George Alagiah’s Passage To Africa Essay

In a passage to Africa George Alagiah conveys his feelings about journalism during the course of his stay in Somalia through the use of various different language and literary devices. In a passage to Africa George Alagiah uses powerful and emotive language to show is views about journalism. An example of this is shown in the quotation: ‘that went beyond pity and revulsion’ , ‘revulsion’ has strong connotations of horror and disease so it marked the reader sympathise with the nature of the terrible scene that Alagiah is encountering in the village which he is observing. Another quotation that shows this is: ‘normally inured to stories of suffering, accustomed to the evidence of deprivation’, this quotation shows the way that Alagiah is hardened by the experiences that he has faced through the word ‘inured’ meaning immune to in conjunction with the words ‘suffering’ and ‘deprivation’, both of which have extensive connotations of evil and terrible hardship on those that it refers to, overall showing that Alagiah was steadfast to the other horrors that were unfolding around him and that the event he had just witnessed ahs managed to break his immunity of disconnection between him and the subject of his journalism. These quotations all show that Alagiah used emotive and powerfully connotated words to show the disconnection and connections with the journalist and subject. In the text Alagiah also uses a variety of sentence structures to show his views an observational journalist. An example of this is: ‘I saw that face for only a few seconds, a fleeting meeting of eyes’, the use of the above sentence structure shows that this very brief moment had deeply impacted Alagiah’s views on the way that he considered his role as a passive observer. Another example of this is the quote: ‘normally inured to stories of suffering, accustomed to the evidence of deprivation’, the way that the sentence is structured shows that Alagiah is meaning to portray a list to show how he feels about the way that a journalist can be susceptible to becoming accustomed to the terrible scenes that are unfolding before there eyes. In ‘a passage to Africa’ Alagiah uses a range of literary devices to show how he feels about journalism. An example of his use of literary devices on the following quotation: ‘If he was embarrassed to be weakened by conflict and ground down by hunger, how should I feel standing there so strong and confident?’, this reflective anecdote shows that as Alagiah is  there he is still reflecting on the way that he is so content and nourished while the people he is standing amongst are suffering terribly. Another example of literary devices in the quotation: ‘what was it about that smile?’, this rhetorical question shows how Alagiah is inquisitive into the thinking of the people he observes. These literary devices show his beliefs about journalism through the way he writes his reports. In conclusion is a passage to Africa George Alagiah uses a variety of language, sentence structures and literary devices to show his beliefs about journalism and the re lationship between him and the people he writes about.

Bantay-Dagat Program (Unfinished)

Introduction Our environment is our primary concern today, for the environment that have nurtured us and provided us with everything that we need for sustenance is now in peril. Pollution, destruction of forests, extinction of floral and faunal species, coral bleaching, loss of arable due to erosion – all of these, and more, are the products of man’s destructive activities that continually threaten our fragile environment. Furthermore, the constant ruining of the environment often creates catastrophes that can, and will, endanger our very own lives.Therefore, we must conserve, protect, and save our environment for environment’s sake, for our children’s sake, and for our sake. In connection, we, the students of the University of the Philippines in the Visayas of the NSTP-CWTS program AY 2012-2013 heed to the call of the world for a new wave of young people who can bring change towards their fellowmen in the context of environmentalism, envisioned to do our part in the fruitful conservation of Mother Nature.This plan of action of ours is our own way as students to meet local and national conservation efforts towards a more sustainable development of our beloved country. Description The Bantay Dagat Project as proposed by the National Service Training Program (NSTP) officers is a program in which the beautification of native beaches and awakening of the community’s awareness regarding proper waste disposal are accentuated as the principal goals.Background The beaches of Brgy. Santo Nino Sur are said to be one of the best beaches in the province of Iloilo, visited annually by many local and foreign tourists alike. However, decades of human occupation have tarnished the beauty of the site, and is now littered with a lot of garbage. There are lot of floating debris in the sea, and the coast is strewn with many unwanted materials, suggesting years of uncareful management of the area.

Women in the Great Depression

The Great Depression was a time of extreme hardship for many around the world especially within Australia. It began before the market crash in prices and lasted until World War 2. Many people became unemployed with a record at 29%. Many lost their houses forcing families, women and men to relocate to alternative accommodation. Women were especially affected by the disastrous depression. The importance of their roles within the household increased. Women were kept busy finding food, providing for their family, working and Juggling between children.Food What was the most common food available? Food In the Great Depression was very limited and scarce. Flower gardens were converted to vegetable gardens, mushrooms and blackberries were collected and fishing or rehabbing also became important if one lived in an appropriate area. The men usually took on the role of hunting, while the women stayed at home and cooked. For women It was particularly difficult, It was hard to create filling meal s due to lack of ingredients. Bread and dripping, mince and soup was the most common food served in a variety of ways, it was the staple diet of many unemployed.Another common and popular meal known throughout many Australian households was Golden syrup and treacle. Housing How did housing styles and architecture change through the great depression? During the great depression, there was a shortage of tradesmen. Ceilings of houses were lowered and the paneling became larger. The floor plan was much more simple and houses were smaller. Most were only one storey In height. The style of roof construction also changed. Many houses In that era had a â€Å"sleep out. † A â€Å"sleep out† was an outside patio or area allowing people to sleep on, on a hot summer night.It was also used for a healthy alternative to fresh air, as a common disease known back then was Tuberculosis and there was no cure. The front bricks were usually a very dark blue/black brick with brown â€Å"co mmons† on the side. The houses were very functional and well built for their time. Many people were evicted of their homes because they were unable to pay the landlord. The houses were left empty which then resulted in most situations becoming vandalized and damaged. What was the most common type of housing known throughout this time and seen In many suburbs across Australia?The most common types of architecture included the California Bungalow, Agrarian, Spanish Mission and the Old English. Clothing Where did women shop and what did they wear during this era? The clothing of women during the sass's reflected highly upon their social status and the levels of unemployment and poverty. Many high-class women shopped at large department stores including Grace Brothers and Meyer. They were influenced upon the high-end fashions seen throughout films. Charity balls were a perfect occasion to show off their new outfits.In an autumn catalogue called Sears, It quotes â€Å"Thrift Is th e spells of he day, reckless spending is a thing of the past. † For the poor, clothing was usually hand-me-downs make from simple fabrics like cotton and wool. Women also began to 1 OFF How did women in particular entertainment themselves through the great depression? Much of the entertainment was centered within the home. Evenings were spent singing round the piano or playing cards. For those who were unable to afford outings, the radio was extremely popular. Sporting events became a main activity for many including Cricket and horse races such as the Melbourne Cup.For the wealthy r those who were able to source full time work, charity balls and parties were held on Friday and Saturday nights in the city or middle-class suburbs. The poor did not attend these events; however for those who could, enjoyed the luxurious scenes, lavish food, tasteful drinks and extravagant dancing. Another popular source of entertainment included going to the cinemas. For many it was a place to es cape their everyday life and sit back and relax. 95% of the films came from Hollywood. Live theatre was a cheap and effective source of entertainment. Many attended a performance by the comedian the clown Roy Rene.Work How was finding work difficult for women? Throughout the great depression many women struggled to earn income and provide for their families. In 1932, the level of unemployment in Adelaide, South Australia was 29% according to http://aura. Anis. Du. AU/R/? Fun=dobbin-Jump- full=unisa25993 written by Rosemary Green. For women it was particularly difficult to find employment, wages were low and many found it hard to make a living. Most married women were expected to devote themselves to household work and caring for children, while on the other hand men worked to earn an income.They also received a greater burden even after working all day they were expected to cook dinner and maintain house order. Loss of Job could've been disastrous, unemployment was a major issue cau sing poverty and the government did not fund women during the depression. What was the most common area of employment? Most women were restricted to only certain areas within the workforce. Women were still concentrated in traditional Jobs, the major area of employment being domestic service, industrial work in clothing and textile manufacturing, consumer goods, commerce and fiance and public and professional administration.

