Studies in Professionalism in Education & Training

I am currently employed in the post 16 training sector as a tutor on the ‘entry to employment’ programme (e2e). The e2e programme is designed to be flexible and individual, with the aim of equipping young people with the necessary skills to become independent; self-motivated; informed and empowered to take control of their own lives. Learners work towards realistic but challenging targets that lead to progression onto suitable training or employment opportunities. There are 3 basic strands to the e2e programme; basic and key skills (literacy, numeracy, communication etc†¦); personal and social development and vocational development.The programme is tailored to suit the individual needs of a variety of young people who are engaged on it. All learners are aged between 16 and 18 years and are not participating in any form of post 16 learning, or in any form of employment. The programme itself is not qualification driven. However, opportunities for the achievement of ce rtificates are available throughout the course. There is no set time limit for the e2e programme ensuring that learners can work at a pace suited to their skills, needs and circumstances – learners can spend as little or as long (within reason) on the programme in order to successfully achieve their goals.The strand I teach is vocational development. This incorporates training sessions such as CV building; interview techniques; job searching and sustaining employment. Learning is individualised, thus meeting the needs across a range of age and ability. Professionalism to me is exceeding the standards as set by various government offices and ensuring that the service young people access at my organisation is a quality one. Further education has received its share of criticism over the last century and this has been reflected in the salaries of the tutors in this sector as opposed to those in the compulsory education sector.To me being a professional is about attitude, behaviou r, self presentation and having a commitment to improvement. How we conduct ourselves in our roles is paramount to earning the respect and appreciation of our fellow workers, managers and indeed the people accessing the services we offer. The learners that access our service are usually low level (below entry 1) and many lack motivation to learn. As the National Foundation for Educational Research conducted research on participants taking part in e2e, â€Å"Around one-third of young people interviewed reported negative school experiences.These related to problems with other students, negative relationships with teachers, lack of achievement and the perceived irrelevance of what they were taught. Many had been expelled from school or had excluded themselves. † (http://www. nfer. ac. uk/research-areas/pims-data/summaries/eet-entry-to-employment. cfm This gives some indication of the difficulties facing tutors in this sector and it is my belief that conducting a programme that r eflects school will only serve to discourage learners from accessing this course.Therefore, although we must be professional, we must also offer something different to the curriculum offered in compulsory education. Thus it is important to consider Abraham Maslow’s Hierarchy of Basic Human Needs. The main points being; physical comfort, safety and shelter, love and belonging, self-esteem leading to self-actualisation. Further education in the UK has seen many changes during the last 10 years. Concerns were raised by the government that Further Education was not producing a skilled enough workforce in line with international standards, impacting upon Britain’s economical viability.Other EU countries were seen to be producing a much higher skilled and trained workforce. The belief was that a cause of this was a lack of suitably qualified teaching staff in FE. This propelled the notion that all teaching and training staff working in the FE sector should be qualified to th e standard set by mainstream schools. It was thought that by doing this, standards of the UK workforce would be raised. In 1999 FENTO (Further Education National Training Organisation) was launched. They were responsible for identifying needs within the FE sector.In 2000 FENTO proposed a set of standards, which addressed wider issues of professional development and considered a new teaching qualifications network. These standards consisted of three main elements: Professional knowledge and understanding, skills and attributes and key areas of teaching. In 2005 Lifelong Learning UK (LLUK) was formed to manage the reform of teacher training. All FE teachers now have to register with the Institute for Learning (IfL) which is part of LLUK, and monitors training and records sector training needs.Since initial reforms, teaching standards in FE have further developed and progressed. In March 2006 the White Paper ‘Further Education: Raising Skills, Improving Life Chances' highlighted further needs to develop a much more highly skilled workforce. It states, â€Å"This is a huge challenge, because there are some deep-seated and long-standing weaknesses in our national skills. We have put in place major reform programmes for 14-19 year olds and adult skills, backed by substantial investment.Those reforms are bringing about real progress. But there is a long way to go to raise skills and qualification levels for young people and adults to world standards† (White Paper ‘Further Education: Raising Skills, Improving Life Chances', 2006). It also goes on to say that FE establishments are central to achieving world standards in the UK workforce, but are currently not realising their full potential in being the driving force behind skills.The paper paints a grim picture in terms of skills levels of the UK in comparison to other developed countries, and with the Leitch report highlighting the skills need for 2020, it is clear that reform is necessary for the U K to compete in the global economic market. The economic mission is at the core of the proposals, with the focus of the FE sector to be equipping young people and adults with the skills and competences that meet the needs of employers. The proposals laid out in this white paper were implemented in the Further Education and Training Act 2007.Reforms such as the above have a resounding impact on organisations such as mine. We have to ensure that the government’s vision and targets for the future are embraced and taken forward in the most effective possible way, thus demanding that we, as FE employees, are professional in all aspects of our work. So how do we as an organisation ensure the commitment and quality of service that is expected by our government? Firstly it is imperative that we have systems in place that effectively transmit information to staff.Accurate and relevant information and communication are vital in order to transmit and effectively implement plans that wil l uphold the government’s wishes in regards proposals for FE. My organisation has a quality improvement department which continually monitors the performance of the company against standards set out by agencies such as the Office for Standards in Education (ofsted), Qualifications and Curriculum Authority (QCA) Learning and Skills Council (LSC) and many more.FE establishments are now subject to inspection by ofsted of which their aim is toâ€Å"inspect and regulate to achieve excellence in the care of children and young people, and in education and skills for learners of all ages† (www. ofsted. gov. uk). This department is crucial for the continuation of improvements within educational settings. Although misinterpreted by many as ‘harrowing’ and ‘stressful’, the inspection process that this agency conducts is the platform for which FE providers need to build their provision.Ofsted inspections are designed to aid improvement in services, raise aspirations and assist in the achievement of higher standards within educational settings. The quality improvement team in my organisation follow the Common Inspection Framework as dictated by ofsted. This ensures we are providing the services and meeting the standards set by the government. In order to ascertain that teaching staff are in line with this framework, regular lesson observations take place by competent staff. By carrying out these observations, staff are able to use the feedback to continually improve their practice.It is also expected of teaching staff to self evaluate and reflect upon every lesson they teach. This is a key part of professionalism within teaching. I will discuss in more detail later in this essay the values and importance of reflection. The quality improvement team are also responsible for official documentation used by all staff. These are regularly reviewed and updated and communicated to all staff. This ensures that all staff are using the same doc uments and helps create seamless processes that are followed by all.As well as ofsted there are many other agencies that regulate the delivery of FE in the UK. One of these is the QCA. As a provider that delivers qualifications in a variety of subjects the QCA is an important source of information. The QCA maintain and develop the National Curriculum and accredit qualifications to appropriate levels in order to meet the needs of learners, employers and the economy. As we deliver accredited qualifications it is crucial that we follow the guidelines set out by the QCA to ensure we are teaching the correct knowledge and skills that learners need to achieve the standards set.We also have to adhere to awarding bodies such as Edexcel and City & Guilds who provide the qualifications which we deliver. As well as organisational procedures and external influences, it is crucially important that we, as teachers strive to continually improve our practice by self reflection. â€Å"Reflective Pr actice is a process of reviewing an experience from practice in order to describe, analyse and evaluate and so informs learning from practice† (Reece and Walker, 2006 p421). This involves using a selection of the models identified during the course of this programme.Donald Schon (1983) identified 2 sub categories of reflection, reflection on action and reflection in action. Reflection in action is often described as ‘thinking on ones feet’; this is done during the course of action and is one that I have had to use many times during the course of my career. Reflection on action occurs after the actual action and gives professionals the opportunity to develop theories and create knowledge. â€Å"Individuals, supported by others, constantly frame and reframe a problem, test it and reach solutions† (Schon, 1983).Another model of reflective practice is one proposed by David Boud. In the introduction to Understanding Learning from Experience, David Boud et al (19 93), present five propositions of experiential learning, the first of which is; experience is the foundation of and the stimulus for learning. â€Å"Learning always relates in one way or another, to what has gone before. There is never a clean slate on which to begin; unless new ideas and new experience link to previous experience, they exist as abstractions, isolated and without meaning† (Boud et al, 1993, p8).Building on previous learning and relating new learning concepts and topics to past experience has been essential in my teaching practice. Linking new experiences to past ones to create new meanings and insights in extremely constructive in reflective practice. â€Å"We attach our own meanings to events. While others may attempt to impose their meanings on us, we ultimately define our own experience. † (Boud et al, 1993, p10) Another important model of reflective practice is Jack Mezirow’s. His emphasis is on disorientating dilemmas, which he believed can be a slow transition rather than a sudden insight.Mezirow believes that, â€Å"learning is different when we learn to perform than when we understand what is being communicated to us. † (Mezirow, 1990) The belief is that questioning and reflective nature results in an altered and more beneficial learning process. â€Å"In reflective practice, practitioners engage in a continuous cycle of self-observation and self-evaluation in order to understand their own actions and reactions they prompt in themselves and in learners† (Brookfield, 1995) The diagram below illustrates Brookfields perspective of reflective practice.Reflecting upon my practice is something I need to be doing continuously to constantly develop in my role. This reflective process is an essential part of teaching, as Kolb’s Four Stage Model of Learning, demonstrates. Reid (1993) states â€Å"Reflective Practice is a process of reviewing an experience from practice in order to describe, analyse and evaluate and so informs learning from practice† (Reece and Walker, 2006 p421). Reflective practice is a vital part of teaching. Effective practice is a beneficial aspect of continuous professional development and without it progression in teaching would be extremely limited.By gaining a better understanding of their own individual teaching styles through reflective practice, teachers can improve their effectiveness in the classroom and strive to achieve the vision as set out by the government, as previously mentioned, for Further Education. Reflection of Learning – CertEd: During the 2 years I have undertaken learning on the CertEd course, I have learnt many underpinning theories that were previously unknown to me. Although I have worked in the industry for 8 years and learnt from experience and reflection, I have been unaware of the background as to why we do what we do and the reasons for it.It began with the first module which was preparation for teaching. In this mo dule we covered learning theories, learning styles, planning effective lessons, presentation of lessons and factors influencing learning. Before I began the module, I believed I had a sound understanding of the teaching process; however I discovered many more vital and useful tools that I now apply when delivering training sessions. Kolb’s theory was something that I was unaware of before this module. Learning theories was also a topic that I had very little knowledge on. This proved to be one of the most useful sections of this module.I did practice the different approaches beforehand but was unaware of the theories behind them. Now I am aware I believe I use them much more effectively in my day to day role and my planning of sessions. The next module was ‘Developing Personal Skills’, and I found this extremely useful. It enabled me to concentrate my efforts upon areas of my career that were not as strong as some of the others. By doing this I was able to improv e my performance at work a great deal. It was good to have agreed learning contract beforehand as this gave me a schedule to work towards.It was more beneficial negotiating with the tutor, what I wanted to develop, instead of being told what to work towards. In â€Å"Learner managed learning† Graves (1993) states the role of the learning contract in higher education takes on board the concept of our individual learning styles. It gives students the freedom to learn in a way they feel comfortable with. It has long been established that adult learners learn in different ways, and that they are self directing and defined in their experience, with the onus and effectiveness of this learning process primarily, on the learner.Upon reflection, I learnt much from this module, both my IT and networking skills have been improved, and this has had a positive impact on my job role. I feel much more comfortable using IT in teaching now than I did before, especially power point presentatio ns which I have used in a few sessions since my online tutorial. However I still have far more to learn, especially in IT as it is a fast changing concept that is constantly introducing new equipment and technologies into society and indeed teaching.The module on assessment was also beneficial as before this assessment was something that I did without really thinking of the underpinning theories to it. This module made me change my practice by ensuring assessment was valid, reliable and relevant and also prompted me to give more feedback to my learners and document this. The module of learning on curriculum studies was again one that developed my understanding of the subject. Designing a curriculum was a valuable learning experience for me and although a successful one, I have seen many opportunities for improvement along the way.In summary, teaching and learning is an ever changing industry and constant evaluation is necessary for the process to be continually successful and for on going improvement to take place. I found that the autonomy I was given helped tremendously as I was able to decide for myself what course of study the students would follow. Obviously I had to account for external influences such as the criteria of the awarding body and contractual requirements from the LSC, but nevertheless my organisation were prepared to allow me to choose the path students would follow to meet these.Kolb’s theory is foremost in my reflective practice as shown in the diagram below: By designing a curriculum and studying theories of curriculum, I gained a better understanding of the concept. I understand that influences such as organisational policies, government policies, awarding bodies and learning styles of learners, all have a bearing on how a curriculum is developed. I also learned much about the models of curriculum and in what context they are used. Many courses of study are designed to accommodate the product model; i. e.they are focused on achievi ng an end result, such as a recognized qualification; however I feel the process model can still be incorporated with better results, such as additional learning taking place and a more enjoyable learning experience for the student. The course I designed was a success. This was reflected in the achievement and retention figures that were collated at the conclusion of the course. I also believe that I added value to the curriculum by incorporating literacy and numeracy support throughout and designing learning to suit all students regardless of learning styles and abilities.I did have to change the course of study slightly of this curriculum, and so in future I hope to be able to build upon my experiences and design an even more effective course which incorporates the learning I have undertaken during this module. The final module on creativity was the one I felt most beneficial of the entire course. I realised during this module that I had always ‘played safe’ during my teaching and that fear of failure had prevented me from implementing ideas that could enhance my teaching and my student’s learning.During this module I researched creativity within an educational environment. I realised that being creative is sometimes about taking risks, and this was something I had previously been reluctant to do. Although I felt I was innovative in my lesson delivery, I now accept that a fear of ‘failure’ prevented me from fully committing myself to creativity. On the whole the CertEd course has been a valuable and worthwhile experience for me and I believe I have progressed professionally due to the modules I have undertaken.Following the course of study I believe I have made excellent progress professionally and feel much more knowledgeable in the sector than I did previously. I still have to continually improve as a professional and I am fortunate to work for a company that recognises this and encourages staff to undertake CPD. Continuous training and development for all staff is now an everyday part of the profession, not a training course that is ‘thrown in’ every few months with no clear structure.CPD must be strategically planned and embedded within the overall objectives of the organisation to ensure that staff are well prepared for any new developments that arise. At my organisation, staff are encouraged my management to take control of their development and inline with the Business Plan and the Self Assessment Report, are supported to undertake relevant, necessary CPD. I try and improve my practice in many ways. As well as the regular training courses I attend I also take responsibility and ensure that I continually strive to learn and become a more effective practitioner.Learning from other teachers is an important way for professional development. One of the most powerful ways to better your practice is to observe other teachers, ones that are experienced and confident in their roles. During th is course of study I have had a mentor and I have observed her on many occasions, as well as seeking advice and guidance on matters I am not confident in. I believe discussion with colleagues can be an important part of development. They can offer different views on situations and propose alternative methods of practice which might have previously not been considered.As well as using colleagues and mentors, learners are also a crucial part of continuing development. By gathering their thoughts and feedback on lessons I teach them, I am able to implement new strategies and adapt teaching methods to enhance the learning experience for my students. A written evaluation at the end of sessions is another useful way to reflect and enable improvements. â€Å"It is important to produce a written evaluation of the lesson which helps to reflect constructively upon practice.By reflecting on what went well and badly and evaluating what we would do differently we are developing professional pra ctice and evolving new ways to meet our learners’ needs (Wallace, 2001, p178). My organisation also conducts 6 monthly appraisals with all staff. During this process a development plan is also agreed and produced and this involves recording any learning that needs to be achieved, any courses that have to be undertaken and any other developmental requirements that staff feel they have. The appraisal process helps the employees to understand the company’s objectives.It helps them to set their goals and precisely know what role they play in their work to serve the organisation. This avoids frustration and gives job satisfaction to the employees. Performance appraisal benefits all parties and can serve to motivate and inspire employees to continuously develop and improve. My own development plan was agreed in February and runs until August. During this time my targets for achievement are Level 2 ICT qualification, Cert Ed qualification and to maintain my CPD file with all relevant learning.Beyond this time I am looking to achieve a business/management qualification during the next 2 years, and to develop my leadership skills due to a recent change in my job role. I will continue throughout my professional life to strive for improvement and new methods of working, which will enhance the experience of learners accessing our services. Professionalism is an ongoing process. It is commitment to self-improvement, competency in work, motivated in attitude and having respect for both colleagues and learners.

