study. He later founded the psychoanalytic school of psychology and is famous for his theories on the unconscious mind and his method of treating psychological patients through psychoanalysis or dialogues between a patient and the doctor. Freud believed that the subconscious or the unconscious was an inroad to the thoughts and actions of a conscious mind and helped in understanding the latter. Dreams, as per Freud, were a method by which one can understand the

The cast of Amontillado By Montresor and Fortunado Essay

The cast of Amontillado By Montresor and Fortunado - Essay Example In an effort to understand Montresor, there is need to focus on his superego, patient and canning nature. Montresor is canning in his attempt to lure Fortunato into his death trap. â€Å"My dear Fortunato! I am indeed glad that I have met you. I †¦tell me is Amontillado.† (Poe 866). this is an attempt by Montresor to try his first move to seek revenge on what he considered an act that was meant to demoralize him. Montresor earlier portrays canning traits as he attempts to pull the audience believe he was justified in what he was about to attempt. He insinuate he had forgiven Fortunato several times and that he was justified in seeking revenge Montresor portrays ego centric traits this highlights the reason as to why he manages to plan a revenge plan on ground that his dignity was at stake. He also brags about his traits which places him supreme to Fortunato. In this case he portrays Fortunato as weak and naà ¯ve. â€Å"He had a weak point†¦Ã¢â‚¬  (866). this is an effort to portray himself superior meaning his plans would succeed without any hitch. The implication that Fortunato portrays his ego centric attributes. His ego centric character ensures his survival through the story. The character also portrays him as being patient. This is evident in his opening statement which he states that "The thousand injuries of Fortunato I had borne as I best could†¦Ã¢â‚¬  (866). Montresor indicates how he was able to forget the past mistakes just to wait for the right time. This traits changes and he becomes an antagonist. He patiently plans his revenge beginning with the wide tasting to the chining and finally to the murder of Fortunato (870). The character is successful in his revenge as he manages to accomplish his goals. His quest to seek revenge is repaid by his patience. He utilizes the naà ¯ve nature of Fortunato to execute his plan. In conclusion the ego centric, caning and patience nature portrays the traits of Montresor. The effort to avenge the

Marketing Management Assignment Example | Topics and Well Written Essays - 4500 words

Marketing Management - Assignment Example It not only has non-stop aircrafts to other Middle-East countries but also has huge number of connecting flights to other countries across the globe. The network of connection by the company stretches from Europe to Asia with its presence in 29 countries and connecting more than 45 cities with a total of 34 fleets of aircrafts. Along with country’s vision of â€Å"Vision 2030†, Gulf Air also has its vision lined on the same line. The company’s strategy is to build a commercially sustainable, efficient airline which effectively serves to the people of Bahrain and also helps in the growth of the economy of the country representing its good image in the global world. Based on its strong strategy of growing at a fast pace the company has its main focus on three core areas which are providing a superior and more consistent product to the customer, a well-targeted and good expansion in the international network and third to become a modern and more efficient aviation c ompany that will provide good value for money to the customers and also will look to optimize value. Having a constant growth in the business operation the company has moved forward in a big way and in 2012 the company was been awarded with Silver Effie for building an effective and innovative brand in Bahrain. Though being in the global market from so many years the goal of the company has remained unchanged and its commitment towards bringing the latest technology in aviation industry is very well known, and its brand image has also increased by its hallmark Aviation hospitality. The company’s strong strategies to provide the best service have become the flagship for the company and the company is well known in the global market because of its high level of service and hospitality. In this report it can be seen how the company has utilised all its resources and capabilities in the best possible way to grow at such a fast rate and also the marketing strategies that are been used by the company

Beethoven Research Paper Example | Topics and Well Written Essays - 1500 words

Beethoven - Research Paper Example Whereas he remains one of the most well recognized and famous classical composers, scholars still debate what the ultimate cause of Beethoven’s hearing loss might have been. Beethoven himself described its onset as a troublesome ringing in his ears. Medical professionals at that time as well as today believe that the condition could have been brought on by an acute illness that he suffered during early adulthood. Whatever the cause, Beethoven began to experience a noticeable level of hearing loss by the age of 26. Scholars are aware of this due to the fact that it was at this age that Beethoven first mentioned that the hearing loss was troubling him in his correspondence to friends and family. As one might expect, for someone as passionate about music as was Beethoven, such a loss was tantamount to complete and total defeat and desolation. Within his own correspondence it was noted that he even experienced suicidal thoughts at times due to the fact that the hearing loss was af fecting his ability to maintain a positive and optimistic attitude. As such, bouts of severe depression ensued by which Beethoven contemplated ending his life. However, the hearing loss was gradual and Beethoven was not aware at any one particular point during the hearing loss process that he would ultimately be entirely and completely deaf.... lthough a definitive date does not exist by which Beethoven completely and entirely could be considered deaf, it is widely reported that the first time he experienced complete and total deafness was at the premier of the 9th symphony; arguably his magnum opus. At this time, Beethoven reportedly went out on the stage at the conclusion of the symphony and was greeted by rapturous applause. However, due to the fact that he could not hear this, he felt initially that his work was a commercial and professional failure and began to cry heavily.1 Even this debacle and embarrassment was not enough to discourage Beethoven from performing publically. Several public performances with Beethoven as a featured musician took place following the debacle of the 9th Symphony. However, during the performance of the Piano Concerto No. 5, Beethoven was forced to allow his student Carl Czerny to perform as he could no longer hear the music or the beat and keep time with the other musicians. Though it is t rue that Beethoven was not completely and entirely deaf at this stage, he was unable to hear certain pitches of music and could only hear the very lowest bass notes. Recent scholarship into Beethoven’s music after the year 1814 notes the fact that his loss of hearing helped to alter the music after this period of time as compared to the music composed before it. What is meant by this is that the music prior to 1814 included something of an equal composition of both high pitches and low pitches within the score. Although it is true that there remain a profound number of high pitches within Beethoven’s music post 1814 (or after the time in which acute hearing loss profoundly impacted upon the way in which he composed music), it can be readily noted that as a direct result of his hearing

Manipulation Case Study Essay Example for Free

Manipulation Case Study Essay Who has manipulated my mind in relation to reality? I believe that society has manipulated my mind in relation to reality in some way because I think that reality is just a state of mind. The physical aspect of the things I can see, touch, taste, etc. make me believe that everything I encounter is factual. Also society says to believe only what you believe to be real and don’t believe in fantasy because you have no physical connections to imagination. How can I break free from the bonds of those who seek to manipulate me? I can break free the bonds of those who seek to manipulate me by choosing what to believe and to have an open mind when using critical thinking. I can use my logic when it relate how I receive information by make choose whether to let negative energy in my life affect me or choose to overcome it decide how I’m going to reaction to the situation. I believe that sometimes if people actually took the time think about things before they reacted on pure emotion then they can see that taking a few seconds think any negativity in their life they choose how they should react. An example when I’m driving and somebody cuts me off naturally I’m upset and wondering why this person would do something like. In some cases I want to speed next to the person in engage in an offensive gesture or go on verbal rant at that person but I usually take a second to think about it and realize maybe this person is in hurry or not pay attention while driving. By me choosing to restrain from getting in a road rage battle with that driver chose to the better person because at the end of the day we both are just trying to get to or destination. What preconceptions do I have in my life that might distort my vision of reality? The preconceptions that I have in my life that distorted my vision of reality is that all people are decent and kind. As a kid growing up I believe that all people were decent and kind because society was more civilized and simple. Now that I’m a adult I know that is not true at all because of how society is nowadays with in rapid increase in crimes such as murders, kidnappings, child molestations, etc. People have ability to be decent and kind but some choose to evil and cruel. Every person has the potential to be criminal because in today’s society have become desensitized.