One Flew Over the Cuckoo's Nest Research Paper Example | Topics and Well Written Essays - 1250 words

One Flew Over the Cuckoo's Nest - Research Paper Example For the purposes of this study, McMurphy code of behavior while in the correctional facility is closely investigated. McMurphy suffers from dissociative disorder. McMurphy as the main character displays a set of behaviors that strongly suggest that he is suffering from dissociative disorders. Primarily, dissociative disorders refer to irregular disruption of memory functions, personal identity, or personality. Dissociative disorder is a skewed psychological reaction in response to previous traumatic or distressful conditions. Simply put, dissociative disorder can be said to be a defense mechanism against previous bad or traumatic experiences. It is claimed that most of the cases of dissociative disorders occur among persons who have gone through traumatic experiences. According to Butler as quoted by Sharhram and Stephen; the most important feature of the dissociative experience is absorption and in all dissociative experiences, pathological and non-pathological, self-reflective mech anisms are terminated and because of that, in any dissociative experience the sense of self is lost and the experience of body and world is changed--which is described as depersonalization and derealization (Sharhram and Stephen, 2011, p. 3) What happens is that the person experiences spasms of impartiality from self when a traumatic or a similar phenomenon. It can be claimed that McMurphy’s dissociative disorder stemmed from the fact that he used to serve in military. Although the movie does not depict clearly the primary cause of McMurphy’s dissociative disorder, he must have developed the problem while serving in the Korean War. In the movie, McMurphy displays many symptoms of dissociative disorder albeit implicitly. Firstly, he is always in brawls with Nurse Ratched. For instance, he uses card games to win over all the cigarettes from the rest of the patients. However, Nurse Ratched confiscates the cigarettes and Murphy gets on her by demanding that the hospital po licies need reevaluation. At this point, Murphy is oblivious of his status as a mental patient and goes ahead to experience a moment of alienation from the reality (Tasman, Kay, Lieberman, First &  Maj, 2011). Possibly, Nurse Ratched reminds him of a painful past in the military whereby he underwent a humiliating experience. In another spectacular scene, Murphy uses the hospital bus without the permission and knowledge of the hospital staff. Interestingly, he carries his fellow patients and takes them to a fishing site whereby they use a fishing boat for deep-sea fishing. Arguably, the events at the fishing site clearly depict that indeed, Murphy is suffering from dissociative disorder. Notably, he tells the colleagues that they should not be afraid since they are fishermen and not mad as the nurses tell them in the hospital. At this moment, it can be posited that Murphy is experiencing a dissociative disorder since he is simply trying to change his personal identity and the ident ity of the colleagues in response to the harsh and unpleasant experience that he undergoes while in hospital. In yet another scene, Murphy takes on Nurse Ratched after she warns Billy that she will tell his mother what they had done in the hospital. Murphy shows yet more severe symptoms of dissociative disorder by experiencing a moment of irregular mental functions (Frederick  & McNeal, 1999; Tasman, Kay, Liebe

Learning and development Research Paper Example | Topics and Well Written Essays - 2250 words

Learning and development - Research Paper Example One can as well learn from experience. Development on the other hand is extending those practical aspects of a concept for growth purposes. It is a way of applying knowledge in order to meet specific objectives (Berrill, 2011). It can as well be described as a kind of transformation that one goes through. It is usually a kind of progress where one moves from a simpler stage to a more complex one. In my research paper, I will focus on learning and development in the Coca-Cola Company. I will basically look at key issues to learning and development, the opportunities presented and the strategies that are meant to make learning effective and also an analysis on the same. Learning and development faces various critical challenges and issues that hamper the process, Coca-Cola not being an exception. Even though Coca-Cola was determined in treating people equally and developing them through giving them a rewarding working life, it faced various challenges initially (Hays,2004).One of the issues that it faced was that employees viewed learning as a must-do process and therefore felt obliged to partake in it claiming that they had no option. This saw most of them attend the training not because they believed that it could help them grow but because they saw it as mandatory. This saw most of them not acquiring the skills that were needed because they were not in any way attentive when the training was being offered. According to Ferrara (2012) another issue regards providing employees with basic topics. These were topics that majored on them knowing how to perform various day-to-day tasks. This made the employees lack the motivation to learning because it was viewed to as a normal process that did not reflect on change. They claimed that it was in a form of cycle that started from the beginning to the end and back to the beginning. It was necessary to offer the employees other skills that were not related to work that would make them all round. Another issue