Lorenzo’s Oil Movie Review Essay

The movie, â€Å"Lorenzo’s Oil†, was about a family that found out that their son had been diagnosed with a rare, genetic disorder of which was considered incurable. The sex-linked disorder ALD, passed on by the x-chromosome, of which is usually accompanied by the unfortunate fate of death, has also been known to bring forth muteness, blindness, comas, seizures, and deafness. With no known cure for ALD, or any possible way of escaping its final result (death), doctors would use a special treatment to prevent any further deterioration of the brain, depending of course on the severity of the damage done prior to treatment. In Lorenzo’s case, the disorder had already corrupted too large of an area of his brain so the treatment given by the doctors would have been of little help to him. In most cases, death occurs nine months after diagnosis, however, Lorenzo’s parents refused to let death be his only option and they did their best to find another treatment to help their boy. This movie relates to chemistry in many ways, especially in the sense that there were chemical imbalances observed and the reactions of these imbalances were noted for future reference. As a major component in the medical field, chemistry is used in producing new solutions, observing their reactions, and testing the effectiveness of these solutions in treating or curing various illnesses. This is shown when Lorenzo’s parents continuously perform their experiments of mixing various substances and noting their ability to lower fat build-up in hopes of finding a cure to their son’s diminishing health. If put under the same circumstances that Lorenzo’s parents were put under, I believe that I would go to the same lengths in attempting to find some kind of treatment for my child. I think that my maternal instinct to care and protect my child would be too strong for me to just sit back and watch my child suffer, and honestly, seeing my child helpless and constantly struggling to live would be more than enough reason to do my best in finding something to ease, if not cure, my child’s illness. Whether or not I had been gifted with the knowledge needed to find such a remedy, I would still want to do all that I could for my child, even if it meant risking my life to save hers, and if nothing could be done, I would be sure to stay by my  child’s side at all times. However, one thing that I would never do would be to tell the doctors to end the life support given to my child. Even if that was the only way to end her suffering, I would rather let nature run its course than to feel guilty at finalizing the action of which would â€Å"help† her (according to other’s opinions who have no idea what she is going through) and feeling like a murderer of my own flesh and blood. When Lorenzo’s parents had made the discovery of a tonic, powerful enough to soothe the symptoms of ALD and lower the fat build-up, they did the right thing in immediately relaying the information of their treatment to doctors in hopes of saving other patients suffering as their son was. However, I feel that the doctors abused their powers as medical authorities in neglecting to accept the remedy, or even look into the composition of the remedy to find their own evidence of the effectiveness and ability to cure of the treatment. As doctors, their duty is to aid and assist the patients and to inform the patient’s families of every option available to ensure that they, as professionals in the medical field, did all that they could to cure or save their patients. However, by refusing to investigate the medicine or give the patients the option of trying this new innovation, the doctors neglected fulfilling their duty to its fullest extent and deprived their patients of anot her possible chance at survival. It is understood that all possible treatments produced are tested for months to confirm their effectiveness at combating ailments, of which is a very beneficial procedure to all. Lorenzo’s parents conducted numerous tests on their tonic’s working ability did and were aware of all possible reactions of their product. They felt confident in its positive benefits, which is why I feel they were so insistent at giving the medicine to other patients. I doubt that Lorenzo’s parents would have passed on such a treatment without knowing all the effects of their remedy, especially since they used the exact same medicine on their own child. However, I do not understand why the doctors would have been so set on refusing outside influences. I believe that one change made to the current system could be for doctors to be more willing to accept suggestions given to them, whether the suggestion be proposed by a medical professional or not. As shown in the movie, helpful information and innovations can be given by people other than medical authorities, such as  dedicated parents, like those of Lorenzo. Another change to the system would be to make medici nes more affordable to ensure everyone the same chance at living a long and healthy life. Even though technology has improved in the field of medicines and researchers have become more educated in areas of which they had once been clueless and lost, the medical field still has yet to be perfected. Many diseases and disorders are still considered mysterious, with very little knowledge known about them, and undiscovered. Until researchers educate themselves of every aspect of these controlling â€Å"monsters†, people will continue to suffer from such ailments. However, with better funding for the investigation of these unknown illnesses, knowledge will be obtained more quickly and long-awaited innovations will be found, an advantage to many, if not all. Researchers being more open-minded and more welcome to outside suggestions and ideas would also help in solving medical problems. They could also try to be more accurate in diagnosing sicknesses to ensure that patients are given the proper treatment and care needed to combat a specific ailment. Although changes to the procedures and actions in the medical field could be made, changes concerning those involved in the well-being of mankind would also need to be made. Unless researchers, doctors, and others capable of saving mankind are more willing to listen to outside ideas and perform their jobs to their fullest extent, the goal of being more powerful than these tricky, microscopic demons, of which for centuries have left us confused and bewildered at their amazing ability to conquer our bodies for their own use, will continue to be unaccomplished.

Spring exam

First Line Managers – supervise people who perform non-managerial duties Middle Managers – oversee the work of large departments or divisions Top Managers – guide the performance of the organization as a whole or of one of its major parts Governance – is the oversight of top management by a board of directors or a board of trustees Accountability – is the requirement so show performance results too supervisor The upside-Down Pyramid – view puts customers at the top of the organization by being served by workers who are supported by the managers below them Social Capital – Is the capacity to attract support and help from others In order to get things done. Emotional Intelligence – Is the ability to manage ourselves and our relationships effectively Conceptual Skill – Is the ability to think analytically and solve complex problems 1 . Self-Awareness ? understanding moods and emotions 2. Self-Regulation – thinking bef ore acting; controlling disruptive impulses 3. Motivation – working hard and persevering 4. Empathy – understanding the emotions of others 5.Social Skills – gaining rapport and building good relationships Global Sourcing – involves contracting for work that is performed in other countries Corporate Governance – is the oversight of a company's management by a board of directors Glass Ceiling Effect – an invisible barrier limiting career advancement of women and minorities Intellectual Capital – is the collective brainpower or shared knowledge of a workforce (Competency x Commitment = Intellectual Capital) Self-Management – is the ability to understand oneself, exercise initiative, accept responsibility and learn from experience ME – Chi. Critical Thinking – the ability to perceive situations, gather and interpret relevant information, and make decisions Sustainable Competitive Advantage – is an ability to ou tperform rivals in ways that are difficult to imitate Corporate Strategy – sets long- term direction for the total enterprise Business Strategy – identifies how a division or strategic business unit will compete in its product or service domain Functional Strategy – guides activities within one specific area of operations Growth Through Concentration – means expansion within an existing business area Growth ThroughDiversification – means expansion by entering related or new business areas Growth Through Vertical Integration – occurs by acquiring suppliers or distributors Retrenchment Strategy – changes operations to correct weaknesses Liquation – occurs when a business sells Its assets to pay creditors Restructuring – reduces the scale or mix of operations Divestiture – Involves selling off parts of the organization to refocus attention on core business areas Strategic Alliance – organizations Join together In partnership to pursue an area of mutual interest Co-petition – is the strategy of working with rivals n projects of mutual benefit business Strategy -strategically uses the internet to gain competitive advantage Scrounging – is strategic use of the internet to engage customers and potential customers in providing opinions and suggestions on implementing strategies Differentiation Strategy – offers products that are unique and different from those of the competition Cost Leadership Strategy – seeks to operate with lower costs than competitors Focused Differentiation Strategy – offers a unique product to a special market segment Focused Cost Leadership Strategy – seeks the lowest costs of operations within a special market segment Strategic Leadership – inspires people to implement organizational strategies Strategic Control – makes sure strategies are scrapped or changed ME – Chi. 9 Colonization – is the proces s through which new members learn the culture of an organization Observable Culture – is what you see and hear when walking around an organization Core Culture – is found in the underlying values of the organization Symbolic Leader – uses language and symbols and actions to establish and maintain a desired organizational culture.

Global Marketing Requires a Very Local Attention: a Lesson from Vodafone’s Loss of Japan Unit Essay

Case Summary: This case is talk about the company, Vodafone KK. This company has good performance in Europe, the Middle East, Africa, Asia Pacific, and their subsidiary is joint ventures with United States. What a famous global company! However, Vodafone was failed in Japan. For example, their products in Japan were being dull and services were got worse. Because their products were not catch on the fashion, so Japanese who is tech-savvy didn’t like, and couldn’t satisfy them. Vodafone was just cared about that wanted to become global brand. They didn’t create some new products to attract the customer. Eventually, they failed. There had two competitors, NTT DoCoMo and KDDT. Because of this, they dispatched Bill Morrow to manage its Japan operation and modified its marketing strategy. As the result, their operation in Japan had getting better. And they hoped they could catch up their two rivals. Discussion Questions: 1. Why a firm would such as Vodafone need to have a global marketing strategy even thought its product development, as well as the rest of its marketing strategy, needs to be localizes for tech-savvy consumers in Japan? I thought they want to let everyone knew their brand. So they decided to develop their reputation first. At least, the company’s name wasn’t a unknown company. When they expand to other country, they need to and have to realize the country culture, and find the best strategy to develop in that country. 2. What alternative strategy might Vodafone have used to set a strong market position in Japan from the very beginning? In the beginning, Vodafone focused on building a global brand and cutting costs by producing large numbers of handsets to sell throughout the world . 3. What implications can you draw from Vodafone’s loss of its Japan unit with regard to global firms’ tapping into the convergence among global consumers? Not the Vodafone which is global company had met this kind of problem. As long as global company, might confront with. When the company expanded and developed their reputation, they all ignored some small details.