Augmentative and Alternative communication (AAC)

Augmentative and Alternative communication (AAC) Introduction: Communication is one of human basic needs. It is an essential part of life that no one can live without it. It is a process of transferring information, ideas, attitudes, or feelings from an individual to another individual or to a group of individuals. The process includes the exchange of experiences between individuals; under the shared common understandings of media or symbols that contain the information in the messages. Communication can occur with at least 2 persons; each being both message senders and receivers simultaneously through the interchanging of these 2 roles. Sending or receiving messages can both be in verbal and nonverbal forms. The verbal communication is considered the basic form of communication. In verbal communications, an individual needs to use several organs such as larynx, vocal cords, tongue, mouth, lips, teeth, and jaws, in order to produce sounds (Ruben, 1983). One can express ones needs to others with the verbal communications. They require fewer interpretations, given that both parties use the same language. Nonverbal communications, on the other hand, include communications through gesturing, nodding, or shaking ones head, touching, facial expressing, moving lips, writing on paper, using pictures, having eye contacts, and etc. They are used as a complimentary of the verbal communications, or are used when verbal communication is impossible (Peel, 1995; Beis, 1996; Sundee, et al., 1998). The nonverbal communications may occur when persons are in quiet places where no voice is allowed, when both parties are in distant and sound cannot be sent from one to another, or when a person has physical conditions that ability to speak is limited, for example in patients on respirator with endotracheal tubes (Verity, 1996; Happ, Garret, oesch, 2003). Normally, the vocal cord vibrates and produces sound when the air flows through it. When the endotracheal tube is inserted, air will flow through the tube introduction not through the trachea and the vocal cord (Ruben, 1984; Guyton Hall, 2000) obstructing the sound making process (Sitzer, 1993; Hafsteindottir, 1996). Patients with good conscious, who cannot verbally communicate, are affected both physically and emotionally by inability of speaking. Need for Study: Clients with endotracheal tube on Mechanical Ventilation tube experienced pain and discomforts. Several complications that can occur include injuries and irritations of the oral mucosa, throat, trachea, pharynx, and larynx. Psychological effects included anxiety, stress, fear, sleeplessness, and in some clients the feeling of social separations. Clients with good conscious, who cannot verbally communicate, are affected both physically and emotionally by inability of speaking. Communication is important in order to provide effective nursing care that respond to clients needs. Effective communication improves the quality of care. The literature suggests that in many facilities AAC intervention is inadequate and that there is a need for increased education of nurses and other caregivers in the area of communication . Leathart observed 8 nurse-patient interactions in an intensive therapy unit (ITU). Patients were intubated but alert and able to com-municate. Patients communication was mainly comprised of replying to yesà no questions. Seven of 8 nurses reported dificulty communicating with patients in ITUs. Reasons cited were dificulty lip-reading, lack of patient feedback, Hafsteind-ttir (1996) described patient frustration with alternative means of communication. The frustrations stemmed from physical weakness, poor vision, and hand tremors (associated with dificulty writing). None of the patients recalled receiving instructions about communication methods. Over half of ventilated patients who participated in a study by Lohmeier and Hoit (2003) reported that they had no history of speech therapy, and only 5 of the 50 respondents had ever received AAC interventions. Problems or frustrations with speech were reported by 36 participants, suggesting a need for increased communication intervention for this population. Happ et al. (2004) investigated 36 records of patients who received mechanical vVentilation and who died during hospitalization in 8 ICUs during a 12-month period. No uses of picture boards, letter boards, or electrolarynx devices were documented. Their findings indicated that most communication consisted of yes/no responses to caregivers questions about orientation or pain, suggesting that nurses controlled the communicative interactions. Wojnicki-Johansson (2001) asked nurses to evaluate the communication of 22 patients who had been mechanically ventilated in the ICU. Nurses reported functional communication in 19 patients, however, this conflicted with the reports of 13 of the patients, who indicated that nurses had failed to understand their needs during their stay in ICU. Six patients reported that no functional communication was achieved, whereas nurses reported this to be the case for only 2 patients. Eight patients reported that nurses were unable to understand their messages. The author suggested that nurses should critically evaluate their communication skills and frequently verify the content of communication with patients. Fried-Oken et al. (1991) interviewed 5 patients who reported negative emotional responses to the sudden onset of communication difficulties, the most common response being fear. Patients reported that some caregivers and family members did not know how to use their AAC systems and emphasized the need for increased training in this area. Hall (1996) studied communication by observing interactions between nurses and their patients who were on ventilators. Hall concluded nurses seemed more concerned about meeting their need to provide specific information to the patient than to discover what the patient might want. The author questioned whether nurses have the skills and knowledge to respond to and/or assess nonverbal communication and felt that this warranted continued investigation. Statement of the problem: A study to assess the effectiveness of Augmentative and Alternative communication (AAC) towards fulfilling the needs and satisfaction of among the clients with endotracheal tube on Mechanical Ventilation in Govt Rajaji Hospital. Madurai. Objectives of the study: The objectives of this study are to: To assess the level of patients fulfilling needs and satisfaction after administering the aided augmentative and alternative communication. To evaluate the effectiveness of administering the aided augmentative and alternative communication. To associates the level of Satisfaction and selected demographic variable. Hypothesis: 1. There will be no significant association between the level of satisfaction and selected demographic variables 2. There will be a significant difference between the level of communication and patient satisfaction among the endotracheal tube on Mechanical Ventilation patients after administering the augmentative and alternative communication. OPERATIONAL DEFINITION Effectiveness It refers that effectiveness relates to how well a AAC works in practice or what the indent results Augmentative and Alternative Communication (AAC) Augmentative and Alternative Communication (AAC) refers way of communication that provide an alternative method by using devices such as paper and pencil and picture board etc Needs In this study need refers that patient fulfill his physical, physiological, therapeutic, social, psychological, spiritual needs by means of alternative communication. Endotracheal tube on Mechanical Ventilation It is a surgical procedure and after the surgical procedure the patients are having impaired verbal communication. Assumption Delimitation