SLP Time Warp 3 Essay Example | Topics and Well Written Essays - 1000 words

SLP Time Warp 3 - Essay Example This paper thus attempts an implementation of the suggested theories, and in this way attempts at discovering the most effective strategy that can be used with the three products (Abbing & van Gessel, 2008). Pricing is largely regarded as a viable marketing strategy that the company can pursue. In this regard, the cost at which product X5 is sold needs an increment since the simulation results proved that the product was still in its growth phase and thus has a greater potential for growth before it attains maturity. On the contrary, the product X7, out of the simulation results, shows that it lies in the pre-growth phase. An increase in its product, though a risky course to take, seems to be the most logical path at the moment in a bid to determine the market reception, as well as acting as a means by which to test its market limits. The third product, the product X6, revealed to be in the maturity phase from the simulation results. Given its relatively impressive market run, it is a wise choice to further push its marginal profit through a slight price increment. The reason for stressing on slight is to avoid a scenario where it is too highly priced making the cost an issue that makes customers opt for competing brands (Beverland, Napoli & Farrelly, 2010). As a marketing procedure, this final strategy takes the combined strategy approach in achieving optimum product performance in terms of sales generation and profits accrued from these sales. In this regard, an implementation of the simulation results taking into account the initial R & D allocation increment (Bivainiene, 2010). Increasing the expenditure allocation of the R & D is done through an increase of that of the product X5, a product in its growth phase, as well as in the introductory phase of the product X7. The projected results out of these changes are as shown below: Year 2012 Product Price $ R&D Allocation % Profits X5 265 33 121, 288, 230 X6 420 34 264, 830, 873 X7 230 33 -22, 254, 435 Total 3 63,864,668 In the succeeding year, the pricing marketing strategy will prove the most logical strategy to be applied. In this strategy, the prices of products X5 and product X7 are reduced in relative margins. The price of the product X6, is however, left constant without any changes made to it. The rationale behind this direction is because the two products, X5 and X7 are relatively weakly established; the strategy to be applied needs to be focused upon two main issues, the increase in sales volumes, and the quick and efficient penetration of the market to establish its niche amongst the more established products in the same category as them (Slotegraaf & Pauwels, 2008). The strategies that call for an increase in the expenditure of the R & D are, however, left to continue. The expected profits changes on the application of the price changes and allocation of the R & D are as reflected below: Year 2013 Product Price $ R&D Allocation % Profits X5 240 35 79, 643, 368 X6 420 28 264, 8 30, 950 X7 180 36 0 Total 344, 474, 318 A thorough application of the strategy is reflective of the continued product success in terms of gaining market ground and penetration. The price reductions were necessary since it is the variable that can be modified as far as the marketing mix is

Global Warming Essay Example | Topics and Well Written Essays - 1750 words

Global Warming - Essay Example In addition, the claim is criticized by the argument that undoubtedly, the weather was coldest as compared to the previous trend in that region; still it was not the coldest if an overall picture of Earth’s climate is considered (NCDC, Climate of 2004, 2004). The coldest region of the Northeastern US still did not break records of the previous record low temperatures which the region went through in the winters of 1986. Thus the claim made by the critics of global warming is not rational. (NCDC, Climate of 2004, 2004). On the other hand, the heat waves observed in Europe were record breaking of the highest temperatures ever experienced. Global Warming is affecting the temperature of the Earth and society needs to understand that we must act now to prevent the end of humanity. A divided hypothesis has been created regarding the effects of global warming and if global warming is a myth or a reality. This assignment would further revolve around this issue and give views as to whi ch side of the scientists comes up with a strong hypothesis regarding global warming. DISCUSSION "All across the world, in every kind of environment and region known to man, increasingly dangerous weather patterns and devastating storms are abruptly putting an end to the long-running debate over whether or not climate change is real. Not only is it real, it's here, and its effects are giving rise to a frighteningly new global phenomenon: the man-made natural disaster" (Barak Obama). There are two differing views about the existence and causes of Global Warming. One group usually links it to the actions committed by the human beings themselves (Matthew et al., 2009). However others strongly believe that nature plays a role in creating the problem of global warming (Abrahamson, 1989). The arguments presented by both groups carry importance and without any doubt, these arguments are leading to more and more researches which are beneficial for knowledge and new theories. The study of Ea rth and its climate is of immense importance and beyond any doubt the reason for such extreme climatic changes should be known. In order to evaluate the reasons behind the changing climate of the Earth, the studies regarding global warming and the arguments against it are helpful. Regardless of all the arguments presented, I believe that humans contribute to the climatic changes and extreme weather conditions. The increased CO2 levels and rising temperature do have a link. The link between greenhouse effect and global warming are valid as put down by one set of the researchers (Weitzman 2007). A study suggests that global warming affects the farmland values. The cropland model used by the author suggests that the warming climate and temperature results in a loss of 4 to 5 percent of the gross farm value (Mendelsohn et al., 1994). Cunningham and Cunningham suggest that reduction in soot produced by diesel engines, coal-fired generators, forest fires and wood stoves may help in curbin g and decrease in the issue of global warming by nearly 40% within a period of 3-5 years (Cunningham & Cunningham 2010). Although the studies and climatic researches are not invalid and the continuous debate over this topic does carry an important place in the Earth’s study. According to my point of view, it is not valid to judge the climatic change just by examining or considering the weather patterns of a small region. Global warming does not

The Diverse Interpretations of Muslim Laws Essay - 1

The Diverse Interpretations of Muslim Laws - Essay Example In exchange for virgins in the afterlife, some Muslim groups interpret Jihad as a holy war to kill innocent civilians. Evidently, the two readings show the Muslim people’s diverse interpretations of the Koran’s Suras and related Muslim resources. The research focuses on the different interpretations of Muslim laws. One of the laws, Jihad, has diverse interpretations. Similarly, the gender issue has different explanations. Other Muslim groups interpret Jihad as a holy war. The holy war includes killing innocent civilians. Asra Nomani questions the diverse interpretations of the Muslim laws, including the gender equality issues. The authors, Mariane Pearl (2003) and Asra Nomani (2005) emphasized that Muslim life is compounded by one Muslim group’s daily struggles to influence the other individuals’ decisions. The story A Mighty Heart (Pearl, 2003) centers on the interpretation of the Jihad principles. The author describes the dangerous life of Danny Pearl, South Asian News Bureau Chief of Wall Street Journal. As a reporter, Danny traveled around South Asian countries to gather the latest news stories. Mariane Pearl writes the story of the life and death of her husband. Danny disappeared when he was about to meet Sheikh Ali Shah Gilan, the founder of a U.S. jihad group. Danny’s research focused on some Muslim groups’ devotion to Jihad as one of their duties. Past Jihad acts includes the 1993 World Trade Center bombing and the 9/11 U.S. airplane attacks (Pearl, 2003). Pearl’s thesis statement: Many Muslim groups have different interpretations of the Muslim Jihad Principle, some violent while others peaceful. The author correctly showed that some Muslim groups prioritize their time and energy to Jihad’s terroristic activities.  