Death Penalty Rewritten Essay

What does one learn about in a first year composition class in Appalachian State University? After  reading from Dr Kimberly Gunter it is still unclear to this writer. Quotes fromthe end of this paper  signified the two ends of the spectrum when it comes to the Death penalty; â€Å"Fry ‘Em All† and â€Å"The Bleeding Heart† (Gunter, 38). This paper written by Dr. Kimberly Gunter from Appalachian State University initially appears on the surface to be about how the class she has been teaching for the last 15 weeks has looked to understand the death penalty in their state and why they oppose it. In the end Gunter describes how she used a topic that she obviously has strong opinions and emotionswith and has her students learn to write about it. The Title of this paper â€Å"In Our Names†: Rewriting the U.S. Death Penalty (32) suggests that maybe there were petitions put together for possible ratifications to the death penalty laws or at least a Billwritten and presented to the state legislators for consideration. There is nothing in the paper suggesting any of that was accomplished. Gunter takes the reader on a field trip with her class to a Maximum Security prison in North Carolina in a final research effort for a class project the students have been working on. Gunter uses analogies like the equating the air in the prison smelling like a â€Å"day of hog-killing† (32) in an attempt to disgust the reader from the beginning with the idea of death row.Gunter continues to describe low life prison guards and overly medicated innocent prisoners. Throwing in one liner comments from students whose life experience equates to growing up in privileged middle class families and having the opportunity to attendan established University like Appalachian State University. Gunter provides partial statistics in an attempt to show the reader her knowledge on the subject of Capital Punishment. As tha paper comes to a conclusion Gunter was attempting to integrate her students into academic writers and focusing on a singular project tied together by the death penalty. In her writings Gunter shows a bias towards the death penalty invoking images  of dead pigs and fowl stenches in the readers mind. Gunter contradicts these images later in the paper when she describes thedeath chamber with a hospital gurney and crisp sheets on it. This is Gunter’s attempt at using a â€Å"pathos† argument. Gunter wants to show the humanity side of the death penalty but fails in ways when she quotes a guard â€Å"he out and out said rape isn’t much of a problem in that prison, but last year, another guard, a bg barrel-chested sergeant who kept saying ‘I like to fight,’ told me that, while the guards ruled the prison during the day, the prisoners ruled at night, and that prisoner rape was widespread and unchecked while the cell blocks were on nightly lockdown.† (35). This example of rape in prison only helps solidify some readers minds about capital punishment and the inability of offenders to be rehabilitated. The writer does not use any evidence to support her argument which is not even clearly defined or understood in the paper. The reader finishes reading the work and searches for the true topic of the work, is it about the death penalty, is it about a first year composition class or is it about a transformation of the student to open their minds or take on different perspectives in life? It is never truly defined within the body of the work. There is misinformation in the body of work. Gunter is quoted on page 34 † We learn that there are no on-site educational programs..† This is untrue according to the Educational Services for the Department of Prisons in North Carolina. It is difficult to identify if the writer of this work is successful in conveying her point to the reader. There is a use of pathos in the work that will pull on the emotions of the reader, but it is not clear what emotions are to be pulled on or the wrong emotions are enacted. If the purpose of the paper was to showthat young college aged students are able to open their minds or embrace academic writing it was not successfully portrayed or documented in any way. Works Cited â€Å"Educational Services.† Educational Services. Web. 22 Nov. 2014. . Gunter, Kimberly K. â€Å"I n Our Names†: Rewriting The U.S. Death Penalty.† Writing On The Edge 21.2 (2011): 32-38. Education Research Complete . Web. 22 Nov. 2014.

Aldosterone Essay Example | Topics and Well Written Essays - 1000 words

Aldosterone - Essay Example The scheme of renin-angiotensin-aldosterone system is shown at the Fig. 2. The renin is enzyme catalysing the reaction of the transformation of angiotensinogen into angiotensin I. Angiotensin I is converted into angiotensin II and the last one is partially converted into angiotensin III (Wehling, 1995). Both angiotensin II and III stimulate the synthesis of aldosterone by the adrenal glomerulosa layer . They bind to G-protein coupled receptors and stimulate the activity of phospholipase C and adenylate cyclase. This results in the increase of conversion of cholesterol to pregnenolone and corticosterone to aldosterone (Horton, 1994; Fuller, 2006). Aldosterone controls electrolyte excretion and intravascular fluid volume. It acts on the mineralocorticoid receptors of the distal renal tubules and cortical collecting ducts of the kidneys. Aldosterone regulates such physiological mechanisms as resorption and excretion of the electrolytes, particularly its action increases sodium resorption and potassium excretion. Sodium and water reabsorption is regulated by opening Na+ channels in the apical membranes of the tubular epithelium (Fuller, 2006; Rosansky, 2006). Correspondingly, opening K+ channels leads to increased potassium conductance from the cell and potassium excretion. These processes are regulated by the Na+/K+-ATPase (see Fig. 3). Aldosterone receptors are localised intracellularly. Their stimulation leads to DNA-binding and to the changes in the transcription of genes (Fig. 4). Fig. 4 Mechanisms of aldosterone action. There is interestingly that aldosterone do not only participate in the regulation of blood pressure but it also influences on the function of mononuclear leukocytes (Chai, 2005; Wehling, 1995). Thus the role of aldosterone in the regulation of blood pressure is related to its ability to increase sodium level in the blood, and, respectively change the tonus of vasculature and by the increase of circulating volume of blood (Hamilton, 2006; Rosansky, 2006). Many pathological conditions can cause hyperaldosteronism (Horton, 1994), which is characterised by the hypertension. Thus primary aldosteronism can be caused by solitary aldosterone-producing adrenal adenoma or mono- or bilateral hyperplasia of the zona glomerulosa. The patients suffering with aldosteronism have hypertension and hypokalemic alkalosis whereas hypernatremia is not common. Aldosterone deficiency causes hyponatriemia, hypovolemia, and hyperkalemia (Horton, 1994). There are many diseases characterising with the decrease of aldosterone biosynthesis, e.g adrenoleukodystrophy, adrenal hypoplasia, infections and excessive haemorrhages. Nevertheless, the most frequent cause of hypoaldosteronism is adrenal insufficiency, i.e. both aldosterone and cortisol secretion are affected. Thus fulminating sepsis, autoimmunic disorders and haemorrhagic

4 cases analysis about strategic managmnent Essay

4 cases analysis about strategic managmnent - Essay Example h at this point, it is more correct to say he started assembling his own PCs) and soon targeted large corporate accounts with his low-cost computers. He also started to be more aggressive in his marketing campaigns, putting out ads in computer trade publications in time with the first-ever sales and product catalog of his company. About a decade later, sales reached nearly US$3.5 billion annually and by 2001, reached the top rank in global market share in computer sales (also number one in the U.S.). However, this rapid growth soon reached a plateau due to a disorganized corporate structure from having a very rapid growth. It abandoned its retail outlet distribution system and went back to direct distribution which was its original business model responsible for its success. Its business model is anchored on an efficient supply-chain management and logistics system that delivers made-to-order PCs direct to consumers. It also deliberately waits for few months for any new computer technology (whether hardware or software) to become standardized for it to be able to leverage its core competence in fast assembly of PCs. This minimizes its risks to technological obsolescence in an industry that is characterized by very rapid changes. Main Strategic Issues – Dell, Inc. is faced with a changed business and economic environment in which its competitors were able to catch up or match its low-cost pricing. This put pressure on the companys finances as profit margins were squeezed. The reductions of its overhead expenses plus manufacturing efficiencies gave it virtual monopoly of low-cost PCs but not anymore. Further, its leverage in terms of purchasing power from its supplies had been somewhat dented with the slowdown in PC sales worldwide to just 5% annually compared to torrid growth rates in prior years. Lastly, the biggest challenge facing the company is the vast change in consumer behaviors. The trend is now for a potential buyer to go to a retail store to

Monetary policy Assignment Example | Topics and Well Written Essays - 2500 words

Monetary policy - Assignment Example The implications of bank lending involve a situation whereby many bank borrowers do not have close substitutes for bank funding. This force the banks undergo challenges especially when they are monitoring their borrowers. Individuals also rely on the banks for credit and many small firms do not access to the capital. Another implication is that contractionary monetary policy reduces the quantity of reserves and deposits in the banking systems (Hammonds, 2006). In addition, banks mend their balance statement by reducing loans and securities holdings therefore, changes in bank lending has got resultant effects on investment spending small firms and debt financed spending. Consequently, the bank lending channel of monetary policy operates in a manner that if the monetary policy contracts, banks cost of refinancing increases hence lending rates also rises. High rates of interest aggravate problems of moral hazard and adverse selection. This is shown below by the following graph: In addit ion, banks cannot tell honest and dishonest borrowers apart since the mix of honest and dishonest borrowers rely on the interest rate. Therefore, at high interest rates majorly high risk borrowers come forward. In this case, increasing the loan rate may reduce bank expected profit (Haan & Eijffinger, 2005). ... What are the lessons for monetary policy from the experience of the international financial crisis? Taylor’s rules are those instrumental principles that are used to determine and formulate the right model for monetary policy that measures the output gap and measures the rate of inflation in the economy (Keel, 2012). These rules are used to determine whether the monetary policies used by various countries are tight or loose. If the monetary policies are tight then it means that financial institutions such as banks will not under go a financial crisis while when the policies are loose then they are like to cause a financial crisis. Taylor’s rule of inflation Taylor rule concerning federal funds rate since 1980 to 1992 is precisely matched by this rule: it = r* + ?T + ? (yt-y*) + ?(?t- ? T) Where by r* =equilibrium real interest rate of 2% ?T =target inflation rate of 2% (Yt-Y*)=output gap (?t -?T)=inflation gap The power of the two gaps (? and ?) is about 0.5. This model suggests that the central bank can care about output and inflation or it can use the output gap to forecast the future inflation (Jadhav, 2006). It is therefore, noted that Taylor’s rule can be used to make decisions on various economic conditions such as inflation. This model also determines whether a policy has transformed after targeting inflation or not. Open economy Taylor rules are to respond on the role of international spill over while non-linear rules are used to respond to aspects of inflation or deflation. Empirical evidence of Taylor’s rule Taylor’s principles in United States practice, have been used to inform policy decisions and therefore, not a mechanistic rule.

Sustainability Assignment Example | Topics and Well Written Essays - 2500 words

Sustainability - Assignment Example Significantly, the economy necessitates people consume in order to maintain healthy growing. As such, every day numerous marketing campaigns are prophesying about their commodities and before we get aware, the market is filled with commodities much of which people quickly forget. Notably, people like consuming and their consumption is engrained as a social activity that numerous people participate. Globally, people consume 30% resources beyond what the earth can replenish (Brebbia 2010). It is significant noting that, the developed countries are the west in offending. Therefore, if each continent is to consume at the European and the Americans’ rate, the planet earth can hardly sustain the people. Currently, we face numerous challenges, such the climatic change, biodiversity loss, accelerating social inequalities, changing demographics, and demands for basic commodities. However, the UK Government has set a complex legally binding carbon reduction policy. Accordingly, there is the need to adopt societies, as well as, economies to sustainable consumption patterns that portray at least low carbon, efficiency in resources, and profitability. Generally, retail businesses play critical roles in responding to demands of consumers hence their principal business controller. However, it cannot deliver the contagious changes; thus we need the creation of prosperous, and resource- efficient world. Additionally, numerous consumers possess inadequate information, motivation, and opportunity; hence they cannot make sustainable choices about buying practices and use of products. Concisely, sustainable consumption is still a niche and numerous companies make mere incremental improvements. Co nsequently, the leading brands must take the initiative and collaborate in order stimulate the pull of consumers on sustainability; hence make sustainable consumption mainstream.

History of the Army Corp of Engineers at West Point Essay

History of the Army Corp of Engineers at West Point - Essay Example The main responsibility delegated to these engineers was to operate the U.S Military Academy at West Point (Office of history, U.S, 2007). Thomas Jefferson established this Corps of Engineers by stating "that the said corps, when so organized, shall be stationed at West Point, and shall constitute a military academy" (U.S Army Corps of Engineers, web). It was up to 1866 that the West Point Academy Superintendent was also performing the functions of the Chief of Engineers. It was during those times that all the members of the Corps had been West Point graduates. All the construction done at the U.S Military Academy was undertaken by the Corps till 1861. This construction was resumed after a gap in 1941. Jonathon William was the Chief of Engineers and the first controller of West Point in 1807. He was held responsible for strengthening the ramparts at the doorway of New York Harbor when the risk of British attach was high subsequent to England’s trade embargo. During the 1812 wa r not a single defense built by an engineering graduate of West Point was overrun by the British. In the initial phase of the Civil War, the Corps constructed five structures, namely, the ‘Fort Hamilton, Schuyler, Totten, Tompkins and Wadsworth’ in the New York region (U.S Army Corps of Engineers, web).