Concepts Of Medicine Adherence And Its Economic Burden Nursing Essay

Concepts Of Medicine Adherence And Its Economic Burden Nursing Essay Even though 45% of all medications prescribed in the UK are for older people, it is postulated that up to 50% of older people are non-compliant with their medication (SCIE, 2005). The prescription of various medicines is central to medical care and the overall drug costs account to about 10 percent of NHS expenditures. Surveys carried out in literature enlighten us with the fact that approximately 30% to 50% of patients do not use of take their medications as recommended by their prescriber. (1). Statistics show that in 2007- 2008, the NHS in England spent  £8.1 billion on drugs if as many as 50% of the patients dont take their medications as recommended, this could mean that  £4 billion worth of medicines were incorrectly used (2) . Furthermore the additional cost of unused or unwanted medicines within NHS totals up to  £100 million each year. On top of that the estimated drug cost of unused or unwanted medicines in the NHS is around  £100 million annually (3). A Cochrane review Interventions for enhancing medication adherence concluded that improving medicines taking may have a far greater impact on clinical outcomes than an improvement in treatments (4). Therefore if the prescription is inappropriate in the first place it not only translates as a loss to patient but also involves the healthcare system and the society. The costs included here are both personal and economic. Concepts of Adherence and terminology There are three major terms which are commonly used in the literature to describe medication-taking behaviours i.e Compliance, Adherence and Concordance (5). According to Pound (6) initially, the term compliance was used to illustrate the medication taking behaviour, which was then replaced by the term concordance. The term compliance came into disfavour because it suggested that a person is passively following a doctors orders, rather than actively collaborating in the treatment process (3) Whereas concordance refers to the anticipated outcome of the consultation between doctors and patients about medicine taking It is viewed as successful prescribing and medication taking based on the partnership with the patient (6). However the most current, fashionable and accepted terminology is adherence, which is defined by McElnay (7) , as the extent to which a persons behaviour (in) in terms of taking medicines, following diets or executing lifestyle changes, coincides with advice given by health care professionals Adherence shifts the balance between professional and patient about the prescribers recommendations. Pound (6) states that the above mentioned three terminologies tend to be used interchangeably but are incorrectly applied. Adherence can be viewed as the central aim, concordance is the process used to apply the central aim compliance is the outcome of the process. The benefits of medication might be restricted thereby causing a further deterioration in health as a consequence of non-adherence. . On top of this the economic costs do not only translate to wasted medicines only but also include the knock on costs which arise from increased demands for healthcare if (on the whole) health deteriorates. It is hence due to this reason that non-adherence is a major issue and should not only be seen as the patients dilemma. A fundamental drawback is represented in the provision of the healthcare, which is often due to a failure in completely agreeing with the prescription in the first place or to recognise the appropriate support that the patients might require later on during the treatment. Hence addressing non-adherence is by no means about getting patients to take additional medicines. Therefore tackling the issue of non-adherence involves the initial understanding of patients opinion on the medicine and then the various reasons to as why they are/m ight be reluctant or unable to use them. Causes of non-adherence There are many causes of non-adherence however they fall into two main overlapping categories i.e intentional and unintentional. Both types relate to the lack of an established pattern of medication taking which led to the incidental omission of medicines and may be experienced concurrently (8). Purposeful or intentional non-adherence occurs when a patient makes a specific decision not to take the prescribed medication. The anticipation of drug-related side effects and general dislike of taking medicines are common causes of intentional non-adherence (9). While accidental or unintentional non-adherence occurs as a result of forgetting or misunderstanding instructions about the drug schedule .Unintentional non-adherence is proposed to be range from a random departure to medication omissions from a prescribed treatment regimen (10). Hence the main features of unintentional non-adherence focuses on altering medication contingent on self assessment or perceptions of mental health, stress or anxiety, forgetting to take medicines or simply altering the doses of medicines to fit in with daily chores. A research carried out by Svensson (10) Kippen (11) showed that older people adherent with their medication often link the administration of medication to specific lifestyle events, location, time, and patterns of daily activities. Below table 1.3.1 shows the common perceptions and characteristics of adherent and non adherent medication taking behaviors. Table 1: Shows common perceptions and characteristics of adherent and non adherent medication taking behaviours. Perceptions related to medication taking behavior Intentional Non-adherence Unintentional Non-adherence Feeling unnatural taking medicines Fears of prescribing errors/addiction Life style change/ Disruption to daily routine Adverse effects of medicines Lack of faith in the prescriber Drug related memory loss/ Forgetfulness Long term risks of medicines Failure to accept diagnosis Altering dosing regimen Past experience of medicines Dislike of taking medicines Being asymptomatic Lack of comprehension of the need to take medicines. Testing medicines against symptoms Period of illness Vulnerable group of people Of all the age groups, medication taking behaviour in older people is of the highest concern. This is due to multiple reasons as described by Huges (12). Firstly, older people are highly likely to suffer from multiple diseases. Secondly, older people frequently administer three or more medicines concurrently to manage these conditions and third as a result of poly pharmacy, they are increasingly likely to mismanage their medicines (13). Furthermore, research shows the following as different lay beliefs by older people on medicine taking The need to reduce the symptoms of hypertension, to feel physically better (14). Fear of complications and desire to control blood pressure (10). Positive confidence in the prescriber (15). Apart from the elderly, another age group, where non- adherence is becoming a significant problem is in the pediatric population. In one of the studies carried out by Bush (16) it has been shown that one-third of the children in grades 3 to 7 reported they had used one or more prescription or non prescription medications in a 48 hour period. Adherence plans for children often require innovative approaches to encourage active participation in caring for their own health and how to use their medications appropriately. Consequences of medication non-adherence No matter how much critical the conditions are a patient might stick to his medication regimen, thus reflecting a loss of the health care system with increased use of medical resources, such as GP visits, unnecessary additional treatments, emergency department visits and hospital admissions. One of the recent research shows that about 3-4% of UK hospital admissions are as a result of avoidable medicine related illness (17) between 11 and 30 % of these admissions result from patients who dont use their medicines as recommended by their prescriber (3). In a similar manner, in 2006-2007, figures show that that the NHS expenditures on hospital admissions (excluding critical care costs) was approximately about  £ 16.4 billion (18). And the estimated costs of admissions, within the same year i.e. 2006 2007, resulting from patients not taking their medicines as recommended was found to be between  £36 and  £196 million respectively (18). Hence a reduction in these admissions and associated costs would be expected as the overall medicines adherence increases. Factors affecting medication adherence In accordance to WHO some of the main common factors reported to have a significant effect on adherence include: poverty, low level of education, illiteracy, poor socioeconomic status, unemployment, unstable living conditions, lack of effective social support networks, long distance from treatment centre, high cost of medication, changing environmental situations, high cost of transport, family related issues and culture lay beliefs about illness and treatment. In accordance to WHO the common belief of patients being the sole responsible for taking their treatment is misleading and most often reflects a misunderstanding of how other factors affect peoples behaviour and the capacity to adhere to their treatment. Adherence, in short, is a multidimensional phenomenon which is determined by the interplay of five different sets of factors, each of which are termed as dimension by WHO (5) . Each of these dimensions are listed as under and shall be discussed in detail Social/ economic factors Provider-patient/ health care system factors Condition related factors Therapy-related factors Patient related factors Social and economic dimension It includes limited access to health care facilities, medication costs, low health literacy, limited English language proficiency, unstable living conditions (homelessness), lack of family/social support network, and cultural beliefs about illness and treatment. Among these factors few shall be discussed in detail as under English language proficiency Both low health literacy and limited English language proficiency are barriers to adherence that deserve special consideration. Health literacy can be defined as the ability to read, understand and act on health information so that appropriate health decisions can be made. The risk of unsafe use of prescription medicine, is high among people with low health literacy and limited proficiency in English language due to the complex nature of the printed information that is available and because these people often do not receive adequate verbal communication or sufficient time from health care providers. Older adults with low health literacy may have trouble reading health information materials, understanding basic medical instructions, following prevention recommendations and adhering to medication regimens. Social factors Medication adherence is positively associated with social support and the availability of help from family and friends. Better outcome to treatment is observed in people who have social support from their friends/family (who assist them with their medication regimens) Cultural beliefs and attitudes Adherence to therapy, may overall be affected as a consequence of different attitudes which the patient may have towards health and medicine. Addressing these issues by the health care professionals is of prime importance so that the patients can get the most out of their medicines without compromising their health In case of adults, different components of health and healing cannot be explained by no one list. Therefore each individual must be considered on individual basis. Two major key components are requisite i.e asking non-judgmental questions listening, when it comes down to understanding the process of gaining an insight into patients beliefs (regarding health and healing) Patients belonging from various ethnic minorities bring along their practices in the health care system. This sometimes puts the health care professionals at test, who have been professionally trained in the light of western philosophy and medicine. Although groups of people may have beliefs or practices in common, yet that doesnt mean that they all can be classified under the same category. Within groups , the major differentiating factors include health status, educational level, sexual orientation etc (5). Respect Taking care of elder patients who belong from such backgrounds where they receive a great amount of respect (e.g. British Asian community ) should involve the element of respect combined with kindness. If they are approached with an attitude that consists even a tiny fraction of scolding or telling off, they might show resentment towards the adherence of medicine even though it may put their lives at risk. Therefore to put such patients at relieve it is of prime importance to show respect towards them . Traditional therapies and cause of illness Literature shows that two components such as religion and spirituality can play a vital role in the overall understanding of illness in its broadest sense among older people (19). The will of God for an improper behaviour, exposure to cold wind, natural causes etc are all different factors which older patients believe are major culprits for causing illness (20). This consequently leads them in such a situation where they end up giving God a chance to heal them or alternatively they seek help from a folk healer, try home remedies or pray for the treatment of their illness. An excellent example of this can be viewed within the Chinese culture where health may be seen as finding norm between ying yang, which is much more like hot and cold (21). Now patients who follow Chinese health belief may try such approaches which targets at restoring the balance between ying and yang (using different varieties of food and herbs). Likewise, some Asian ethnic groups rely solely on traditional remed ies for the treatment of long term conditions (21). At this stage it is also important to mention that the patient may not be cooperative if he believes that the health care provider may disapprove information surrounding the use of non-traditional remedies. This may ultimately lead to different interactions with the prescribed medications. Medication For some patients the preference lies in the dosage form or the size or colour of the medication. For example some cultures in Latin America view