Sandy Skoglunds Essay Example | Topics and Well Written Essays - 250 words

Sandy Skoglunds - Essay Example scale thus teetering balance amidst reality and unreality were heightened most emphatically when populace were included within the scenes due to the undeniably real live models (Bleicher, pp76-124). Sandy Skoglund is commonly associated with the big format photographs containing her bright and amusingly unsetting, room-sized fitting that poke fun at the existing suburban reality. The two installations coupled with the photographs were at the Museum of Glass. Every installation is approximately fifteen feet in height, width and corresponding breath and entailed backdrop panel, floor and constructed figures (Bleicher, pp76-124). The blue backdrops were covered with numerous fluttery glass dragonflies and marshmallows. Moreover, the floor was made of the inlaid blue glass tiles within the crackles pattern approximately six inches beneath the distinct glass sheet. The photographs of Skoglund are more effective and less stagy than the prevailing installations. Nevertheless, the photographs were very bright. Moreover, within the photographs three human models join the two sculpted figures in order to develop a tableau with the corresponding narrative implications by leaving the view imagination on the

Percy bysshe shelley Research Paper Example | Topics and Well Written Essays - 1000 words

Percy bysshe shelley - Research Paper Example The discussion becomes easy if a look at his poetic ideas is done first. Shelley is of the opinion that a poet is a moral teacher. He does not agree that a poet is merely an imitator. At the same time, he asserts that a poet is a creator, who not only creates but also provides ideas to the society, guides the people, and in a way teaches what should be done to improve one’s life. He rejects Thomas Love peacock’s remark that a poet is a â€Å"semi-barbarian†. He not only counters this negative remark about the poet but also declares that â€Å"Poets are the unacknowledged legislators of the world† (Defense). In his essay defending poetry, he explains the true role of a poet in his society and states that†Poetry turns all things to loveliness; it exalts the beauty of that which is most beautiful, and it adds beauty to that which is most deformed; it marries exultation and horror, grief and pleasure, eternity and change; it subdues to union under its li ght yoke all irreconcilable things† (Defense). Unlike Keats for whom poetry means beauty, Shelley finds poetry as a form of intellectual beauty. He treats politics, love, and nature on equal scale. He looks sometime melancholic, but his melancholy is closely related to his ideas. â€Å"Ode to West Wind† can be taken as an ideal poem to study Shelley as a poet and revolutionary. As a poem, it is very remarkable because in it the poet treats everything in nature as an instrument of melody. The poet becomes totally spellbound by the power of the wind, the cloud, the sun, the ocean, and all these in nature for him become the right subject for poetry. He is so much inspired that he prays, â€Å"Be thou, Spirit fierce, / My spirit! Be thou me, impetuous one!† (Ode). The poem deals with the regenerative power of nature. It praises how everything that is old and dead in nature is driven out to leave space for the birth of new and beautiful. In other words, it speaks abou t the likely situation in which the world has to exist with everything unwanted and decayed, if regeneration does not take place. The poet feels that this unfortunate situation is avoided in nature because of the support of the sweeping powers of west wind: â€Å"Thou, from whose unseen presence the leaves dead/ Are driven, like ghosts from an enchanter fleeing† (Ode). It is with similar spirit that the poet wants changes in the political situation in his society. However, he does not possess the sweeping powers seen in the west wind to drive out the old and conventional ideas in his society to pave the way for the new and creative ideas. That is how the poem becomes significant as an example of the poet’s political perspective. As Sydney Waterloo says, â€Å"He was a dreamer, but he never dreamed merely for the sake of dreaming; he always rushed to translate his dreams into acts† (Sydney). â€Å"Ode to the West Wind† shows how Shelley tries to translate his poetical and political dreams into reality. The poem, â€Å"Ode to the West Wind†, is in the form of a prayer. It is addressed to West Wind, and not to any particular God, as Shelley finds in the invisible power in nature what man generally finds in God. The political idea with which he was obsessed is identified with the power of the wind. Though he tried to impress his philosophical ideas upon the people through many pamphlets he found very poor response coming from the people. So he was disappointed.

Statistics problems Essay Example for Free

Statistics problems Essay Based on a simple random sample of one hundred an analyst estimates the average hourly wage earned by workers in a city to be $30 and computes the margin of error to be $5. Can we conclude from this that most workers there earn between $25 and $35 per hour? Is the right interpretation for the margin of error? Polls showed the two main candidates in the 2004 presidential election were nearly tied on the day before the election. To predict the winner a newspaper would like to have a poll that has margin of error of less than 1%. Roughly how large a sample would be needed for such a poll? Chapter 8 6. A large population of overdue bills ha balances that follow a normal curve. When we take a sample of 100 of these the average is $500 and the SD is $100. (a) What statement can you make about the range $300 to $700? (b) What statement can you make about the range $480 to $520? 10. Pollsters try to determine whether or not a person is a â€Å"likely voter† before they count their opinion in a poll. If we assume 40% of the registered voters will actually vote, in a random sample of 100 registered voters we can be 95% confident that somewhere between ______ and ________ of them will actually vote. Fill in the blanks with numbers. 22. An investment firm with 10,000 clients would like to accurately forecast the average dollar amount their current customers will deposit over the coming year. They decide to telephone a random selection of 25 of their customers to ask how much they plan to deposit, and they would like to keep this sample as small as possible so the calls do not annoy too many customers. Since they will be multiplying his average by the total number of customers to get an overall forecast, they would like to accurately estimate this average with a margin of error of less than $4,000. Last year, the average deposit for all 10,000 clients was $25,000 with a standard deviation of $30,000 Do you think a sample of 25 is enough to give them the margin of error they want? If not, how large a sample do you suggest they need to take? Justify you answer with relevant calculations.

Twice-exceptional students Essay Example for Free

Twice-exceptional students Essay The article titled How Can Such a Smart Kid Not Get it, is a document on implementing programs for twice-exceptional students in public schools. A twice-exceptional student is one who is gifted but also has a learning disability. Often in the public school system educators are forced to focus on the weakness of a student rather than the strengths which are often ignored. Therefore when a student has an IEP the school will focus on the IEP goals and objectives rather than improving on the strengths of the child in collaboration with the weaknesses. According to Yssel, Prater, Smith (2010), when educators focus on strengths rather than weaknesses, and when twice-exceptional students are provided with appropriate coping strategies and accommodations, social and academic success is possible. Researchers agree that a twice-exceptional student unique educational and emotional needs require an individualized approach not a one size fits all method (Yssel et al, 2010). Researchers suggest that in order to boost academic self-efficacy, twice-exceptional students must be empowered by opportunities to be successful and that traditional self-esteem programs alone cannot accomplish this task. A nurturing climate and emotional support system are crucial elements in effective learning experiences for twice-exceptional learners (Yssel, 2010. Therefore the authors of this article suggest that this population undergo certain programs and criteria within the public school system. Because twice exceptional children often feel isolated due to feeling like â€Å"one of a kind,† and not fitting in with their peers they should engage themselves with other students who are also twice-exceptional. Furthermore students with this disability are often distractible and have difficulty staying on task and therefore these students should be engaged in areas of strength and interest (Yssel, 2010). Also effective programming for these students cannot be accomplished without collaboration among teachers, special educators, and school counselors (Yssel, 2010). The author of this article agrees with the document written because they have a child who is twice-exceptional and often educators find it hard to alter their curriculum and have little understanding about the diagnoses. The author of this document can also relate to many of the stories explained in the article. In conclusion the writers of the original article created a camp for twice-exceptional students over the last six years. When they began their program they asked parents to rate how the public school system addressed the needs of their child. Almost all of the parents of the students reported that the schools focused more on the weaknesses of their child rather than the strengths. The authors of the text suggested a program that can be implemented into the school system. This includes having twice-exceptional students engage with other students, have the students participate in interests to their liking and focus on their strengths, and also having the students involved in extracurricular activities they enjoy such as an after school art class, drama class, or robotics class. The article employs that implementing a program for twice-exceptional children can be a difficult task but also successful if a team of educators and parents can collaborate effectively together.