What is the heart of Catholicism Essay Example | Topics and Well Written Essays - 1250 words - 1

What is the heart of Catholicism - Essay Example For salvation and redemption, people need to gather around the bishop since he is the true descendant of God and, therefore, of Jesus. In Catholicism, this institutional approach to belief and the importance of communion with the Holy See through a religious medium like church or other religious authority are essentially inspired by Biblical evidences and history. One of Jesus’ speeches supports Catholicism’s claim about the importance of a believer’s communion with the religious authority is as following: â€Å"I say to you, something greater than the temple is here† (Barron 24). Indeed in Catholicism, the ideas of ‘temple’ and ‘bishop’ are the representatives of each other. In this regard, Barron says, â€Å"If Jesus is, in his person, the true temple, then he should be the definitive source of teaching, healing and, forgiveness and this is just what the Gospel tells us† (Barron 24). Indeed this very basis of Christ’s persona as the sole source salvation and redemption lies at the heart of Catholicism. Indeed, proper religious authority plays an important role in shaping the rites and rituals of Catholicism. The propriety of religious authority is often determined by sacramental evidences. While the Catholics unanimously believe in the ministration of Christ as the temple of teaching, salvation and redemption, the bishop is believed to be the true spiritual descendant of Christ himself. Therefore a bishop plays a very important role in catholic rites and rituals. For an instance, Catholic dogma asserts that the sacrament of the Lord’s Supper must be administered by certain qualified persons. According to the Roman Catholic Church, â€Å"only a Catholic Priest ordained into the apostolic succession can administered the Eucharist† (Erickson 1122). Erickson further says in this regard, â€Å"If any other person should take the same physical elements and pronounce the same words over them, they would remain bread and

International monetary Essay Example | Topics and Well Written Essays - 1500 words - 1

International monetary - Essay Example This occurs when it becomes impossible to maintain the deficit in the current account. This situation indicates, in general sense, that there will be shortage in the foreign exchange reserves and the particular country is no longer in a position to attract sufficient amount of capital inflows for financing the deficit. For handling this situation of crisis, the government takes measure with the motto of reducing the spending of consumers on imports (Economics Help, 2011). The paper will be presented in a compact manner with the brief explanations about the policies undertaken within the exchange rate regime and alternative approaches and then taking up the interrelationships between the two phenomena along with their critical evaluation. Exchange Rate Regime in Resolving BoP Crisis The approaches under the exchange rate regime are floating, fixed and pegged exchange rate regime. ... r the interest rates and monetary aggregates; whereas in the case of pegged exchange rate system, the central bank does so for achieving stability in price. In case of the floating exchange rate regime, the government does not intervene and the rate is determined by the foreign exchange market itself (Olson & He, 2011). Alternative Approaches in Resolving BoP Crisis The alternative approaches to resolve balance of payment crisis deals with the adjustment mechanisms which can be either automatic or discretionary. Automatic adjustment for resolving BoP crisis takes into account four variables under the fixed exchange rate regime. The variables are prices, interest rates, income and money. The alternative approaches, however, are three schools of thought on the adjustment mechanism. The viability of the three schools of thought that will be discussed in this paper are classical approach (1800s - early 1900s) which was centered around standard of gold and mainly emphasized on interest ra tes and prices, the Keynesian approach (1930s onwards) that emphasized on changes in income affecting adjustment and Monetary approach that emphasized on the role of money in adjustment and changes (Carbaugh, 2005). Viability of Classical and Keynesian Approach with Respect to Exchange Rate Regime The mechanism in the classical approach with respect to price adjustment was that money supply (in terms of gold) was directly related to BoP and BoP deficit would cause the money supply to shrink. This means nations in crisis would lose gold and cause the prices to fall. The lowered prices would result in competitive exports and reduce import demands, thus would restore equilibrium. The problem with this approach is that gold flows are not directly related to domestic supply of money and the

How desalination of seawater for use as drinking water relates to the Essay

How desalination of seawater for use as drinking water relates to the principles of osmosis - Essay Example The process utilizes the principle of reverse osmosis and has its own share of advantages and disadvantages. Description and Evaluation Osmosis is defined as â€Å"the passage or diffusion of water or other solvents through a semipermeable membrane that blocks the passage of dissolved solutes† (Kershner, 2012). Technically, water moves from an area of less solute concentration to that of greater solute concentration, because water seeks equilibrium and thus seeks to make the concentration of the area with greater solute more or less equal. It does so through osmosis and water only stops moving once balance is attained or until equal osmotic pressure is reached. This is the state where there is no more movement by solvent. The desalination of water is not osmosis but rather the opposite of it: reverse osmosis (Kershner, 2012). In the case of reverse osmosis, there is movement of solvent molecules through a semipermeable membrane from an area of greater solute concentration to t hat of less solute concentration, or simply the movement of the solvent away from where solute concentration is relatively higher. ... Applying pressure to saltwater to pass through the semipermeable membrane will make the solvent or water component to pass through but not the relatively bigger particles of salt. Thus, one has salt on one side of the semipermeable membrane and freshwater on the other (Kershner, 2012). See Figure 1 for the schematic diagram of the reverse osmosis desalination plant. Figure 1. Schematic representation of a Reverse Osmosis Desalination Plant Source: http://freshlysqueezedwater.org.uk/waterarticle_reverseosmosis.php The reverse osmosis system includes several features. One of these is the type of semipermeable membrane used, upon which the percentage of tap water impurities removed depends. Cellulose Tri-Acetate, or CTA, membranes possess a removal rate of around 88 to 94% of tap water impurities. Thin Film Composite, or TFC, membranes remove around 94 to 98% of all solids, and Hi-S membranes are responsible for the elimination of 97.5 to 99% of all impurities especially fine silicates (FAQs: Reverse Osmosis Water, 2013). Moreover, the three main components of the system include the high pressure pump, the energy recovery device and the reverse osmosis membranes. The high pressure pump is responsible for providing the pressure needed for seawater in order for it to move from an area of high solute or salt concentration to an area of lower solute concentration. Depending on the salinity and temperature of the seawater, the amount of pressure provided by the high pressure pump ranges from 55 to 85 bars. The pressure then creates not only the movement of the flow of concentrate, but also energy. The energy recovery devices are then responsible for the reuse of the energy coming from the flow of the

Do nation states seek to maximize wealth or power Essay

Do nation states seek to maximize wealth or power - Essay Example Core states would fight to control the international in an effort to stamp their wealth dominance over givens states. In an event a political based conflict arises, the states would deploy methods that will ensure their political and power dominance over other states. The essay will focus on power and wealth enjoyed by states and will determine the magnitude of each in enhancing dominancy. Humans are unique thus set their goals based on their needs at a specific period. The nature in which they satisfy their needs may vary. Those satisfied by their needs will tend to seek surplus dominance over the others. The concept applies to states in that core states seek more control of the world thus deploy various means to ensure they attain their goals. The satisfaction of citizen is measure by the economic growth and other government indicators. Peripheral and semi peripheral state tend to focus more in attain the basic needs, as there exist a gap between the wealth and the poor. Closing the gap would mean more resources are channelled towards social issues. The struggle to attain a specific economic status prompt these countries to depend on aid from the core states to enable them substantiate their limited resources (Dunne & Schmidt , 2008) Economic strength enables a country to dominate the world in matters decision making. Countries would stamp their authority after they dominate the world trade. Krasner (2000) attributes the concept of dominance to hegemony effect where a state proves its economic prowess over a group of other states. Countries try to dominate the market by creating supply to meet the global demand. The amount of activities by a given country will determine its economic supremacy. Core countries pull out resources in effort of ensuring their supremacy in the global economy. Trade is a determinant when evaluating the global economy. Country will tend to focus on increasing their

How to change the world Essay Example | Topics and Well Written Essays - 250 words

How to change the world - Essay Example They therefore see the realization of national vision and goals of their respective nations. The individuals who have been discussed in â€Å"How to Change the World† are from countries such as brazil, United States, India, Hungary, Burkina Faso, and Bangladesh (Bornstein 28). These people have advanced systemic change and shifted perceptions and behavior patterns. They have innovated massive ideas for solving problems; and they are determined and yearn to spread the ideas throughout the society. One of the social entrepreneurs that have been profiled by Bornstein is Gloria de Souza, a 45-year-old elementary school teacher in Bombay (Bornstein 29). In 1981, she was inspired to transform education across India; this was stirred up by her observation of 20 years of rote learning, a thing she desired to change (Bornstein 34). Souza adapted her teaching ideas to India’s specific circumstances and founded an organization to build a team to spread her ideas. Her project got stipend from a social entrepreneur organization, named Ashoka. She managed to disseminate her Environmental Studies (EVS) approach to teaching. By the end of the 1980s, Souza’s success was very eminent; the Indian government had incorporated EVS into its curriculum, and it was reported that this approach had significantly increased student performance. The lessons I have learned from Souza’s case is that change requires an intrinsic motivation, coupled with action steps; Souza acts upon her observation by taking step to set up her own organization. There is also need to secure for some source of human resource and funds to institute a transformative project; Souza gets stipend from Ashoka-a social entrepreneur organization and builds a team to realize her goal. In addition, it is important to create a relevant project for easy adoption and integration; Souza adapts her teaching ideas to India’s specific issues, a thing that saw the incorporation

Article reviews Assignment Example | Topics and Well Written Essays - 500 words - 1

Article reviews - Assignment Example The author admits that technology has managed to generate a long chain of social networks but regrets that the manner of communication in those links has not been as effective as in the past. Lately, people communicate via email and phones even to the closest ones who they should interact with face to face such as family and close friends. An instance is a case where a child writes a requisition note and sends it to the parent’s email. It indicates the detachment that has evidently been brought by new communication mediums. Families have broken away from the traditional systems and cultures where they could gather around a table for dinner as they discussed issues affecting them. Nowadays, an individual just needs to go behind a computer and share their problems online. The author is, therefore, appealing to the community to abandon the ineffective technology-aided communication and reincorporate the traditional methods that enhanced attachment. To solve this, it is in order for some of the traditional cultural ways of interaction to be revisited and reintegrated back into the modern life. The community should move from digital interactions to real face-to-face co mmunications. The author, in this article, explores some of the negative effects information communication technology (ICT) has brought to learning. This article addresses this issue by giving a practical instance in which classroom sessions have been interrupted profoundly by the many electronic gadgets that students use to surf the internet with. Freedman, appreciates the fact that technology is a real advancement that has improved lives. However, the trend of excessive internet obsession has brought more harm than benefits in classroom learning. A case is highlighted of a war that raged on between the teacher and a student in which the lecturer had to smash the leaner’s phone to show how much serious he intolerant he was with the issue. The author

Research into the Marketing Environment Essay Example | Topics and Well Written Essays - 1500 words

Research into the Marketing Environment - Essay Example Therefore, the marketing mix designed cannot be uniform. To cater to the needs of different customers, companies have to rely on market segmentation. The markets may be segmented on the basis of demographic, geographic, psychographic, and behaviouristic. The markets can be segmented based on other factors as well such as geography. Let us look into PepsiCo as a particular company and it is affected. In this study, PESTEL analysis will be used to understand the effect of macro environment on PepsiCo and then suggest ways by which it can achieve smart objectives. PepsiCo is a multinational food and beverage corporation with its headquarters in the United States. Best on net revenue it is second largest food and Beverage Company in the world. Its revenue based on the 2013 data was 66,415.00 million USD and Gross profit levels were 35,340.00 million USD (PepsiCo Inc., 2014). Starting from its incorporation in Delaware in 1919 PepsiCo now has its presence in almost all countries starting from USA to New Zealand. PepsiCo has performed so well goes on to show that company has effectively and efficiently catered to the needs of various customers in various environments. It has understood the customer’s mentality correctly and has developed products that cater to their taste buds. For example, to be successful in Chinese market the company started manufacturing potato chips that are cucumber flavoured and which is not available in other countries. They got the idea of this flavour from a common Chinese dish named as â€Å"pai huanggua† (shredded cucumber) and surprisingly it is one of its best selling potato chips products in china (Ho, 2013). They have developed marketing strategy including use of celebrities with whom the customers can relate to for brand endorsement. For example, in their campaign for European market they have used David Beckham, for their campaign in India they have used celebrities such as Shah Rukh Khan and Sachin Tendulkar who have mass

Research, identify and discuss the 4 basic functions of management Essay

Research, identify and discuss the 4 basic functions of management. .Week TWO - Essay Example Having done a SWOT analysis, it can then proceed to making a more detailed strategic plan. An example of the planning stage is when a marketing manager designs a marketing plan in launching a new product. Wijesinghe enumerates various positive characteristics of planning such as being â€Å"goal-oriented, primacy, pervasive, flexible, continuous, involves choice, futuristic and involves mental exercise† (Wijesinghe, 2010, par 5). The second function of management is organizing. Organizing involves gathering all the resources of the company including the physical, human and financial resources. The tasks or activities that are needed to be done should be classified and assigned to the particular departments and individuals. Responsibilities are created and authorities delegated (Norman, n.d.). The organizing function of management is important because it encourages specialization, describes the work that must be done and by whom and it categorizes authority and command (Wijesinghe, 2010). Leading is the third management function. Under this function, the manager motivates and positively influences the employees so that they will be able to perform their tasks well. Managers should learn to communicate effectively with the employees to ensure that the company’s goals are achieved. Providing for monetary as well as non-monetary incentives may be necessary to influence and motivate the employees. Managers must be able to teach and assist the employees especially when they are faced with difficulties in performing their duties. The last function of management is controlling. Controlling involves â€Å"measuring achievement against established objectives and goals† (Norman, n.d., par 5). If there is any deviation from the achievement of the goals, the manager must identify the reason for the deviation and think of a way to correct it (Norman, n.d.). Monitoring and evaluating employee performance is a part