injections as more potent in comparison to oral medications. Likewise it is believed that Western medications are too strong by Chinese older patients hence therefore they might choose to not take the full dose of medicine (22). Health care system dimensions It includes different factors such as provider-patient relationship, provider communication skills, patient information materials written at too high literacy level, restricted formularies (changing medications covered on formularies), poor access or missed appointments, long waiting time and lack of continuity of care (23). The quality of the HCP-patient relationship is one of the most important health care system-related factors impacting adherence. Adherence to medicines can be increased as a result of good relationship between the patient and the HCP (which features the element of reinforcement and encouragement from the HCP), however there are many factors which have negative effect (24). These include lack of training and knowledge for health care providers on managing chronic diseases, lack of incentives and feedback on performance, poor medication distribution systems, short consultations, overworked health care providers, weak capacity of the system to educate patients and provide follow up, lack of knowledge on adherence and of effective interventions for improving it. Condition related dimensions It includes Psychotic disorders, severity of symptoms, chronic conditions, depression, lack of symptoms, mental retardation (25). Among these factors few shall be discussed in detail as under Chronic conditions and lack of symptoms Information within literature supports the fact that adherence to such treatment options (often declines as the time progresses) where medications have to be taken on an unlimited basis for the management of a chronic ailment. Example of two perfect clinical conditions which would fit into this profile include high BP and osteoporosis (26) , in which the symptoms are totally invisible to the patient. Furthermore, in the absence of symptoms these ailments lack the cues which would motivate the patient to adhere towards his treatment regimen. Depression A study carried out by Krueger (28) showed significantly lower rates of medication adherence among people with chronic illnesses and who are depressed. It is therefore crucial for the HCPs to be aware of the devastating impact, depression has on adherence consequently on regular basis should assess older patients who are sad all the time or who report symptoms of sleeping disturbances to eliminate the possibility of clinical depression. The slow onset of the pharmacological actions posed by different classes of antidepressants is classified as one of the major factor that contributes towards decreased adherence among elder patients. Adding on to that if the patient begins to experience the side effects (before even the symptoms are relieved), might consequence discontinuation of the therapy at a very early stage. In a similar fashion, a research conducted by Kemyttenaere (29) shows that once the patients (suffering from depression) start feeling bette,r they might stop the antidepre ssant therapy midway. Psychotic disorders A patients experience with unpleasant side effects is mainly one of the key causes which drives them from continuing their antipsychotic therapy. Literature shows that interventions which focus mainly on the persons attitude and beliefs about medications 9rather than on the knowledge) helps improve adherence. The addition of two key ingredients i.e Behavioral techniques motivational interviewing within compliance therapies, have proven to be very effective in improving medicines adherence among patients who suffer from psychotic disorders (31). Therapy related factors/dimensions It can be sub-divided into other different factors such as duration of therapy, lack of immediate benefit of therapy, frequent changes in medication regimen, actual or perceived unpleasant side effects, medications with social stigma attached to use, treatment requires mastery of certain techniques, complexity of medication regimen and treatment interferes with lifestyle or requires significant behavioural changes. Research by Tabor (32) Krueger (27) showed that decreased adherence is associated with medications with a social stigma attached to its use and with medications which require following complex regimen ( e.g. duration of therapy, number of daily doses required, or therapies that interfere with a persons lifestyle. Adherence can also be affected by other factors e.g. if administration of a medication requires the mastery of specific techniques like injections (32). In a similar fashion, when medications such as antidepressants are slow to produce effects, the patients/older person may believe that the medication is not working and might stop taking it. Likewise the side effects of a medication too can lower adherence if the patients start believing that they cannot manage or control them (25). Patient related factors/dimensions They can be sub-divided into two major factors i.e psychological/behavioral factors and physical factors. Psychological factors include fear of dependence or possible adverse effects, knowledge about disease, motivation, perceived risk to disease benefit of treatment, understanding reason of medication need, confidence in ability to follow treatment, feeling stigmatized by the disease, frustration with health care providers , psychosocial stress, expectations towards treatment and substance (alcohol) abuse. Physical factors include issues like swallowing problems, hearing, visual cognitive impairments and impaired dexterity or mobility. Few of these physical and psychological factors can be discussed in detail as under: Psychological factors that influence adherence The WHO proposes a foundation model for medication adherence which is based on three major factors i.e. motivation, information and behavioural change. Behavioural change has been found to be influenced effectively by making interventions based on this model (33). In accordance to WHO, adherence and non-adherence are different behaviours. In order to change behaviour, information is a prerequisite, but in itself it is insufficient to achieve this change. Hence at this stage behavioural and motivational skills are critical determinants. Motivation and information work largely through the behavioural skills to produce an impact on the behaviour. However, when the behavioural skills are uncomplicated or are familiar, the two aspects i.e motivation and information can produce a direct effect on the behaviour (33). Physical Factors that influence adherence The risk for non-adherence among older patients is increased due to physical and cognitive limitations. Visual Impairment Decreased ability to perform activities of daily living and an increased risk for depression is associated with vision impairment (34), (35). Furthermore there are many other medication safety issues associated with vision loss. A persons ability to read patient information leaflets, prescription labels, determine the colour and markings distinguishing a medication is affected by low vision and blindness. Therefore consequently people who cannot read prescription labels or distinguish among different medications have to rely on their memory or depend on someone else for help and hence may not be able to take their medications correctly. Hearing Impairment Hearing loss is directly related with age. The natural aging process not only affects the ability to detect sounds at lower levels but also the capability to understand speech at a normal conversation level (36). This condition does gets worse with age and is progressive. It is therefore important to not assume when a deaf person nods his head in acknowledgement that he/she has understood, as he/she might be relying on a family member or a companion to explain later (36). Impaired Mobility Older patients with poor mobility may have difficulty in self administration of medicines or in obtaining medicines from the pharmacy (37). Cognitive Impairment Poor medication adherence is associated with Impaired cognition (25). Elderly patients with memory problems and cognitive impairment may have difficulty in understanding when to take, how to take or how much to take their medications. Others factors also include as swallowing difficulties and impaired dexterity. PREDICTORS OF medication non-adherence Predictors of medication non-adherence can be a useful tool in the improvement of medicine adherence among older adults. Few of the non-adherence warning signs (38) include failure to fill in a new prescription, failure to fill in prescription for choric medication or failure to obtain refills as often as expected for medications taken on chronic basis. Below are some of the more common predictors of medicines non-adherence (38): Forgetfulness Lower cognitive function or cognitive impairment. Lack of insight into illness Lack of belief in benefit of treatment. Belief that medications are not important or are harmful. Complexity of medication regimen Tied of taking medications. Inconvenience of medication regimen. Side effects or fear of medication side effects. Missed Appointments. Substance Abuse Limited English language proficiency. Role of NICE (National Institute of Clinical Excellence): The issue of non-adherence to medicine is a very important issue in its own essence. After assessing and understanding the impact of non adherence on the NHS the NICE (National Institute of Clinical Excellence ) came into action and published a guidance in January 2009 (Medicines Adherence: Involving patients in decisions about prescribed medicines and supporting adherence) to tackle and address this core issue (of non adherence). Before moving further it would be essential here to describe the role of NICE in terms of its function. NICE was established as a special health authority on 1st April, 1999 is an independent organisation that provides national guidance on promotion of good health and prevention and treatment of ill health in England and Wales (39). The institutes main purpose is to offer NHS health care professional advice on how to provide patients with the maximum attainable standards of care and to decrease the variation in the quality of care . Furthermore, NICE is not part of the European Medicines Evaluation Agency (which assess the efficacy and safety of drugs), only licensed drugs on the basis of their added value relative to existing practice in the NHS are assessed by NICE (40). It has four programmes that produce guidance which are mentioned as under (39): Public health guidance Clinical Guidelines Interventional procedures Health technology appraisals ( for surgical interventions, pharmaceuticals, medical devices, etc) Most programmes take into account both the elements of cost-effectiveness (how well an intervention works relative to its cost) and effectiveness (how well an intervention works) NICE has an annual budget of 33 million pounds annually with over 250 full-time staff members working at offices based in London Manchester. The processes NICE uses in the development of its guidance are highly consultative, evidence based and transparent. It also involves all relevant stakeholders, including policy makers, health professional managers, specialist, academics, representatives of health care industries, general public and patients (39). The guidance that NICE produced to address the issue of medicine adherence was CG76 Medicines Adherence: Involving patients in decisions about prescribed medicines and supporting adherence. This guideline was produced taking into account the patients views as to what they perceive as barriers to effective medicines adherence and thus encourages healthcare professionals to have a discussion with patients about their prescribed treatment especially for long term conditions. In addition to this the guidelines also open a pathway for dialogue and negotiation between the patient and the health care professional regarding their medication. A quick summary of the guidelines is as mentioned below Summary of the NICE guidelines Bullet-points below quote from summarise recommendations from the CG76 guidelines (41). The key recommendations from NICE guidelines are as under Table 1: Shows the key recommendations from NICE CG76 guidelines. Involving Patients: Improve communication with patients Increase patient involvement in the decision making process about their medicines. Understand the patients perspective on their condition and possible treatments. Provide information about their condition and possible treatments. Supporting Adherence: Assess adherence levels Identify adherence issues Address adherence issues Review medication and its effective use Improve communication between health care professionals in the care pathway. From www.nice.org.uk/pdf/CG76fullguidelines.pdp Significance of the Study Community Pharmacists are the health care professionals which are most readily accessible to the general public and therefore continue to be the first line of Healthcare. They are experts on medicines and represent an important link in the chain of the health care professional team. Thus the main objective of this research project will be to provide a new insight as to what the community pharmacists reflect/perceive about these NICE CG76 guidelines. Hence their views and opinions will be assessed and analysed with regards to these NICE recommendations (as this would help in the implementation process). Any differences in the views of the pharmacists or any disagreement on the effectiveness of the NICE guidelines would mean that further investigation could be required to improve or update these recommendations. Hypothesis: H0 = There will be no statistically significant relationship between the years of experience of the pharmacists and the awareness of NICE CG76 guidelines. H1 = There will be a statistically significant relationship between the years of experience of the pharmacists and the awareness of NICE CG76 guidelines. H0 = Majority of the community pharmacists will not agree (on to a large extent) that CG76 recommendations have been effective in the improvement of medicines adherence among their patients. H1 = Majority of the community pharmacists will agree (on to a large extent) that CG76 recommendations have been effective in the improvement of medicines adherence among their patients.