The Business Strategies Of Tesco And Asda Marketing Essay

The Business Strategies Of Tesco And Asda Marketing Essay Porters Five Forces: Named after Michael E. Porter this model identifies and analyses five competitive forces that helps in determination of an organisations strengths and weaknesses. These forces include According to classical economics rivalries between companies must drive profits to zero because of the threat of substitutes. General substitution is able to reduce demand for a particular product, as there is a threat of consumers switching to the alternatives (Porter M. 1980). For example, if Tescos competitor ASDA provides substitutes for their goods then this will drive the price of groceries down for customers of both companies. Buyer power forces prices down. Fortunately the market is disciplined and they have a disciplined approach to price setting which prevents them from destroying each other in a profit war. Bargaining power of supplier may have implications for Tesco and ASDA. Supplier power is demonstrated by suppliers demand that they are paid a certain price for their goods. If retailers dont agree they dont get the goods to sell. But large supermarkets like Tesco and ASDA have an overwhelming advantage over the small shopkeeper. These supermarkets can dictate the price they pay the supplier. If the supplier does not agree they will be left with a much smaller market for their products. The new competitor factor of porter model also does not have much adverse implications on already established supermarket chains like Tesco and ASDA In fact they put up a lot of barriers to entry either implicitly or explicitly. For instance, Tesco may have cornered the market for some specific goods which the new supermarket will not be able to find cheap, reliable suppliers. Tesco and ASDA also has the advantage of economies of scale. They buy goods in bulk or in large volumes thereby considerably lowering the price they pay to suppliers per-item. A new small supermarket chain not well established can only buy a relatively small volume of goods and that will be at much higher rates. Porter theorized that the more products that become standardized or undifferentiated, the lower the switching cost, and hence, more power is yielded to buyers (Porter M. 1980). Tescos Clubcard remains the most successful tool in customer retention strategy and is highly effective in dealing with this problem of bargaining power of customers. PEST ANALYSIS FOR TESCO Political Factors Tesco with its massive operations on global scale is highly influenced by the political and legal conditions of host countries. For employment legislations, the government encourages retailers to provide a mix of job opportunities from flexible, lower-paid and locally-based jobs to highly-skilled, higher-paid and centrally-located jobs (Balchin, 1994). Economic Factors These factors mostly affect demands, cost, and profits and thus have implications for Tesco. They are largely beyond the control of Tesco, but their effects can be profound. Tesco is expected to do well internationally but is highly dependent on UK markets and any slowdown may have adverse affect on Tescos performance. Social Factors Changing shopping trends indicate shift towards one-stop and bulk buying to accommodate this Tesco has increased the number of non-food items available. Changes in population demographic and eating habits means retailers are focusing on products with added-value. Technological Factors The launch of the Efficient Consumer Response (ECR) initiative provided the shift that is now apparent in the management of food supply chains (Datamonitor Report, 2003). Tesco has fully integrated new technologies like intelligent scale, electronic labelling, self check-out machine with its operations. The use of Electronic Point of Sale (EPoS), Electronic Funds Transfer Systems (EFTPoS) and electronic scanners have greatly improved the efficiency of distribution and stocking activities, with needs being communicated almost in real time to the supplier (Finch, 2004). SWOT ANALYSIS FOR TESCO Strengths 1. Increased market share: Tesco already holds major share in the world market and because of strong fundamentals and multi-format will continue to do so. Their main strategy of attracting more customers through various methods like Tesco Clubcard has been very affective in winning customers long term loyalty. 2. Insurance: In fiscal 2003 Tesco Personal Finance became the fastest growing motor insurance provider by crossing the important mark of one million motor insurance policies. 3. Tesco online is the worlds biggest online supermarket with operations in more than 270 stores throughout the country. 4. Brand value: Tesco has a strong brand image, associated with its good quality, trustworthy goods representing excellent value. 5. Tesco has continued to develop a successful strategy to maintain its market leadership position. Weaknesses 1. Tescos high dependence on the UK market may be of concern in future for example, the Morrisons groups takeover of Safeway chain may alter the power balance. 2. Debt reduction: Tesco has aggressive expansion plan which leaves little free cash for any other operations. Opportunities 1. Expansion in non-food retail: Tescos telecom is the latest example of how it can expand in non-food retail industry. 2. Expansion into health and beauty; Tesco currently operates 19 stores with opticians and nearly 200 stores with pharmacies. 3. Tescos massive buying power gives it added advantage of economies of scale. 4. Tesco can further develop its revenue stream of online operation. Threats 1. Lower profit margins because of rising raw material costs for food and non food. 2. Structural changes in domestic markets may trigger price war. 3. Wal-Mart/ASDA challenge: Wal-Marts takeover of ASDA threatened Tescos rank as the top UK supermarket. 4. International expansion is good but is expensive and requires heavy investment. PEST ANALYSIS FOR ASDA Political Factors Like any other supermarket ASDA will also be affected by political factors whether they are new legislation regarding taxes or new employment laws. Thus EU enlargement, the euro etc all may have some implications for ASDA. Economic Factors Factors such as national income, recession, inflation may have some adverse affect on the performance of ASDA. Unemployment is the most influential factor on the economy. It lowers the demand for many goods thereby affecting the demand required for production of such goods. Social Factors The type of goods demanded by consumers reflects their social conditioning. One important factor applicable especially in the UK is increasing ageing population which has increased the costs for firms who are committed to pension payments for their employees because of their staff are living longer. ASDA has started to recruit older employees to tap into this growing labour pool. Technological Factors Technology is a major environmental variable which can help in development of many various beneficial processes and methods for cost reduction like improved efficiency in stock control due to bar coding, self scanning products etc. SWOT FOR ASDA Strengths 1. ASDA after its takeover by world giant Wal-Mart has increased its market share considerably and at present is just behind Tesco in UK markets. 