How smoking can negatively affect your life Essay Example for Free

How smoking can negatively affect your life Essay My name is Kimberly Robinson. Today, I will be discussing how smoking can negatively affect your life in so many different ways. Like many people, you already know that smoking is bad for your health. But not many fully understand just how dangerous smoking really is. Every single cigarette you smoke does damage to your body. According to the Centers for Disease Control and Prevention (CDC, 2017), cigarette smoking is the leading preventable cause of death in the United States, causing more than 480,000 deaths each year and the risk of dying from cigarette smoking has been increasing over the past 50 years. It causes nearly one in five deaths which are more than car accidents, illegal drugs, Aids, murders, and suicides combined. That is scary to think about. Smoking can affect many things in your life including your health, appearance and your finances. Smokers are more likely than non-smokers to develop heart disease, stroke, and lung cancer. Smoking can cause yellow teeth and fingers and also bad breath. Don’t even get me started on the fact that smoking can be an expensive hobby. In the state of Virginia, the average cost for a pack of cigarette is $5.25, according to fairreporters.net. If a smoker smokes three packs per day, that is about $5748.75 per year. That extra money could be spent on your family. Choosing to damage your body is one thing, but smoking doesn’t only affect your health, it also affects the health of the people are the closest to you. According to the (Center for Disease Control and Prevention CDC, 2017), second-hand smoke has the same harmful chemicals that mainstream smoke contains and prolonged exposure increases to the risk of lung disease by 23% to 25%. According to the U.S Food and Drug Administration (2017), there are more than 7,000 chemicals found in cigarette smoke and more than 70 of those chemicals are linked to cancer. Nicotine is the main component of tobacco. It is highly addictive, hence, the addiction that comes with smoking cigarettes. Nicotine causes the adrenal gland to release hormones that stimulate the brain and increases blood pressure and heart rate. Cigarette smoke also contains tar. Tar is a sticky brown substance that is produced when tobacco is burned. When the smoke is inhaled, tar forms a sticky layer inside of your lungs which will damage it and can cause cancer of the lungs, mouth, and throat. There are so many advantages of quitting smoking. By quitting smoking, you will improve your health and the health of others around you. The minute you stop smoking, the risks of getting a smoke-related disease will start to decrease. Because of the level of nicotine present in cigarette smoke, you may encounter some difficulties while trying to quit smoking but there are resources that can help you throughout the process. The first thing you should do is make the decision to quit and then make a list of the reasons why you want to do it. This way you will have something to refer to when you feel like giving up. Secondly, set a date at which you will quit and inform your family and friends about your upcoming journey. They might be able to motivate and help you when you are having hard days. The next thing to do is to remove any stimuli from your surrounding that could potentially cause you to revert. Some tools that can help you cope and have a smooth transition are counseling, nico tine replacement therapy, hypnosis, acupuncture therapy and support groups.

TH Empire Ltd Essay Example for Free

TH Empire Ltd Essay To whom it may concern: It is with great pleasure to provide you with a summary about our business and our operations. TH Empire Ltd. is a British trading company that was established in 1995 and was incorporated in 2008 under the rules and laws of the United Kingdom. TH Empire Ltd. is based in the United Kingdom and is operating across the Middle East and other wider regions. The company has been successful in the market with a 10 year experience and is expanding its business in the region The core business of our company is the provision of market research consultancy and presentation, including provision of marketing services with great emphasis on construction, oil field industry and marine works. It has operations in all the Gulf Regions and Middle East markets, with recent expansion in Europe and UK. TH Empire Ltd has an established connection with companies, related to construction of bridges, towers, roads and hotels. It is also involved in oil services such as drilling, maintenance and air pollution control, with great experience in digital mapping, geophysical surveying, and oil exploration with agencies throughout the Middle East. We are also developing relationships with various chambers of commerce and professional unions to liaise us with our corporate clients. We are actively taking part in all major construction, oil field service and marine works events worldwide, sharing our ideas and innovations, refining our expertise to provide leading edge solutions to our clients. Â  We organize our tools and expertise to elaborate customized solutions to meet the needs and targets of our clients. We provide Representation services, Communication strategies and media relations, Promotional materials production, Event and exhibition management, Sales and branches offices opening, Agent network development, Liaison with Middle Eastern and international institutions. If your company is interested to start business with us; kindly send us your company’s activities and catalogues including the services you provide for the negotiation process to begin. Note: We are looking for huge companies (undertaking huge projects) with efficient business procedures and are interested in the aforementioned services Business will be in Libya and Saudi Arabia Waiting for your reply Thank you