Heaneys Poem Follower Essay -- Heaney Follower Essays

Heaney's Poem "Follower" Follower is a poem about the poets love and admiration for his father. It is also about the changes that occur between father and children as children move out from their parent’s shadow. In the first half of the poem the poet draws a vivid portrait of his father as he ploughs a field. The poet, as a young boy, follows his father as he goes about his work and, like most boys, he idolises his father and admires his great skill, ‘An expert. He would set the wing and fit the bright steel – pointed sock’. In the poem, Heaney looks up to his father in a physical sense, because he is so much smaller than his father, but he also looks up to him in a metaphorical sense. This is made clear by the poet’s careful choice of words. An example of this is in the lines, ‘His eye narrowed and angled at the ground, mapping the furrows exactly.’ These words effectively suggests his father’s skill and precision. We are also told that young Heaney ‘stumbled in his hob – nailed wake,’ which brings to our mind a picture of the ploughman’s heavy boots, the carefully ploughed furrow and the child’s clumsy enthusiasm. The poet uses onomatopoeic words to capture the details of his father as he works the plough. At the end of the first stanza he describes him leading the team of plough-horses, instructing them with his â€Å"clicking tongue†. In the second stanza his father guides the horses with â€Å"a single pluck Of Rains†. It is interesting that the onomatopoeia here emphasises the great skill with which the poet’s father controls and guides his horses. It shows again his â€Å"expertise† and ease with the animals as he ploughs the field into furrowed lines. In the second half of the poem, the focus shifts... ... burst" shows growth and reproduction. Heaney's school teacher, Ms Walls, is hiding the reality of reproduction from the young children as they are not yet ready to accept the reality of the situation. He is disgusted at the thought of reproduction because he sees things through the surrealistic eyes of a child because of the stage he is at. He isn't ready to accept sex. He can't rationalise. Puberty makes him feel guilty. In the end he runs away, "I sickened, turned and ran", which shows that he has not fully grown up. In this poem, Heaney uses terms we do not expect to see in poetry, and presents nature as the very opposite of beautiful. Heaney shows how children are very ingenuous and naà ¯ve and see the world as being very pure and wholesome just as it is in their imagination. He also shows that there is a transformation from childhood to adult hood.