2. Major employer in UK markets thus it has a major pool of talented and experienced work force. It has a focused strategy in place for human resource management and development. 3. Well established brand name with strong social image. 4. ASDAs strategies of smart price, price guarantee offer and ASDA direct have really changed the way customers look at them. Weaknesses 1. In comparisons to its competitors ASDA has low market penetration. 2. Lack of smaller superstores to compete with Tesco express, metro etc. 3. Product recalls which not only affects the business financially but also adversely affects the brand name. OPPORTUNITIES 1. ASDA can widen its product range especially non-food retail. 2. Expansion into European markets. With well established management strategies and strong parent firm like Wal-Mart this is the area where it should focus. THREATS 1. Major threat to ASDA is from its competitors especially Tesco mainly being the threat of substitute products available through the competitor stores at lower prices. 2. ASDAs major market is still in UK, so any slowdown or downturn in UK economy may affect ASDA very badly. 3. Consumer tastes and shopping trends are continuously changing. It is important for ASDA to continuously accommodate those changes if they want to keep their competitive edge. 4. Rising labour cost can also cut into ASDAs profits. SCENARIO PLANNING AND GAME THEORY Every organisation in order to develop strategic options and be future prepared needs to anticipate and think through how different options will impact them. Most organisations therefore use scenario planning and game theory to be future prepared. Tesco and ASDA Scenario 1: My way The conditions: Customers have do it yourself attitude. The society and economy is dynamic with consumers requiring more product information therefore the companies would have to continuously invent new methods to maintain their competitive edge. Products and services have undergone major changes with advanced technology like smart packaging that refrigerates individual packaging, fuelled by cells that automatically turn off on the use-by date. (The grocer, 2007). Consumers no longer trust big brands and do business through network of friends causing major change in retail structure with power balance shifting to individuals with high level of consumer trust. Large supermarkets chains like Tesco and ASDA will have to become logistics expert at local level. Scenario two: Sell it to me Customers have do it for me attitude In this scenario there is high customer confidence, good economy and customers trusting big brands and expecting organisations to solve problems for them. Large supermarkets like ASDA and Tesco do not undergo major changes and still dominate. The only major change that comes is the more personalised touch they give to their businesses like customised products based on the customers nutritional or personal requirements. Scenario three: from me to you. Here we have uncertain economy, less prosperity, environmental disasters, climate change. Consumers have do it yourself attitude as they dont trust the government and large organisations. Brand loyalty is almost nonexistent and customers prefer home grown cheaper solutions. Retail structure is badly affected with high street struggling. Scenario four: Im in your hands The economy is shaky, slow growth, debt crisis, with do it for me attitude of customer. Only trusted brands have survived. Development of new technologies is at much slower pace. It is the most favourable situation for Tesco and ASDA with smaller units struggling to survive with them dominating high streets. They enjoy strong customer trust with compulsory loyalty card schemes. (The grocer, 2007). PORTERS DIAMOND We now with the help of Porters diamond try to identify which of Tesco or ASDA is more competitive. Factors Conditions Tesco gained competitive advantage over ASDA through advanced factors mainly by successful technological integration into their business. Tesco has been successful in using these factors to make themselves more attractive to the customers. It was the first to diversify into various other nonretail sectors like mobile phones, insurance, digital entertainment. ASDA although has embraced these changes but by being first Tesco has gained an upper hand over ASDA. Demand Conditions Tesco was the first one to start own-label products. These are highly appreciated and in demand among the main middle class target group of these supermarkets because of low prices and good quality. Unlike ASDA Tesco stores are differentiated into various formats on basis of sizes and location like Tesco extra, Tesco metro, Tesco express making them easily accessible to everyone locally. Related And Supporting Industries Tesco gained advantage in this third attribute by mainly developing new products and selling it to existing customers. Strategy, Structure And Rivalry Tescos cost leadership strategy has given it a competitive edge over ASDA. Tesco is still continuing with its initial approach of pile it high, sell it cheap. Tesco stores in UK are divided into 6 classes depending upon their size, structure and range of products they sold. These size based structure helps it to serve their main target middle class group more effectively than ASDA. VISION MISSION AND GOALS Tesco Mission statement: Creating value for customers, to earn their lifetime loyalty.(Tesco PLC, our values, 2010). Tescos people centred value, our success depends on people both people who shop with us and people who work with us, explains how they would go an extra mile to win the loyalty of their customers and employees. Their Clubcard initiative has been their most successful customer retention strategy by gaining customers loyalty. ASDA Mission statement: To be Britains best value retailer exceeding customers needs.. always Statement of purpose: To save everyone money, everyday. (ASDA, all about us,2008) Thus according to the mission statement they want to become best retailer with priority on the customer satisfaction. ASDA has been working relentlessly towards this aim laying down various strategies to become market leader. One of these strategies as discussed in SWOT analysis is of price guarantee where the customers can easily do an online comparison with other supermarkets and if they are not cheapest then customer gets a printable voucher redeemable at ASDA stores. This along with ASDA smart price strategy shows their commitment towards their mission statement.