Factors Affecting Antipsychotic Medication Compliance

Factors Affecting Antipsychotic Medication Compliance INTRODUCTION The aim of this dissertation is to explore the factors affecting concordance with prescribed antipsychotic medications. The rationale for selecting this topic is derived from personal working experience with mental health service users. Having worked as a nursing assistant for the past eight years on acute admissions wards and as a student nurse for the past three years it was observed that a large proportion of compulsory re-hospitalisation under the Mental Health Act 1983 occurs due to relapse of mental illness as a result of non- concordance with medications, particularly service users with a diagnosis of schizophrenia. This led to believe that concordance with antipsychotic medications plays a crucial role in managing psychosis as it positively contributes towards the effective management of the illness in the community. In support to this view, Gray et al (2002a) assert that prophylactic use of antipsychotic medication reduces the risk of relapse among individuals with schizophr enia and non-concordance with medication has the potential for frequent re-hospitalisations. This has been recognised as the revolving door syndrome. During most mental health placements it was noted that non-concordance with medication has become significant, as this has been identified as a risk factor within the risk assessment checklist. Furthermore, despite the well-documented therapeutic effect of antipsychotic medications, some patients are reluctant to accept treatments and some may even wish to cease taking medications altogether. Therefore, this empirical knowledge has reinforced the desire to examine the factors associated with non-concordance with antipsychotic medications. According to Brimblecombe et al (2005) medication is one of the major therapeutic tools available to help people with schizophrenia. There is also growing evidence that schizophrenia can be treated effectively with a range of psychological and social interventions together with antipsychotic medications. Norman Ryrie (2004) emphasised that antipsychotic medication has been the mainstay of treatment for schizophrenia since the 1950s when it was discovered that the dopamine antagonist haloperidol and chlorpromazine exerted antipsychotic effects. The National Institute for Clinical Excellence (NICE) (2002) recommends that atypical antipsychotic drugs such as amisulpride, aripiprazole , olanzapine, quetiapine or risperidone must be considered in the choice of first-line treatments for individuals with newly diagnosed schizophrenia or to promote recovery for those who have experienced unacceptable side-effects on conventional antipsychotics, as atypical antipsychotics appear to have less extrapyramidal symptoms (side effects) than the conventional antipsychotics such as haloperidol and chlorpromazine. The care and treatment of individuals with schizophrenia have advanced considerably over the past ten years, since the introduction of atypical antipsychotics and medication continues to be the first line treatment for schizophrenia (Walker MacAulay, 2005). However, Gray et al (2002b) claim that despite the effectiveness of these atypical antipsychotic drugs, non- concordance with prescribed antipsychotic medications is observed in around 50% of people with schizophrenia and is a major preventable cause of psychiatric morbidity. In addition, Mitchell Selmes (2007) claim that over the course of a year, about 75% of patients will discontinue prescribed antipsychotic medications, often coming to the decision themselves and without informing a health professional. According to Gray et al (2006) relapse rates is five times higher among individuals with schizophrenia, who are non-concordance with medication compared with concordance. Non-concordance during acute treatment of psychosis le ads to chronic symptomswhereas non-concordance after remission increases the risk ofrelapse and both may have serious consequences; re-hospitalisation (Hamer Haddad, 2007). Furthermore, the impacts of non-concordance with medication not only affect the individuals with schizophrenia, as each relapse causes a stepping down of cognitive functioning which is rarely retrieved but also their carers and the costs of treatments (Institute, 2007). To facilitate this project as a literature review, an analysis of secondary sources only will be use. Secondary sources were mainly obtained from nursing journals such as Nursing-Standard, Nursing-Times, Advances in Psychiatric Treatment, Mental health practice, Schizophrenia Bulletin and The British Journal of Psychiatry, containing the key words: schizophrenia, oral antipsychotic, medication management and non-concordance. An Internet search of Google was also done with the same keywords to access any relevant documents. To address the factors affecting concordance with prescribed antipsychotic medications, these will be divided into patient-related factors, medication-related factors and clinician-related factors. LITERATURE REVIEW According to White (2007) schizophrenia is a debilitating psychiatric disorder characterised by a range of positive and negative symptoms and these symptoms were first described in detail by the British neurologist Hughlings-Jackson in the late 1800s. There is no physical test for schizophrenia rather it is diagnosed by the presence of certain positive and negative symptoms over a period of time (Brennan, 2001). According to Issacs (2006) the neurotransmitter hypothesis suggests that the dopamine over activity in the mesolimbic dopamine pathway, which is between the midbrain, is thought to cause the positive symptoms of schizophrenia and dopamine under activity in the mesocortical dopamine pathway is thought to result in the negative symptoms of schizophrenia. Positive symptoms represent a distortion of normal experience, such as delusions, hallucinations and thought disorder, whereas negative symptoms represent a loss or dimming of normal function and social norm, such as avoidance of social interactions (Baker, 2003). There are different types of schizophrenia such as paranoid, disorganised, catatonic, undifferentiated and residual (Issacs, 2006). However, Gillam (2002) claimed that the exact causes of schizophrenia remain unclear but genetic, environmental and social factors are all thought to influence its development. The risk for a child to develop schizophrenia is 46%, if both parents have the disorder (Kirk et al, 2006). Women who have certain viral illnesses during their pregnancy may be at a greater risk of giving birth to children who later develop schizophrenia and the 1957 influenza A2 epidemics in England resulted in an increase in schizophrenia in the offspring of women who developed this flu during their pregnancy (Frankenburg, 2007). 1 in 100 UK populations will develop schizophrenia in their lifetime and the world prevalence is about 2-4 in 1000, as it affects men and women equally (Rethink, 2008). However, the onset in men is about five years earlier than women with the peak age of incidence is between 16 and 25 and the presentation of the illness varies tremendously, not only between individuals, but also within the same individual at different stages of their illness (Magorrian, 2007). Schizophrenia seems to be more common in city areas and in some ethnic minority groups and premature mortality in people with schizophrenia is 2 to 3 times higher than that in the general population (Royal college of Psychiatrists 2008). The premature mortality might be due to poorer health care, physical health, unhealthy lifestyles and people with schizophrenia may be at greater risk of type 2 diabetes as a result of antipsychotic medications (Nash, 2005). Moreover, according to WHO (2008) schizophrenia is a treatable disorde r but many individuals remain untreated regardless of effective treatments. There has been an unresolved debate about how best to define patients engagement with medications and until the 1980s most work on patient engagement with medications regimes was described as compliance (Norman Ryrie, 2004). The term compliance is often used interchangeably with adherence or concordance (Snelgrove, 2005). According to Kikkert (2006) the term compliance has fallen out of favour in clinical practice because it carries an assumption that patients are the passive recipients of clinicians and implies unquestioning obedience with no opportunity for patients choice. To add to the complexity of this term, patients can be intentionally or unintentionally non-compliant such as a deliberate decision not to comply with treatment and patients may have misunderstood the guidance that they have been given or unable to open the medication container. Velligan et al (2006) claimed that in recent years there has been a shift from this paternalistic model of doctor-patient interactions with the consequent preference for the use of the term adherence. However, while adherence emphasises negotiation between clinician and patient, it still implies a degree of passivity and obedience (Snelgrove, 2005). Gray et al (2002b) assert that concordance may be a more acceptable term as it suggests a collaborative process of decision-making regarding medications regimes and acknowledges the importance of the two-way communication. The NHS Plan (2000) emphasises the importance of placing patients at the centre of services and the transformation of patients into consumers of the health service has changed the context of health care, as patients are expected to become more active and informed about their treatments (Jasper, 2006). Murray et al (2007) emphasise that shared decision-making between clinicians and patients has the potential to improve concordance with treatment plans. Furthermore, The Chief Nursing Officers review of mental health nursing (2006) recommends that building and maintaining positive interpersonal relationships with service users is essential to successful mental health nursing practice and person-centred values is helpful in building positive relationships. This indicates that by not agreeing to health professionals advice patients may be labelled as non-compliant. Nonetheless, compliance could also be problematic, for example if patients continue to take medication obediently, although it is causing adverse side effects. However, from the empirical knowledge the term compliance is still being used in clinical settings despite the paternalistic conception. Therefore, the term concordance is favoured here as it promotes the idea that medication treatment should be a collaborative process between clinicians and patients, which emphasises the patients rights. Ultimately, the term concordance corresponds with the current ethos of modern mental health care set out in the National Service Framework (1999), the NHS Plan (2000) and the Chief Nursing Officers review of mental health nursing (2006), which is concerned with working in partnership with patients and carers. However, according to the term concordance patients have the right to make t reatment decisions, for example, stopping medication even if health professionals do not agree with that decision. For decades researchers have worked to explain the causes of non-concordance with medication unfortunately there have been no valid way of measuring concordance (Velligan et al, 2006). Rates of concordance have been measured by using the subjective and objective methods. Subjective method includes patients` self report and direct interviews, although this method is less expensive, it tends to overestimate the degree of concordance, as patients may not admit non-concordance (Gray et al, 2002b). Snelgrove (2005) claims that objective method such as blood and urine analysis also pose problems as they do not account for individual metabolism and do not reflect inconsistencies in concordance over time. Moreover, from empirical knowledge blood test is effective in monitoring concordance with mood stabilisers such as lithium, but for schizophrenia it is the manifestation of symptoms can support the evidence of non-concordance. According to Gray et al (2002b) pill counts are more reliable, b ut it is impossible to tell whether patients have actually ingested the medication. Even expensive objective method such as electronic monitoring which records every occasion that a pill bottles is opened can also be problematic when patients choose not to swallow the medication that was removed or do not replace the caps and electronic prescribing is still fallible, just because medication is available does not mean that it is taken (Velligan et al, 2006). One of the major clinical problems in the treatment of people with schizophrenia is partial or complete non-concordance with medication and this limits the clinical effectiveness of the prescribed medications (Kikkert et al, 2006). Antipsychotics medication can only be effective if they are taken continuously over a sustained period of time (Norman Ryrie, 2004). Urquhart (2005) claims that partially concordant patients can be difficult to identify because they do not actively refuse to take their medication but the dosage deviations for different reasons and this may only be detected when psychotic symptoms re-emerge. Partial concordance creates significant problems for the treating physician as it creates difficulties in determining whether medications are working adequately, dosing is appropriate or concomitant medication is needed (Velligan et al, 2006). Therefore, this indicates that medication or dosage changes and the addition of concomitant medications are more likely to occu r among patients who are not fully concordant with prescribed medications. Non-concordance with prescribed medication is believed to be a significant factor to increasethe probability of relapse in patients with schizophrenia and relapse is one of the most costly aspects of schizophrenia (Almond et al, 2004). Knapp et al (2004) undertook a study of 658 patients receiving antipsychotics medication of whom 20% reported non-concordance with prescribed medication and concluded that non-concordance was one of the most significant factors in increasing service costs, predicting an excess annual cost per patient of  £2500 for inpatient services and an overall additional cost of  £5000 for total service use. In addition, Almond et al (2004) estimated that costs for relapse cases are four times higherthan those for non-relapse cases. Therefore, these two studies show that relapse in patients with schizophrenia as a result of non-concordance isa major factor in generating high hospitalisation rates and costs. This implies that patients who do not concord with the ir medication are likely to requiremore treatment and support from a range of services and given the high costs associated with relapse non-concordance is a key factor in the use ofin-patient and external services. Antipsychotic medication has proven efficacy in the treatment of schizophrenia and the prevention of relapse. In spite of vast evidence that antipsychotics can be effective in treating the symptoms of schizophrenia, almost 90% of patients will relapse within the first five years of treatment following an acute episode and in general the illness has a tendency to recur or become chronic (Velligan et al, 2006). According to White et al (2007) non-concordance with drug therapy is common in schizophrenia; approximately 50% of patients are non-concordant within one year and 75% within two years after being discharged from hospital. Such high rates of non-concordance with medication may initially seem alarming (Gray et al, 2002b). However, it is similar with other conditions such as asthma where maintenance treatment is required. A study of concordance with asthma medication conducted by Newell (2006) estimated that 70 % of asthma patients in the UK are non-concordant with medication and t he levels of non-concordance in long-term conditions, such as asthma are known to be high as many asthma sufferers will only take medicine when they feel they need it rather than as instructed by clinicians. Therefore, considering the Newell (2006) findings it can be argued that the rates of non-concordance with antipsychotics are not significantly different than those on non-psychiatric medications and the myth that non-concordance with medication is more common among mental disorders as compared to physical disorders needs to be dispelled. Several factors have been shown to increase the chance of relapse but probably the single most important cause of relapse is the discontinuation of effective antipsychotic medication regime. A large number of factors influence non-concordance with prescribed antipsychotic medications, however Gray et al (2002b) have identified the main factors as impaired judgement, negative beliefs about treatment, poor worker-user relationship and the side-effects of medication. Additionally, Kikkert et al (2006) conducted a study in four European countries exploring medication adherence in schizophrenia and identified insight, beliefs about treatment, side effects and treatment efficacy as factors that influence concordancewith medication in patients with schizophrenia. Urquhart (2005) suggests that the problem of non-concordance may be more prevalent among those with schizophrenia due to its nature, for example, lack of insight. Magorrian (2007) claimed that non-concordance with medication is often linked to the persons level of insight into his or her illness and lack of insight is a frequent concomitant of psychosis. In schizophrenia, insight has been defined as an awareness of illness and an ability to recognise symptoms as part of an illness (Gray et al, 2002b) According to Surguladze David (1999) between 50% and 80% of patients diagnosed with schizophrenia have been shown to be partially or totally lacking insight into the presence of their mental disorder and these individuals are often difficult to engage with treatments due to impaired insight. Recent conceptualisation has formulated insight as a continuum representing the combination of three factors; awareness of illness, need for treatment and attribution of symptoms. Lack of insight is continuously problematic but an emotional element can be associated with denial of symptoms or rejection of treatment at key points in the illness (Byrne, 2000). Mitchell Selmes (2007) claim that having a perception about the illness and the knowledge of medications are the key factors of concordance in mental health and patients who understand the purpose of the prescription are twice more likely to collect it than those who do not understand. A study by Cuesta et al (2000) reported that patients suffering from schizophreniashowed poorer insight than patients with affective disorders. Cuesta et al (2000) findings demonstrated that the severe disturbances of insight persisted over the time and the level of insight was not significantly improved in patients suffering from functional psychosis as between 29% to 49% of these patients continued to have fair to poor insight at the follow up assessment. This is consistent with the findings of Kikkert et al (2006), where poor insight was a strong predictor of non-concordance with medication. In contrast, Tait et al (2003) conducted a study to examine changes in insight and symptoms of psychosis on fifty participantswho met the ICD—10 diagnostic criteria for schizophrenia. The participants were interviewed and insight was measured duringacute psychosis using the Insight Scale with the score 0- 12 and all the participants were reinterviewed at 3 and6 months following the init ial interview. Tait et al (2003) findings indicated that duringthe acute episode, 48% of participants scored 9-12 on the InsightScale and the majority of participants (63%) werein the 9-12 range of scores. The study of Tait et al (2003) clearly indicated that level of insight was high among many participants. In considering the findings of both Cuesta et al (2000) and Tait et al (2003) it appears that some patients with psychosis are unaware of their illnesses and insight is a strong predictor of concordance with medications and a good indicator of prognosis. However, evidence for a relationship between insight and concordance with treatment is inconclusive as the discrepancies found between the two studies might be due to the methodological factors, such as selection of participants. In both studies all the participants had a diagnosis of schizophrenia and all of them gave informed consent to enter the study. According to Appelbaum (2006) several studies in America regarding the decisional-capacity of patients with schizophrenia to consent or participation to research have raise some concerns due to the cognitive impairments associated with schizophrenia and using the MacArthur Competence Assessment Tool for Clinical Research clearly indicated that patients with schizophrenia do lack und erstanding and reasoning of research ethics. McCann Clark (2005) emphasise that antipsychotic medications some of which have a sedating effect can also have an impact on the cognitive processes, such as illogical thinking and this can hinder the quality of responses. Moser et al (2005) argued that some studies have shown that a high percentage of individuals with schizophrenia have adequate decisional capacity to consent to research participation, however in a medication-free schizophrenia research, participants