Turkey Economy :: essays research papers

Turkey’s economy has weathered some spectacular pratfalls in the past, with a major economic crisis in 2001 almost bringing the country to its knees. What’s different in 2004 from the previous "recoveries" is how committed Turkey is to establishing firm economic footing once and for all. The government is swallowing the International Monetary Fund’s painful economic medicine, making tough choices for fiscal discipline. Turkey’s financial wunderkind, the 37-year old Minister of State for Treasury Ali Babacan credits a strong, popular and unified government with having both the clout in Ankara and the backing of the people to administer badly-needed shock therapy. "During the last decade, stability has been a problem," Babacan concedes. "We had coalition governments and [frequent] early elections. "But after the 2002 elections," which ushered his faintly Islamic yet pro-Western Justice and Development Party to power under Prime Minister R. Tayyip Erdogan, "we have a stable government, one the people have confidence in, which provides a much-needed base for economic recovery." Erdogan came to Ankara under heavy suspicion due to his past in radical Islamist politics. But as mayor of ungovernable Istanbul he won grudging praise from political opponents for his hard work on civic issues and muted Islamic rhetoric. As Prime Minister he has focused on bread-and-butter issues, leading with gusto the country’s drive to join the European Union. Indeed, the JDP’s acceptance of fiscal reform and pro-EU stance has rebuilt confidence in Turkey’s ability to manage its finances once the IMF decamps. "Our economic program was declared in detail before the election," Babacan, a graduate of the Kellogg School of Management notes. "We’re doing what we promised." It was only during the 1980s that Turkey ditched its closed command-economy, replete with Soviet-style Five Year Plans and huge state-run monopolies. The result was a roller-coaster of boom and bust, with hyperinflation and a Wholesale Price Index at 160% by the end of 1995 and a Nominal Interest Rate of 320% at one point. Such shenanigans were offset by production in overdrive – growth through the turbulent ‘90s averaged 5% per year. But in the late ‘90s the Asian crises and the collapse of the Russian economy cost Turkey valuable export markets. Foreign exchange sought calmer waters, leaving the government to resort to offering 140% interest on its T-bills to finance its deficit. Annual inflation ran at a Weimaresque 102%. The IMF stepped in with a three-year stabilization program and a $4 billion jump start.

Adults and Children Essay

A gated community is a type of residential community that upholds privacy and exclusivity. Residential houses within gated communities are bounded within limited proximities that are bordered by walls, gates, fences, and such. Access or entrance to gated communities is highly restricted not only for pedestrians, but also to various types of transportation as well. Within gated communities, residents are provided with services or amenities that are exclusive only to them. Sometimes, gated communities adapt the concept of larger communities by providing services and amenities that will allow residents to enjoy a comfortable home and lifestyle within the bounds of the area. Large-scale and highly private or exclusive gated communities even provide small to medium sized shopping centers, recreational facilities, food and dining centers, and such that enables residents within it to enjoy daily living tasks and activities comfortable within its proximities. (Blandy & Lister, 287) The purpose of establishing gated communities is to provide the community with safe and secure housing opportunities for individuals allowing them to experience a peaceful and relaxed home environment. Security systems established within gated communities for limit access from non-residents ensure individuals that the area is sheltered and guarded from criminal activities. (McGoey) Another objective for the establishment of the concept of gated communities is to allow residents to control or manage the community or environment they live in by granting them the power or authority to supervise roles or activities within it. Gated communities are guarded by appointed security officers, but it is usually managed by a Homeowner’s Association – a group or organization which handles everything that has something to do with living within the gated community. The owners of the properties within the gated community gather and elect leaders who will be in charge of overseeing all needs, problems, concerns, and other issues that might require urgent attention and resolutions. In addition, gated communities also serve as housing facilities that promises to provide residents with the best quality of life by offering unlimited access to fun, entertainment, and privacy. For instance, some large-scale gated communities have golfing areas that are accessible only to residents. Residents are allowed to play within the golfing areas without any limitations. (â€Å"Explore Gated Communities! †) Due to the benefits and advantages of living in gated communities, some discussed previously, it has become a major trend in modern housing. (â€Å"Explore Gated Communities! †) However, although the positive attributes or aspects of gated communities have been discussed, there seems to be some issues raised on its influence or effect to the behavior and lifestyle of adults and children who live within and outside the community. Adults and children who live in and outside gated communities acquire both positive and negative qualities and perspectives from the context or dimensions of walled housing arrangements. The effects of living within gated communities vary from emotional and psychological, to moral and social influences. The remainder of this paper will discuss how the behavior and lifestyle of adults are influenced by the structure of gated communities. In terms of the relationship between adults and children, living within gated communities allows parents and older members of families to feel at ease with the whereabouts of their children within the community. The focus of gated communities on providing safe and secure home environments ensure parents that their children are safe without their close supervision as long as they stay within the confines of the gated community. (Le Goix, 2003) This helps them to focus on other urgent things or concerns as they feel no worries or stress regarding the safety of their children. On the other hand, parents who live outside gated communities feel the worry and stress due to the relocation or concentration of criminal activities outside the walls of gated communities. Since the difference between gated communities and the public is most observable in terms of safety and security measures, the distinction between these two kinds of communities gives way to the unequal division or distribution of criminal activities within the entire community. Criminal activities will converge on areas neighboring non-gated communities. (â€Å"Diagonal Mar – A Gated Community,†) This concern allows parents to feel worried or stressed about the safety of their children leaving them deeply involved with ensuring that they keep them protected at all times.