The Criticisms of Kohlbergs Moral Development Stages Essay -- Moral D

The Criticisms of Kohlberg's Moral Development Stages Part One:The criticisms of Kohlberg's moral development stages seem to center around three major points, his research methods, the "regression" of stage four, and finally his goals.The first criticism that I would like to address is that of his research methods. Kohlberg is often criticized for not only his subject selection, but also the methods by which he tries to extricate data from those subjects. His initial study consisted of school boys from a private institution in Chicago. The problem with this is fairly obvious, that this does not represent a significant portion of the population to allow for generalized conclusions. In other words, how can we test some boys from Chicago and ascertain that this is how all people develop worldwide?I believe that the answer to this criticism comes from the theory that it relates to. Kohlberg's moral development schema is highly dependent upon the idea that there are fundamental truths that cannot be dismissed. These ideas are "in the ether", wound into the very fabric that constructs human nature. Granted, his descriptions of the various stages also seem very dependent upon the surroundings and social institutions that an individual would be subjected to. Yet these institutions would be have to be built upon people, all of whom would share these ideological truths. It seems fairly obvious that all people have undeniable needs, survival and some group membership. Kohlberg's stages are merely methods by which one could fulfill these needs. For instance, Spartan societies were adamant about maintaining the purity and strength of the civilization. Citizens saw no wrong in exposing a sick or lame baby to the elements so that it might die. Surely an act of cruelty today, but in that society, a necessary evil The prosperity and wealth of the whole was of greater importance than that of the individual.In addition to these justifications, additional research substantiated Kohlberg's claims. Different subjects were tested, from all ages and regions, and the same conclusions were drawn from the data. Assuming that these conclusions are correct, and the data leads to the same interpretation, is there any other possibility? This argument seems most impressive, especially considering the differences between people that are evident in everyday life. Similarities ... ...o a small compromise to fit their needs. In conclusion, it seems that there is definitely a way to combine the Kohlberg justice theme and the Gilligan caring theme of moral development. Mr. Kohlberg provides a method to police a society that does not include 100 percent utopian citizens. Ms. Gilligan gives us the ability to relate to each and every person, as a person. She indicates ways that we can identify with their perspectives, understand their needs, and compromise. Although the real world seems infinitely more complex than either of these models, they bear a frightening resemblance to real societies and real people. Maybe someday, a perfect model will be constructed, judged by a perfect path of moral development. Until then, I hope that I have found a good combination of these two ideas. One last side note: I think I could spend weeks typing a paper on this subject. There are thousands of facets of each system that could fit into the other's potential flaws. However, I think I've been long-winded enough as it is. I have tried to make my points as succinct and reasonable as possible, but without sacrificing exactly what I wanted to say. Thank you for your patience.

True Human Nature Exposed in Lord of the Flies Essay -- Lord of the Fl

True Human Nature Exposed in Lord of the Flies       The island in Lord of the Flies represents "a microcosm of human society." Stranded on an island where no definite authority is to be obeyed, the boys quickly forget the social standards that their parents have impressed on them. Eventually, the wildness of their ids cannot be suppressed. They lose their pride as "British boys" and choose their leaders, their social groups, and their lifestyles with their basic instincts rather than with practicality. Fear and superstition rule the island instead of the laws of science. Without the constant pressure of society's expectations, the boys display the fundamental elements of human nature in the way that they choose to live.    In society, a constant struggle exists between what people want to do and what they need to do. If Freud's ideas about the human mind are correct, those who stress the former are more strongly controlled by their ids. Those whose lean more towards the latter are controlled by their ego. The government tries to enforce rules while the people struggle for more freedom. This is plainly displayed in how Ralph and Jack fight for the loyalty of the other boys. Ralph promises rescue, which works for a time. However, Jack promises them fun. People would rather have pleasure than security. The boys cannot see the importance of following the rules. In society, people have a similar problem. Everyone desires to be "liberated from shame and self-consciousness." Unfortunately, this inclination is not always in their best interest.    Humans will always separate themselves into groups based on appearance and similarities. The boy automatically separate themselves into "biguns" and "littluns." The older c... ...s in self-defense, Jack tells them "I told you- he's dangerous." This type of manipulation is common in human society, particularly when a fight for power is involved.    In human society, people will do what comes easiest. They will be manipulated and mistreated before they start to think for themselves or to act as individuals. This is shown well by the boys in The Lord of the Flies because boys have not yet suppressed their basic natures as completely as adults have. The thoughtless attitudes that the boys have is common in human society, even if adults pretend otherwise.    Works Cited Baker, James R.   William Golding, A Critical Study.   New York: St. Martin's Press, 1985. Golding, William.   Lord of the Flies.   New York: Harcourt, 1962. Riley, Carolyn, ed.   Vol. 1 of Contemporary Literary Criticism. Detroit: Gale Research Company, 1993.

Being a Good Tutor :: essays papers

Being a Good Tutor Tutoring, you think it is the easiest job that you could have. You think so because of the flexibility of time, and the only thing you need to do is be there on time to help students (Tutees) with the subject that they have difficulty understanding, which you obviously have the full knowledge about because you earned an ‘A’ or ‘B’ in earlier semesters. However, all that you were thinking is definitely wrong. The tutees don’t care how much you know, until they know how much you care. There are many qualities you need to have in order to be a good tutor besides being intelligent. As Clayton College and State University Peer Tutoring Program (CCSU) mentioned in their web site, â€Å"Intelligence alone does not result in successful tutoring; more important is what kind of person you are† (Characteristics of a Good Tutor). Also, as CCSU mentioned, the tutor should have a â€Å" Positive outlook, having a desire to help others, liking for the subject matter, open minded by accepting others points of view, having the ability to see what needs to be done and do it, understanding, and having the ability to feel what another person is feeling.† So what do you need to do when you have an appointment with a tutee for the first time? Besides having all the personal characteristics that I mentioned earlier, you also need to know about the subject that you are going to help the tutee with before going to the appointment. Then you need to review this subject even though you are good at it because you can gather the different ideas on this subject and also analyze the information that you might have forgotten. You need to think after that about how the session with the tutee is going to be, write some notes, and be ready to answer any question your tutee might ask you. Now you are ready to meet the tutee. When you meet the tutee, the first thing you need to do is to introduce yourself and tell him or her that you are a student, especially if that is his or her first time having a tutor. Try to be friendly in order to help the tutee lose his or her nervousness by asking the tutee how the class is going on. Use the first ten to fifteen minutes to organize, plan, and show the tutee what you are going to talk about in the session.