did not show a major decline in decisional capacity. In addition, Jeste et al (2006) claimed that there is a risk in assuming that decision-making capacity of individuals with schizophrenia is always impaired, when they are capable to make autonomous decisions and in considering their decision-making capacity as permanently impaired by virtue of their diagnosis. Consequently, in order to investigate factors associated with schizophrenia, it can be argued that only individuals with schizophrenia can provide the answers of their experiences and protecting vulnerable populations from research activity can also exclude them from its benefits. According to Gerrish Lacey (2006) there two key concepts that concern the quality of a research: validity and reliability. Roberts et al (2006) define reliability as how far a particular test will produce similar results in different circumstances, whereas validity is to ascertain the methods are actually measuring what is intended to measure. Both Cuesta et al (2000) and Tait et al (2003) had used structured interviews to gather the data and have chosen a quantitative approach. Structured interview provides the opportunities to change the words but not the meaning of the questions thus, Parahoo (2006) claimed that validity is enhanced because participants can be helped to understand the questions and interviewers can ask for clarifications and probe for further responses, if necessary and since all the questions are ideally asked in the same way, structured interview has a high degree of reliability. It seems that both Cuesta et al (2000) and Tait et al (2003) have adopted the appropriate approach to their research, as quantitative research is the conduct of investigations primarily using numerical methods. It infers that to examine correlations between insight and service engagement qualitative approach could not have produced the same data in this area of study. Moreover, in both studies purposive sampling were used as all the participants had a diagnosis of schizophrenia. According to Polit Beck (2006) all participants in a phenomenological study must have experienced the phenomenon under study and must be able to articulate what is like to have lived the experience. Johnson Orrell (1996 cited in Surguladze David, 1999 P 166) have argued that some patients may have their own explanations of their illnesses, such as religion or cultural beliefs which may not coincide with the Western medical model of mental disorders and this can be even more complicated if one tries directly to impose the models of insight on patients from non-Western cultures. Gamble Brennan (2006) claimed that different cultures in England perceive mental illness in different ways and this can have an impact on treatments as some cultures rather seek help from religious leaders than mental health services. Alternatively, religion or spiritual beliefs in the Western culture can have a positive impact on concordance with medication, as religious individuals with schizophrenia have a better social support compare to non-religious individuals with schizophrenia (Borras et al, 2007). Therefore, it can be put forward that awareness of illness is a crucial factor in the motivation to receive pharmacological treatment. Both cultures and religion can have a positive and negative influence on concordance with antipsychotics. Patients can have different levels of awareness into their illness and they may consciously or unconsciously avoid acknowledging that they are suffering from mental health problems because of their reluctance to bear the stigma of mentally ill (Surguladze David, 1999). Byrne (2000, p65) defined `stigma as a sign of disgrace or discredit, which sets a person apart from others and the stigma of mental illness although more often related to context than to a persons appearance, remains a powerful negative attribute in all-social relations`. Stigma of mental illness has become an indication for unpleasant experiences, such as bringing shame to the family or social exclusion. According to Phillips et al (2002), in some parts of china, schizophrenia is still considered as a punishmentfor an ancestors misbehaviour or for the familys currentmisconduct and the effect of stigmais greater if the patient had more prominent positive symptoms or highly educated. Moreover, a study by Lee et al (20 05) concluded that 60 % out of 320 patients with schizophrenia had experienced interpersonal stigma from p arents, siblings or close rel atives. This indicates that people with schizophrenia are more likely to experience stigma from family members than the general public. Having a diagnosis of schizophrenia does not only affect ones health but also carries all the prejudice, discrimination and social exclusion, for example many individuals are attacked on the streets, rejection in the society and denial of employments because they were known to have mental health problems (Gamble Brennan, 2006). According to Byrne (2000) in two identical UK public opinion surveys, 80% of participants claimed that most people are embarrassed by mentally ill people and about 30% agreeing `I am embarrassed by mentally ill persons`. There is also evidence that supports the concepts of stereotyping of mental illness. The power and influence of the media on mental illness has been a key issue of debate over many years as people with schizophrenia are frequently portrayed as violent and dangerous. In contrast, people with schizophrenia are more likely to be dangerous to themselves than to others, while the greater danger to the public is posed by people without mental health problems and people with mental health problems are six times more likely than the general public to be the victims of murder (Stickley Felton, 2006). Moreover, Gamble Brennan (2006) claimed that when the boxing champion Frank Bruno was admitted to hospital in 2003, one of the newspaper headlines was `Bonkers Bruno locked up`. This indicates that stigma has the grave potential to cause reluctance to seek treatments and this can be detrimental to the persons health. Therefore, as a mental health clinician, it will be vital to assist people wit h mental health problems to rebuild their lives and this requires moving beyond the traditional focus on symptoms and medication by exploring alternatives in reducing stigma of mental health that avert people from social inclusion. It has been predicted that families with high expressed emotion compared to low expressed emotion can contribute towards the relapse rate in symptoms of schizophrenia and this can also be a triggering factor for non-concordance with medication. High expressed emotion carers appear to perceive their caring situation as more stressful and this could be conceptualised as a catastrophic appraisal of the role of caring (Raune et al 2004). Kuipers et al (2006) identifies the components of expressed emotion as emotional over-involvement, hostility, critical comments, warmth and positive remarks. A study by Kuipers et al (2006) indicates that patients whose carers showed high expressed emotion had considerably higher levels of anxiety and lower self-esteem due to the components of expressed emotion. However, a significant amount of data from western cultures suggests that high expressed emotion subjects who were not on medication are three times likely to relapse than those who were on medic ation (Bhugra McKenzie, 2003). This clearly signifies that despite being concordant, high expressed emotion subjects are vulnerable to relapse. The interactions between patient and the carers are crucial, especially cross-culturally as in some cultures for example, in some parts of India, emotional over-involvement is the norm and if carers do not show emotional over-involvement, this can be seen as lack of care (Bhugra McKenzie, 2003). Hashemi Cochrane (1999) conducted a study in UK on expressed emotion and they observed that 80% of the British Pakistani, 45% of the White and 30% of the British Sikh families exhibited high levels of expressed emotion and emotional over-involvement was notably higher among the British Pakistani group. The findings concluded that White patients with high expressed emotion relatives were significantly more likely to relapse than those from low expressed emotion families, whereas for both Asian groups high expressed emotion did not predict relapse. The study of Hashemi Cochrane (1999) also indicated that that Pakistani families in the UK were more likely to be rated as high expressed emotion than White families, indicating that components such as emotional over-involvement may be cultural rather than pathogenic traits. Conversely, low expressed emotion families who are not over-anxious in their response to the patients illness may tend to perceive stigma in less threatening ways whereas, families with high expressed emotion, who respond to the patients illness in a highly anxious may experience stigma more intensely (Phillips et al 2002). Therefore, it appears that family members levels of expressed emotion could influence their perception and response to stigma of mental health and concordance with medication is essential for patients irrespective of the expressed emotion status in the family. Thus, family interventions need to improve in order to lower the levels of anxiety and to increase self-esteem among families with hig h expressed emotion. As a clinician it will be vital to acknowledge the cultural aspect of expressed emotion status in the family to facilitate concordance with medication. There is overwhelming evidence for patients with schizophrenia, who misuse illicit drugs and alcohol to have an increased rate of re-hospitalisation (Sokya, 2000). According to Barnes et al (2006) the higher relapse rate in people with established schizophrenia who usesubstances may be partially explained by non-concordant tothe medication regimen. Evidence suggests that the substance used most frequently by people with schizophrenia is cannabis (Gamble Brennan, 2006). Arseneault et al (2004) emphasise that rates of cannabis use in UK are higher among people with schizophrenia than among the general population and patients detained under the MHA (1983) have even higher rates of lifetime use of cannabis. Substance misuse in schizophrenia may be explained as a form of self-medication to alleviate the symptoms of schizophrenia, to improve the side effects of antipsychotics and to respond to social pressures (Sokya, 2000). There has been little evidence to support the self-medication hypothesis despite its popularity with users and in contrast, substance misuse can aggravate the symptoms of schizophrenia and can also trigger psychotic episode particularly in people with a pre-exis Factors Affecting Antipsychotic Medication Compliance Factors Affecting Antipsychotic Medication Compliance INTRODUCTION The aim of this dissertation is to explore the factors affecting concordance with prescribed antipsychotic medications. The rationale for selecting this topic is derived from personal working experience with mental health service users. Having worked as a nursing assistant for the past eight years on acute admissions wards and as a student nurse for the past three years it was observed that a large proportion of compulsory re-hospitalisation under the Mental Health Act 1983 occurs due to relapse of mental illness as a result of non- concordance with medications, particularly service users with a diagnosis of schizophrenia. This led to believe that concordance with antipsychotic medications plays a crucial role in managing psychosis as it positively contributes towards the effective management of the illness in the community. In support to this view, Gray et al (2002a) assert that prophylactic use of antipsychotic medication reduces the risk of relapse among individuals with schizophr enia and non-concordance with medication has the potential for frequent re-hospitalisations. This has been recognised as the revolving door syndrome. During most mental health placements it was noted that non-concordance with medication has become significant, as this has been identified as a risk factor within the risk assessment checklist. Furthermore, despite the well-documented therapeutic effect of antipsychotic medications, some patients are reluctant to accept treatments and some may even wish to cease taking medications altogether. Therefore, this empirical knowledge has reinforced the desire to examine the factors associated with non-concordance with antipsychotic medications. According to Brimblecombe et al (2005) medication is one of the major therapeutic tools available to help people with schizophrenia. There is also growing evidence that schizophrenia can be treated effectively with a range of psychological and social interventions together with antipsychotic medications. Norman Ryrie (2004) emphasised that antipsychotic medication has been the mainstay of treatment for schizophrenia since the 1950s when it was discovered that the dopamine antagonist haloperidol and chlorpromazine exerted antipsychotic effects. The National Institute for Clinical Excellence (NICE) (2002) recommends that atypical antipsychotic drugs such as amisulpride, aripiprazole , olanzapine, quetiapine or risperidone must be considered in the choice of first-line treatments for individuals with newly diagnosed schizophrenia or to promote recovery for those who have experienced unacceptable side-effects on conventional antipsychotics, as atypical antipsychotics appear to have less extrapyramidal symptoms (side effects) than the conventional antipsychotics such as haloperidol and chlorpromazine. The care and treatment of individuals with schizophrenia have advanced considerably over the past ten years, since the introduction of atypical antipsychotics and medication continues to be the first line treatment for schizophrenia (Walker MacAulay, 2005). However, Gray et al (2002b) claim that despite the effectiveness of these atypical antipsychotic drugs, non- concordance with prescribed antipsychotic medications is observed in around 50% of people with schizophrenia and is a major preventable cause of psychiatric morbidity. In addition, Mitchell Selmes (2007) claim that over the course of a year, about 75% of patients will discontinue prescribed antipsychotic medications, often coming to the decision themselves and without informing a health professional. According to Gray et al (2006) relapse rates is five times higher among individuals with schizophrenia, who are non-concordance with medication compared with concordance. Non-concordance during acute treatment of psychosis le ads to chronic symptomswhereas non-concordance after remission increases the risk ofrelapse and both may have serious consequences; re-hospitalisation (Hamer Haddad, 2007). Furthermore, the impacts of non-concordance with medication not only affect the individuals with schizophrenia, as each relapse causes a stepping down of cognitive functioning which is rarely retrieved but also their carers and the costs of treatments (Institute, 2007). To facilitate this project as a literature review, an analysis of secondary sources only will be use. Secondary sources were mainly obtained from nursing journals such as Nursing-Standard, Nursing-Times, Advances in Psychiatric Treatment, Mental health practice, Schizophrenia Bulletin and The British Journal of Psychiatry, containing the key words: schizophrenia, oral antipsychotic, medication management and non-concordance. An Internet search of Google was also done with the same keywords to access any relevant documents. To address the factors affecting concordance with prescribed antipsychotic medications, these will be divided into patient-related factors, medication-related factors and clinician-related factors. LITERATURE REVIEW According to White (2007) schizophrenia is a debilitating psychiatric disorder characterised by a range of positive and negative symptoms and these symptoms were first described in detail by the British neurologist Hughlings-Jackson in the late 1800s. There is no physical test for schizophrenia rather it is diagnosed by the presence of certain positive and negative symptoms over a period of time (Brennan, 2001). According to Issacs (2006) the neurotransmitter hypothesis suggests that the dopamine over activity in the mesolimbic dopamine pathway, which is between the midbrain, is thought to cause the positive symptoms of schizophrenia and dopamine under activity in the mesocortical dopamine pathway is thought to result in the negative symptoms of schizophrenia. Positive symptoms represent a distortion of normal experience, such as delusions, hallucinations and thought disorder, whereas negative symptoms represent a loss or dimming of normal function and social norm, such as avoidance of social interactions (Baker, 2003). There are different types of schizophrenia such as paranoid, disorganised, catatonic, undifferentiated and residual (Issacs, 2006). However, Gillam (2002) claimed that the exact causes of schizophrenia remain unclear but genetic, environmental and social factors are all thought to influence its development. The risk for a child to develop schizophrenia is 46%, if both parents have the disorder (Kirk et al, 2006). Women who have certain viral illnesses during their pregnancy may be at a greater risk of giving birth to children who later develop schizophrenia and the 1957 influenza A2 epidemics in England resulted in an increase in schizophrenia in the offspring of women who developed this flu during their pregnancy (Frankenburg, 2007). 1 in 100 UK populations will develop schizophrenia in their lifetime and the world prevalence is about 2-4 in 1000, as it affects men and women equally (Rethink, 2008). However, the onset in men is about five years earlier than women with the peak age of incidence is between 16 and 25 and the presentation of the illness varies tremendously, not only between individuals, but also within the same individual at different stages of their illness (Magorrian, 2007). Schizophrenia seems to be more common in city areas and in some ethnic minority groups and premature mortality in people with schizophrenia is 2 to 3 times higher than that in the general population (Royal college of Psychiatrists 2008). The premature mortality might be due to poorer health care, physical health, unhealthy lifestyles and people with schizophrenia may be at greater risk of type 2 diabetes as a result of antipsychotic medications (Nash, 2005). Moreover, according to WHO (2008) schizophrenia is a treatable disorde r but many individuals remain untreated regardless of effective treatments. There has been an unresolved debate about how best to define patients engagement with medications and until the 1980s most work on patient engagement with medications regimes was described as compliance (Norman Ryrie, 2004). The term compliance is often used interchangeably with adherence or concordance (Snelgrove, 2005). According to Kikkert (2006) the term compliance has fallen out of favour in clinical practice because it carries an assumption that patients are the passive recipients of clinicians and implies unquestioning obedience with no opportunity for patients choice. To add to the complexity of this term, patients can be intentionally or unintentionally non-compliant such as a deliberate decision not to comply with treatment and patients may have misunderstood the guidance that they have been given or unable to open the medication container. Velligan et al (2006) claimed that in recent years there has been a shift from this paternalistic model of doctor-patient interactions with the consequent preference for the use of the term adherence. However, while adherence emphasises negotiation between clinician and patient, it still implies a degree of passivity and obedience (Snelgrove, 2005). Gray et al (2002b) assert that concordance may be a more acceptable term as it suggests a collaborative process of decision-making regarding medications regimes and acknowledges the importance of the two-way communication. The NHS Plan (2000) emphasises the importance of placing patients at the centre of services and the transformation of patients into consumers of the health service has changed the context of health care, as patients are expected to become more active and informed about their treatments (Jasper, 2006). Murray et al (2007) emphasise that shared decision-making between clinicians and patients has the potential to improve concordance with treatment plans. Furthermore, The Chief Nursing Officers review of mental health nursing (2006) recommends that building and maintaining positive interpersonal relationships with service users is essential to successful mental health nursing practice and person-centred values is helpful in building positive relationships. This indicates that by not agreeing to health professionals advice patients may be labelled as non-compliant. Nonetheless, compliance could also be problematic, for example if patients continue to take medication obediently, although it is causing adverse side effects. However, from the empirical knowledge the term compliance is still being used in clinical settings despite the paternalistic conception. Therefore, the term concordance is favoured here as it promotes the idea that medication treatment should be a collaborative process between clinicians and patients, which emphasises the patients rights. Ultimately, the