American Quail

In Europe, it refers to several kinds of game birds of the pheasant family. A brood may include from 10 to 18 eggs or more. Bold face markings and tilting crests identify the males from the females. Their feathers usually are slate blue, olive-brown, and black and white. Other kinds of American quail are the California quail, Gambles quail, mountain quail, scaled quail and mearn`s quail. These small plump quail prefer open woodlands, chaparral and grassy valleys. Hunters have killed so many of these birds that many states have hunting laws to protect them. Quails scatter at the approach of an enemy. Then they sound a gathering call. Bird authorities believe quail gather together this way. In Europe, it refers to several kinds of game birds of the pheasant family. A brood may include from 10 to 18 eggs or more. Bold face markings and tilting crests identify the males from the females. Their feathers usually are slate blue, olive-brown, and black and white. Other kinds of American quail are the California quail, Gambles quail, mountain quail, scaled quail and mearn`s quail. These small plump quail prefer open woodlands, chaparral and grassy valleys. Hunters have killed so many of these birds that many states have hunting laws to protect them. Quails scatter at the approach of an enemy. Then they sound a gathering call. Bird authorities believe quail gather together this way. In Europe, it refers to several kinds of game birds of the pheasant family. A brood may include from 10 to 18 eggs or more. Bold face markings and tilting crests identify the males from the females. Their feathers usually are slate blue, olive-brown, and black and white. Other kinds of American quail are the California quail, Gambles quail, mountain quail, scaled quail and mearn`s quail. These small plump quail prefer open woodlands, chaparral and grassy valleys. Hunters have killed so many of these birds that many states have hunting laws to protect them. Quails scatter at the approach of an enemy. Then they sound a gathering call. Bird authorities believe quail gather together this way. In Europe, it refers to several kinds of game birds of the pheasant family. A brood may include from 10 to 18 eggs or more. Bold face markings and tilting crests identify the males from the females. Their feathers usually are slate blue, olive-brown, and black and white. Other kinds of American quail are the California quail, Gambles quail, mountain quail, scaled quail and mearn`s quail. These small plump quail prefer open woodlands, chaparral and grassy valleys. Hunters have killed so many of these birds that many states have hunting laws to protect them. Quails scatter at the approach of an enemy. Then they sound a gathering call. Bird authorities believe quail gather together this way. Doug Ose was born in Sacramento on June 27, 1955. He graduated from Sacramento's Rio Americano High School. Then went on to earn a Bachelor of Science in Business Administration from the University of California at Berkley in 1977. Doug worked in his family†s business, Ose Properties, for eight years as project manager. There he was responsible for developing three sub-divisions of approximately 273 residential lots in Sac and Roseville. He started his own real estate development and investment company in 1985. It specialized in mini-storage development projects. Today, Doug is recognized as an expert in mini-storage facility development. Doug and his wife, Lynnda, have two daughters, Erika and Emily. He has been a member of the Board of Directors for the California State Automobile Association, the Board of Directors for the Citrus Heights Chamber of Commerce, and the Sacramento Housing and Redevelopment Commission. Doug also served on the Citrus Heights Incorporation Project, where he was a leading force in the drive to incorporate the City of Citrus Heights in Sacramento County. On Nov.3 98, Ose was elected to the u.s. house of reps. He represents California's Third Congressional District, which includes Yolo, Sutter, Glenn, and Tehama Counties as well as portions of Sac, Solano, and Butte Counties. In the 106th Congress, Congressman Ose serves on three committees: Agriculture, Banking and Financial Services, and Government Reform. Sub committees include: general farm commodities, resource conservation, and credit/risk management, research, and specialty crops, Banking and financial Services: sub committee: domestic and international monetary policy, and Government Reform sub committees: criminal justice, drug policy and human resources/ government management, info and tech. This was a hard paper for me. I waited too long to start and could not find much information. Next time I†ll work harder to get my assignments done to my full ability. Anyways, I went to search on AOL, Net Explorer, and the Doug Ose website.

Multivitamin

In my house I have two types of multivitamins on hand. I have Marvel’s, The Amazing Spider-man complete multiple Vitamin and Mineral Supplement with DHA. I also have Equate Woman’s One Daily with calcium, Iron, and Zinc multivitamin and Mineral Supplement. My son, although an adult, prefers the taste of a chewable, which is why I have Spider-man vitamins on hand for a 20 year old. The benefit of taking either of these vitamins every day is that no matter what you eat each day, since a daily diet usually varies, your body is guaranteed to receive at least the minimum amount of essential vitamins and minerals a body needs to perform at its best. Almost every person has a day where they didn’t eat breakfast, or maybe they skipped lunch, the vitamin, helps to replace what they missed in getting from the nutrients given to a body through food. For instance, I do not drink a lot of milk. Therefore, unless I am eating a larger amount of other dairy products to compensate, I need a vitamin that contains calcium to support my bone growth, structure, and to prevent osteoporosis since I am in my 40’s. While not having enough vitamins and minerals in your body can cause many health related problems, over taking them can also cause health problems. They fact is that most vitamins and minerals are absorbed into the body, and eating a healthy diet with only one supplement can keep a person healthy and balanced. However, most people do not eat a healthy diet, therefore the supplements can help keep them on track. One must keep in mind as well though that some people over use supplements thinking they are increasing their health when the reality is they may be causing the very problems they are trying to prevent. The textbook relates to a study showing that too much pyridoxine caused people to lose the ability to walk (Chapter 8: The Vitamins, n.d.), whereas not enough was thought to cause anxiety and depression. The text also explains how sailors did not get scurvy when they took vitamin C. Too much vitamin C causes stomach ailments. Based on the guidelines, in my home, vitamins are needed. We do not eat a proper healthy diet that would contain all the correct amounts of vitamins and minerals our bodies need to support good health. Taking a vitamin everyday, which we do, makes me feel a little bit better about the state of our health and daily diet.

You Vs. Fast Food

Remember how simple it was to pull up to the drive through and tell the little speaker box what combo you wanted? You weren’t ashamed of asking for large fries and a chocolate milkshake because your stomach can handle anything you decide to digest. The salty golden arches crunched as you took a bite, the juicy double cheeseburger melted in your mouth or the sweet tea quenched your thirst and the hot fudge sundae sent you on a sugar rush. The teenage years were carefree because there was no distinction between healthy and life threatening when it came to choosing where to eat during lunch break. Unfortunately, your figure cannot handle careless food decisions anymore. Now you need to drive past that McDonald’s and find the nearest salad bar. Fast food is not your friend; it’s your enemy. Looking back you must wonder why you thought greasy cheeseburgers and fried chicken were the ideal meal; they certainly did not do any good for your body. Yes it was a quick and easy way to get food but that was during the years you stayed active. As a woman well over her thirties, you are smart enough to know that you don’t have the same metabolism as any eighteen-year-old girl. Face it, you are no longer that little girl who could devour her way through all you can eat buffets and midnight snacks. You are a mother who may have gained a few pounds here and there; nevertheless, you are not allowed to let yourself go. More importantly, do not feed yourself straight into a heart attack because you divert to fast food for dinner. A meat patty is made from the unhealthy parts of the beef. White bread will only make you want to eat again in a couple hours. The oil used to make your favorite value menu snack can eventually clog up your arteries if eaten excessively. Why risk your life for chicken nuggets that never look as good as the ones on the TV commercials? Don’t forget that you are no longer thinking of yourself, you have a husband and children. Are those deep fried onion rings really worth thousands of dollars toward hospital bills and the thought of your family losing its primary caretaker? Now you can pull up to the drive through teller and ask the little speaker box if it knows where the nearest Subway is because you have conquered your need for unhealthy fast food. Don’t let the golden arches confuse you, they are swords to the stomach and the milkshakes will only give you brain freezes. Stay away from that double cheeseburger because it is soaked in oil that leads to high cholesterol and heartburn. Don’t give in to the artificial sweeteners and chocolate because they satisfy you when you have them, but will only make you crash harder. You are stronger than any of the unhealthy products fast food throws your way. If you stay away from them all together, you will no longer have to worry about fast food taking you down. You will come out well figured, healthy, and victorious.

Public health and health policy Discuss the health problems and health Essay

Public health and health policy Discuss the health problems and health service issues that are associated with homelessness in L - Essay Example In London, the homeless face the problem of insufficient primary and secondary care, in spite of their critical health situations. National Health Service, the primary provider of public health in the UK, cannot provide such essential services to people without access to fixed address, a common feature in developed nations (Daly, 2013, p.213). In addition, Rogers and Pilgrim (2010, p.60) asserts that the homeless are prone to neglecting their health status, more than the general population, and they only seek such services when their health status have reached advanced stages. Homelessness is a complicated global issue that is caused by several issues while at the same time it does not have a single solution. In recent years, the government and global health organisations such as the World Health Organisation (WHO) have identified the complex health challenges affecting the homeless as the underlying problem apart from the obvious accommodation issues amongst others. In England, ther e are several National Health Services and other privately sponsored charitable services, which provide the necessary healthcare and support to the homeless. The civil society in England, noted that during the global downturn, the National Health Services reduced its spending on the homeless. ... Gramlich (2008, p.70) observes that there is not a single specific definition of the term as variance in temporal dimensions, cognition and lifestyle amongst the homelessness street people. Since homelessness is mirrored in different settings, several situations come into play; this paper posits that the political agenda as well as the prevailing social values have been strongly linked to the definitions. Conventionally, homelessness has a residential dimension and this can often be used to redefine the term in this context. This is because the apparent feature of the classification stems from the lack of conventional housing for those deemed homeless. Levy and Sidel (2013, p.176) applies the United Nations Committee on Human Rights definition of the term and they intone that people who sleep in outdoors such as vehicles and abandoned non intended for human dwelling. Legal and statutory definition of the term have a characteristic contradictory nature and in the United Kingdom alone, there are several acts that define the term both at the national level and in the devolved systems. However, housing authorities in the United Kingdom consider domiciled individuals who have applied for their accommodation as homelessness applicants and therefore categorized. In the strictness of the term, the city of London has often distinctly identified two groups; the homeless and the rough sleepers. The rough sleepers are those who live and sleep on the streets of several English cities, yet in our case we shall be confined to London and Newham in particular. The Department of Communities and Local Government (2013) describes a person as statutorily homeless

Starbucks Essay Example | Topics and Well Written Essays - 750 words - 1

Starbucks - Essay Example Other countries where Starbucks has opened several stores include Canada, where it operates 1,248 and Japan where Starbucks has 965 stores (Garza par. 1). Industry Starbuck Corporation deals with the sales of drip brewed coffee, hot drinks of espresso, coffee beans, hot and cold drinks, sandwiches, salads, sweet pastries, Panini, snacks and other items such as tumblers and mugs. In addition, Starbucks sells coffee and ice cream at its grocery stores (Stevens and Loudon, 2005). As aforementioned, Starbucks is currently the largest coffee company and chain in the world operating more than 20,000 stores in 62 countries. Starbuck also stands out as one of the major employer company in the world with more than 149,000 employees. In addition, the company has over 4 million followers on Twitter plus 34 million likes on Facebook (Garza par. 3). Regarding growth, Starbucks currently operates at a mature stage of its lifecycle. Since its founding more than 2 decades ago, the company has experi enced rapid growth since its formation. Nevertheless, the growth prospects have significantly slowed down in recent times, which have even forced it to close some of its chains. Starbucks is currently focusing its efforts on its earlier endeavors and internationalization (Allison 4). Starbuck’s Mission Statement Starbuck’s mission statement is more than just words. ... Starbuck’s Sales History Starbuck has always registered increased sales over the last two decades of its existence. With a market capitalization worth $50 billion, the company has always been able to register increased sales, thanks to its quality coffee, which continue to attract more customers. In the year 2012, for example, the company registered $13 billion in sales (Murphy par. 3). Target Markets Starbuck has a very diverse market with segments varying depending on the different products that the company offers. However, in general terms, Starbuck’s target market comprises of the coffee drinkers throughout the country. Starbuck also targets mainly men and women aged between 18 to 35 years since they form about 40% of the total market. Most of the company’s customers reside in cities and suburban areas. Starbuck’s target market also comprises of university faculty members and students, as well as individuals working in managerial, professional, and exe cutive positions. Further, the company also targets people with earning relatively higher incomes, since the company’s products are more expensive than other coffee shops such as Tim Hotton and Coffee Times (Murphy par. 5). Competitive advantage Starbuck’s competitive advantage is based on the company’s strengths. These include the premium quality of its coffee drinks and other products that it offers. Starbuck also provide its customers with a brand experience that goes beyond the products that it deals with, including excellent customer service, peculiar drink names, and elegant looking stores that serves as an excellent meeting point. The company also gives back to the community and protects the environment through corporate social responsibility. In addition, the company has strong personnel

3d printing Essay Example | Topics and Well Written Essays - 750 words

3d printing - Essay Example innovative technological invention of 3D-printers, members of the society have no business ordering for the items they require for their daily activities. Although the time factor is one among the major benefits of using 3-D printing, this paper aims at analyzing how 3-D printing affects manufacturing, quality, the economy, and inflation. The paper discusses the operational, strategic, financial, and social effects of 3-D printing. Manufacturing involves the process of transforming raw materials into consumable products for commercial, personal or final use. With reference to technological advancements, 3D-printing has brought the manufacturing process closer to the end user. Through 3D-printing, individuals are able to manufacture the items they require from the convenience of their living areas. However, when considering the processes involved in manufacturing, it is evident that 3-D printing has varying effects on the community as a whole and the manufacturers in particular. For instance, the use of 3D-printing is a solution-driven invention that aims at eliminating the costs associated with the manufacturing process, distribution, storage, and security of products. On the other hand, it eliminates an employment segment as manufacturing processes that required vast categories of labor are replaced with machines functioning through the use of virtual intelligence. While the manufacturing process making use o f 3D-printing is likely to put a number of people out employment, it allows great deal of diversity for the options available to customers. In addition, the use of 3D-printing engages the customer with the manufacturing process making it easy for customers to manipulate design, taste, content, and feel of various objects to match personal preferences (D’Aveni, para 1-4). A machine is an operational device which combines various parts working in various patterns to form a system. Through the application of virtual logic, a system is directed or programed to

The application of balanced scorecard in the performance evaluation of Essay

The application of balanced scorecard in the performance evaluation of higher education - Essay Example In the case of non-proï ¬ t organizations, the BSC lays huge emphasis on customer satisfaction and therefore a priority is given in all matters regarding to customer services. in organizations where a financial crisis is a daily affair, their BSC prioritized financial perspective. Focusing on different prioritization perspective of BSC, organizations have an opportunity to allocate resources appropriately with minimal wastage or fraud. The study case has also provided a platform for non-profit organizations to measure how they perform. In this, performance measure indicators (PMIs)are applied as indicators of efficiency. Again, different definition of PMIs can be adopted to fit the objectives of the business. In case of institutions of higher learning, â€Å"student/staff ratio† and â€Å"Ph.D ratio† PMIs are appropriate. For manufacturing concern, â€Å"customer satisfaction† is applicable while â€Å"service delivery† PMIs works with non-proï ¬ t org anization. Though implementation of the BSC has not been effected in Taiwan and other developing countries, America and Europe are already reaping its benefits. BSC is yet to gain momentum and relevant in third world countries. However, this study has clearly demonstrated that BSC can be instrumental in delivering positive changes in strategic and performance management in higher learning institutions. Furthermore, the study has recommended that senior management and supervisors must fully support the implementation of system managing tools, otherwise they are destined to failure. In conclusion, institutions should me motivated by their vision and mission so that they are run like any other business where efficiency is highly