term concordance corresponds with the current ethos of modern mental health care set out in the National Service Framework (1999), the NHS Plan (2000) and the Chief Nursing Officers review of mental health nursing (2006), which is concerned with working in partnership with patients and carers. However, according to the term concordance patients have the right to make t reatment decisions, for example, stopping medication even if health professionals do not agree with that decision. For decades researchers have worked to explain the causes of non-concordance with medication unfortunately there have been no valid way of measuring concordance (Velligan et al, 2006). Rates of concordance have been measured by using the subjective and objective methods. Subjective method includes patients` self report and direct interviews, although this method is less expensive, it tends to overestimate the degree of concordance, as patients may not admit non-concordance (Gray et al, 2002b). Snelgrove (2005) claims that objective method such as blood and urine analysis also pose problems as they do not account for individual metabolism and do not reflect inconsistencies in concordance over time. Moreover, from empirical knowledge blood test is effective in monitoring concordance with mood stabilisers such as lithium, but for schizophrenia it is the manifestation of symptoms can support the evidence of non-concordance. According to Gray et al (2002b) pill counts are more reliable, b ut it is impossible to tell whether patients have actually ingested the medication. Even expensive objective method such as electronic monitoring which records every occasion that a pill bottles is opened can also be problematic when patients choose not to swallow the medication that was removed or do not replace the caps and electronic prescribing is still fallible, just because medication is available does not mean that it is taken (Velligan et al, 2006). One of the major clinical problems in the treatment of people with schizophrenia is partial or complete non-concordance with medication and this limits the clinical effectiveness of the prescribed medications (Kikkert et al, 2006). Antipsychotics medication can only be effective if they are taken continuously over a sustained period of time (Norman Ryrie, 2004). Urquhart (2005) claims that partially concordant patients can be difficult to identify because they do not actively refuse to take their medication but the dosage deviations for different reasons and this may only be detected when psychotic symptoms re-emerge. Partial concordance creates significant problems for the treating physician as it creates difficulties in determining whether medications are working adequately, dosing is appropriate or concomitant medication is needed (Velligan et al, 2006). Therefore, this indicates that medication or dosage changes and the addition of concomitant medications are more likely to occu r among patients who are not fully concordant with prescribed medications. Non-concordance with prescribed medication is believed to be a significant factor to increasethe probability of relapse in patients with schizophrenia and relapse is one of the most costly aspects of schizophrenia (Almond et al, 2004). Knapp et al (2004) undertook a study of 658 patients receiving antipsychotics medication of whom 20% reported non-concordance with prescribed medication and concluded that non-concordance was one of the most significant factors in increasing service costs, predicting an excess annual cost per patient of  £2500 for inpatient services and an overall additional cost of  £5000 for total service use. In addition, Almond et al (2004) estimated that costs for relapse cases are four times higherthan those for non-relapse cases. Therefore, these two studies show that relapse in patients with schizophrenia as a result of non-concordance isa major factor in generating high hospitalisation rates and costs. This implies that patients who do not concord with the ir medication are likely to requiremore treatment and support from a range of services and given the high costs associated with relapse non-concordance is a key factor in the use ofin-patient and external services. Antipsychotic medication has proven efficacy in the treatment of schizophrenia and the prevention of relapse. In spite of vast evidence that antipsychotics can be effective in treating the symptoms of schizophrenia, almost 90% of patients will relapse within the first five years of treatment following an acute episode and in general the illness has a tendency to recur or become chronic (Velligan et al, 2006). According to White et al (2007) non-concordance with drug therapy is common in schizophrenia; approximately 50% of patients are non-concordant within one year and 75% within two years after being discharged from hospital. Such high rates of non-concordance with medication may initially seem alarming (Gray et al, 2002b). However, it is similar with other conditions such as asthma where maintenance treatment is required. A study of concordance with asthma medication conducted by Newell (2006) estimated that 70 % of asthma patients in the UK are non-concordant with medication and t he levels of non-concordance in long-term conditions, such as asthma are known to be high as many asthma sufferers will only take medicine when they feel they need it rather than as instructed by clinicians. Therefore, considering the Newell (2006) findings it can be argued that the rates of non-concordance with antipsychotics are not significantly different than those on non-psychiatric medications and the myth that non-concordance with medication is more common among mental disorders as compared to physical disorders needs to be dispelled. Several factors have been shown to increase the chance of relapse but probably the single most important cause of relapse is the discontinuation of effective antipsychotic medication regime. A large number of factors influence non-concordance with prescribed antipsychotic medications, however Gray et al (2002b) have identified the main factors as impaired judgement, negative beliefs about treatment, poor worker-user relationship and the side-effects of medication. Additionally, Kikkert et al (2006) conducted a study in four European countries exploring medication adherence in schizophrenia and identified insight, beliefs about treatment, side effects and treatment efficacy as factors that influence concordancewith medication in patients with schizophrenia. Urquhart (2005) suggests that the problem of non-concordance may be more prevalent among those with schizophrenia due to its nature, for example, lack of insight. Magorrian (2007) claimed that non-concordance with medication is often linked to the persons level of insight into his or her illness and lack of insight is a frequent concomitant of psychosis. In schizophrenia, insight has been defined as an awareness of illness and an ability to recognise symptoms as part of an illness (Gray et al, 2002b) According to Surguladze David (1999) between 50% and 80% of patients diagnosed with schizophrenia have been shown to be partially or totally lacking insight into the presence of their mental disorder and these individuals are often difficult to engage with treatments due to impaired insight. Recent conceptualisation has formulated insight as a continuum representing the combination of three factors; awareness of illness, need for treatment and attribution of symptoms. Lack of insight is continuously problematic but an emotional element can be associated with denial of symptoms or rejection of treatment at key points in the illness (Byrne, 2000). Mitchell Selmes (2007) claim that having a perception about the illness and the knowledge of medications are the key factors of concordance in mental health and patients who understand the purpose of the prescription are twice more likely to collect it than those who do not understand. A study by Cuesta et al (2000) reported that patients suffering from schizophreniashowed poorer insight than patients with affective disorders. Cuesta et al (2000) findings demonstrated that the severe disturbances of insight persisted over the time and the level of insight was not significantly improved in patients suffering from functional psychosis as between 29% to 49% of these patients continued to have fair to poor insight at the follow up assessment. This is consistent with the findings of Kikkert et al (2006), where poor insight was a strong predictor of non-concordance with medication. In contrast, Tait et al (2003) conducted a study to examine changes in insight and symptoms of psychosis on fifty participantswho met the ICD—10 diagnostic criteria for schizophrenia. The participants were interviewed and insight was measured duringacute psychosis using the Insight Scale with the score 0- 12 and all the participants were reinterviewed at 3 and6 months following the init ial interview. Tait et al (2003) findings indicated that duringthe acute episode, 48% of participants scored 9-12 on the InsightScale and the majority of participants (63%) werein the 9-12 range of scores. The study of Tait et al (2003) clearly indicated that level of insight was high among many participants. In considering the findings of both Cuesta et al (2000) and Tait et al (2003) it appears that some patients with psychosis are unaware of their illnesses and insight is a strong predictor of concordance with medications and a good indicator of prognosis. However, evidence for a relationship between insight and concordance with treatment is inconclusive as the discrepancies found between the two studies might be due to the methodological factors, such as selection of participants. In both studies all the participants had a diagnosis of schizophrenia and all of them gave informed consent to enter the study. According to Appelbaum (2006) several studies in America regarding the decisional-capacity of patients with schizophrenia to consent or participation to research have raise some concerns due to the cognitive impairments associated with schizophrenia and using the MacArthur Competence Assessment Tool for Clinical Research clearly indicated that patients with schizophrenia do lack und erstanding and reasoning of research ethics. McCann Clark (2005) emphasise that antipsychotic medications some of which have a sedating effect can also have an impact on the cognitive processes, such as illogical thinking and this can hinder the quality of responses. Moser et al (2005) argued that some studies have shown that a high percentage of individuals with schizophrenia have adequate decisional capacity to consent to research participation, however in a medication-free schizophrenia research, participants did not show a major decline in decisional capacity. In addition, Jeste et al (2006) claimed that there is a risk in assuming that decision-making capacity of individuals with schizophrenia is always impaired, when they are capable to make autonomous decisions and in considering their decision-making capacity as permanently impaired by virtue of their diagnosis. Consequently, in order to investigate factors associated with schizophrenia, it can be argued that only individuals with schizophrenia can provide the answers of their experiences and protecting vulnerable populations from research activity can also exclude them from its benefits. According to Gerrish Lacey (2006) there two key concepts that concern the quality of a research: validity and reliability. Roberts et al (2006) define reliability as how far a particular test will produce similar results in different circumstances, whereas validity is to ascertain the methods are actually measuring what is intended to measure. Both Cuesta et al (2000) and Tait et al (2003) had used structured interviews to gather the data and have chosen a quantitative approach. Structured interview provides the opportunities to change the words but not the meaning of the questions thus, Parahoo (2006) claimed that validity is enhanced because participants can be helped to understand the questions and interviewers can ask for clarifications and probe for further responses, if necessary and since all the questions are ideally asked in the same way, structured interview has a high degree of reliability. It seems that both Cuesta et al (2000) and Tait et al (2003) have adopted the appropriate approach to their research, as quantitative research is the conduct of investigations primarily using numerical methods. It infers that to examine correlations between insight and service engagement qualitative approach could not have produced the same data in this area of study. Moreover, in both studies purposive sampling were used as all the participants had a diagnosis of schizophrenia. According to Polit Beck (2006) all participants in a phenomenological study must have experienced the phenomenon under study and must be able to articulate what is like to have lived the experience. Johnson Orrell (1996 cited in Surguladze David, 1999 P 166) have argued that some patients may have their own explanations of their illnesses, such as religion or cultural beliefs which may not coincide with the Western medical model of mental disorders and this can be even more complicated if one tries directly to impose the models of insight on patients from non-Western cultures. Gamble Brennan (2006) claimed that different cultures in England perceive mental illness in different ways and this can have an impact on treatments as some cultures rather seek help from religious leaders than mental health services. Alternatively, religion or spiritual beliefs in the Western culture can have a positive impact on concordance with medication, as religious individuals with schizophrenia have a better social support compare to non-religious individuals with schizophrenia (Borras et al, 2007). Therefore, it can be put forward that awareness of illness is a crucial factor in the motivation to receive pharmacological treatment. Both cultures and religion can have a positive and negative influence on concordance with antipsychotics. Patients can have different levels of awareness into their illness and they may consciously or unconsciously avoid acknowledging that they are suffering from mental health problems because of their reluctance to bear the stigma of mentally ill (Surguladze David, 1999). Byrne (2000, p65) defined `stigma as a sign of disgrace or discredit, which sets a person apart from others and the stigma of mental illness although more often related to context than to a persons appearance, remains a powerful negative attribute in all-social relations`. Stigma of mental illness has become an indication for unpleasant experiences, such as bringing shame to the family or social exclusion. According to Phillips et al (2002), in some parts of china, schizophrenia is still considered as a punishmentfor an ancestors misbehaviour or for the familys currentmisconduct and the effect of stigmais greater if the patient had more prominent positive symptoms or highly educated. Moreover, a study by Lee et al (20 05) concluded that 60 % out of 320 patients with schizophrenia had experienced interpersonal stigma from p arents, siblings or close rel atives. This indicates that people with schizophrenia are more likely to experience stigma from family members than the general public. Having a diagnosis of schizophrenia does not only affect ones health but also carries all the prejudice, discrimination and social exclusion, for example many individuals are attacked on the streets, rejection in the society and denial of employments because they were known to have mental health problems (Gamble Brennan, 2006). According to Byrne (2000) in two identical UK public opinion surveys, 80% of participants claimed that most people are embarrassed by mentally ill people and about 30% agreeing `I am embarrassed by mentally ill persons`. There is also evidence that supports the concepts of stereotyping of mental illness. The power and influence of the media on mental illness has been a key issue of debate over many years as people with schizophrenia are frequently portrayed as violent and dangerous. In contrast, people with schizophrenia are more likely to be dangerous to themselves than to others, while the greater danger to the public is posed by people without mental health problems and people with mental health problems are six times more likely than the general public to be the victims of murder (Stickley Felton, 2006). Moreover, Gamble Brennan (2006) claimed that when the boxing champion Frank Bruno was admitted to hospital in 2003, one of the newspaper headlines was `Bonkers Bruno locked up`. This indicates that stigma has the grave potential to cause reluctance to seek treatments and this can be detrimental to the persons health. Therefore, as a mental health clinician, it will be vital to assist people wit h mental health problems to rebuild their lives and this requires moving beyond the traditional focus on symptoms and medication by exploring alternatives in reducing stigma of mental health that avert people from social inclusion. It has been predicted that families with high expressed emotion compared to low expressed emotion can contribute towards the relapse rate in symptoms of schizophrenia and this can also be a triggering factor for non-concordance with medication. High expressed emotion carers appear to perceive their caring situation as more stressful and this could be conceptualised as a catastrophic appraisal of the role of caring (Raune et al 2004). Kuipers et al (2006) identifies the components of expressed emotion as emotional over-involvement, hostility, critical comments, warmth and positive remarks. A study by Kuipers et al (2006) indicates that patients whose carers showed high expressed emotion had considerably higher levels of anxiety and lower self-esteem due to the components of expressed emotion. However, a significant amount of data from western cultures suggests that high expressed emotion subjects who were not on medication are three times likely to relapse than those who were on medic ation (Bhugra McKenzie, 2003). This clearly signifies that despite being concordant, high expressed emotion subjects are vulnerable to relapse. The interactions between patient and the carers are crucial, especially cross-culturally as in some cultures for example, in some parts of India, emotional over-involvement is the norm and if carers do not show emotional over-involvement, this can be seen as lack of care (Bhugra McKenzie, 2003). Hashemi Cochrane (1999) conducted a study in UK on expressed emotion and they observed that 80% of the British Pakistani, 45% of the White and 30% of the British Sikh families exhibited high levels of expressed emotion and emotional over-involvement was notably higher among the British Pakistani group. The findings concluded that White patients with high expressed emotion relatives were significantly more likely to relapse than those from low expressed emotion families, whereas for both Asian groups high expressed emotion did not predict relapse. The study of Hashemi Cochrane (1999) also indicated that that Pakistani families in the UK were more likely to be rated as high expressed emotion than White families, indicating that components such as emotional over-involvement may be cultural rather than pathogenic traits. Conversely, low expressed emotion families who are not over-anxious in their response to the patients illness may tend to perceive stigma in less threatening ways whereas, families with high expressed emotion, who respond to the patients illness in a highly anxious may experience stigma more intensely (Phillips et al 2002). Therefore, it appears that family members levels of expressed emotion could influence their perception and response to stigma of mental health and concordance with medication is essential for patients irrespective of the expressed emotion status in the family. Thus, family interventions need to improve in order to lower the levels of anxiety and to increase self-esteem among families with hig h expressed emotion. As a clinician it will be vital to acknowledge the cultural aspect of expressed emotion status in the family to facilitate concordance with medication. There is overwhelming evidence for patients with schizophrenia, who misuse illicit drugs and alcohol to have an increased rate of re-hospitalisation (Sokya, 2000). According to Barnes et al (2006) the higher relapse rate in people with established schizophrenia who usesubstances may be partially explained by non-concordant tothe medication regimen. Evidence suggests that the substance used most frequently by people with schizophrenia is cannabis (Gamble Brennan, 2006). Arseneault et al (2004) emphasise that rates of cannabis use in UK are higher among people with schizophrenia than among the general population and patients detained under the MHA (1983) have even higher rates of lifetime use of cannabis. Substance misuse in schizophrenia may be explained as a form of self-medication to alleviate the symptoms of schizophrenia, to improve the side effects of antipsychotics and to respond to social pressures (Sokya, 2000). There has been little evidence to support the self-medication hypothesis despite its popularity with users and in contrast, substance misuse can aggravate the symptoms of schizophrenia and can also trigger psychotic episode particularly in people with a pre-exis