Nasality In Cleft Palate Individuals Health And Social Care Essay

Introduction:Nasality is a voice upset that is most normally met by the address linguistic communication diagnostician in topics with repaired cleft roof of the mouth, which affects the address intelligibility. The perceptual appraisal of nasality constitutes an of import facet of a comprehensive appraisal of the address of persons with repaired cleft roof of the mouth and/or velopharyngeal disfunction ( Kuehn & A ; Moller, 2000 ) . The perceptual appraisal in complex populations like cleft roof of the mouth is made more ambitious by the many-sided nature of voice ( Bzoch, 1979 ) . The comparative impact of changing constituents of the voice ( e.g. , pitch, volume, resonance ) can farther act upon the signal perceived by a hearer ( Zraich, 1999 ) . In add-on the diverse array of perceptual appraisal of nasality has some troubles including the definition of footings, dependability and the usage of different types of graduated tables ( Kreiman, Gerratt, Kempster, Erman, & A ; Berke, 19 93 ) . Several invasive techniques are used clinically to image velopharyngeal port. Inactive sidelong radiogram are used to see the velopharyngeal structures during sustained sounds ( Hirschberg, 1986 ) . Multiview videoflouroscopy allows observation of the constructions during connected address from several planes of infinite. Flexible fiberoptic nasoendoscopy allows direct observation of velopharyngeal motions during connected address. However, these techniques appear to hold more value as pre- or post-surgical appraisal, because the correlativity of the informations from these techniques with hypernasality is frequently hapless. The inclusion of quantitative measurings in a clinical appraisal battery would lend to the overall truth of an probe. Literature reveals several quantitative methods developed to mensurate facets of rhinal resonance, for illustration, the Nasometer ( KayPENTAX, Lincoln Park, NJ ) , the Oro-Nasal System ( Glottal Enterprises, Syracuse ) or the NasalView ( Tiger D RS, Inc. , Seattle, WA ; Bressmann, 2005 ) , Horii Oral-Nasal Coupling Index ( Horii,1980 ) , Sonography ( Dillenschneider, Zaleski & A ; Greiner,1973 ) , Palatal Efficiency Ratings Computed Instantaneously-Speech Aeromechanics Research System ( PERCI-SAR ; MicroTronics Corp. , Chapel Hill, NC ) . The application of these instruments is frequently limited by a combination of grounds, including a deficiency of comparative surveies straight contrasting each technique, clinical uncertainity associating to the sensitiveness and specificity of viing methodological analysiss, the popularity of imaging surveies ( typically, nasoendoscopy and videoflouroscopy ) that provide direct information on velopharyngeal inadequacy ( Bekir et al.,2008 ; Rowe & A ; D'antonio, 2005 ) and the demand of specific device and/or detector, such as the helmet required for nasalence, the accelerometers required for HONC, the aerophonoscope required for rhinal emanation sensing and frequent standardization of th e instruments. Nasality can besides be evaluated utilizing non-invasive and simple processs like, spectral analysis of speech signal. Acoustic techniques frequently entail arduous analysis governments that can necessitate extended user expertness ; the rightness of selected stimulation has non been strictly evaluated ( Watterson et al, 2007 ) . Acoustic techniques do offer some possible, as small expertness is required to enter address samples, and repeated samples can be easy obtained, doing acoustic techniques appropriate for curative pattern. Some of the spectral features associated with hypernasality are reduced strength of the first format ( F1 ) , the presence of excess resonance, displacements of the Centre of the low-frequency spectral prominence, increased amplitudes of the sets between first formant ( F1 ) and the 2nd formant ( F2 ) , and a lessening of the F2 amplitude ( Curtis, 1968 ; Hawkins & A ; Stevens, 1985 ; Kataoka et Al, 2001 ) , increased continuances of acoustic phonic sections in CVC vocalizations ( D'Antonia, 1982 ) ; prolonged VOT ( Gamiz, Fernandez-Valades, 2006 ) and decreased burst continuance ( Vasanthi, 2000 ) , decrease in volume ( Mc Williams & A ; Philip, 1979 ; Vasanthi, 2000 ; Peterson-Falzone et al. , 2001 ) . In recent old ages, nasality is evaluated utilizing spectral analysis of the address signal. The two common methods which are reported in the nasality measuring literature are one-third octave spectra analysis ( Yoshida et al, 2000 ; Kataoka et Al, 2001 ; Lee et Al, 2009 ; Vogel et A l, 2009 ) and the Voice Low Tone to HHhhhhhhhhhhhhhhhhhjjkiuigh Tone Ratio ( Lee, Wang, Yang & A ; Kuo, 2006 ) . Both methods focus on strength fluctuation around the first, 2nd and 3rd frequence formants, an acoustic form normally seen in hypernasal address ( Chen, 1996 ; Huffman, 1990 ; Kent, Weismer, Kent, Vorperian & A ; Duffy, 1999 ) . The Voice Low Tone to HHhhhhhhhhhhhhhhhhhjjkiuigh Tone Ratio ( VLHR ) was developed as a quantitative acoustic step based on the strength spectrum to measure rhinal resonance. Lee et Al ( 2009 ) defined the voice low tone to high tone ratio as the power ratio of the low frequence to high frequence energy obtained by spliting the voice spectrum with a specific cutoff frequence. Lee et Al, ( 2003 ) measured VLHR in topics with rhinal obstruction before and after intervention for rhinal congestion. Results revealed increased VLHR values significantly after decongested intervention. In the follow survey by same writers in 2006, obtained sustained vowels ( /a: / ) and a nasalized ( /a : / ) vowel from eight hypernasal grownups. The writers observed higher VLHR values in nasalized sounds than unwritten sounds, supplying farther grounds in support to the VLHR technique for measuring hypernasality. Lee et Al ( 2009 ) measured VLHR in topics with hypernasality caused by palatine fistulous withers and velopharyngeal inadequacy for sustained vowels. The consequences of their survey revealed important differences between VLHR values, hypernasality tonss and nasalence steps. In contrast to the old surveies, Vogel et Al ( 2009 ) compared VLHR and one 3rd octave analysis in cleft roof of the mouth kids to mensurate hypernasality. Consequences revealed that merely one 3rd octave spectra analysis differentiated hypernasal address between cleft roof of the mouth and normal kids. The difference obtained between these two surveies ( Lee et al, 2009 ; Vogel et al. , 2009 ) may be because of the methodological analysis employed to pull out VLHR and the pathological status and age of the topics participated in their survey. Sing all these factors the efficaciousness of non-invasive technique, like VLHR to measure hypernasality remains inconclusive in clinical population like Cleft lip/palate. Need FOR THE PRESENT STUDY:Very few surveies have been conducted to mensurate the nasality in cleft roof of the mouth topics utilizing VLHR. But, the consequences of these surveies are inconclusive and necessitate farther probe in other linguistic communications besides. Hence, the present survey was aimed to observe the differences in VLHR between cleft roof of the mouth and normal topics utilizing address samples collected in Malayalam linguistic communication.AIM OF THE PRESENT STUDY:The present survey was aimed to observe the differences in VLHR between cleft roof of the mouth and normal persons for voice undertaking, word list undertaking and transition reading undertaking.MethodologySubjects: A sum of 40 immature grownups within the age scope of 17 to 26 old ages participated in the survey. They were divided into two groups. Group I consisted of 20 cleft roof of the mouth persons ( 10 males and 10 females, average =19 old ages ) . They were included in the survey if they had a diagnosing of inborn cleft roof of the mouth, undergone primary surgery to mend the cleft roof of the mouth, and go toing or had been referred for address therapy. Group II consisted of 20 normal, age and gender matched control topics. The topics were screened for address, linguistic communication and hearing by speech linguistic communication diagnostician. All the topics were native talkers of Malayalam linguistic communication. Subjects with a upper respiratory piece of land infections, blocked nose or with rhinal congestion as assessed during the oro-motor scrutiny were excluded from the survey. Test Material: The stuffs involved three different assortments of address samples ( 1 ) sustained voice samples ( /a: / , /i: / and /u: / ) ; ( 2 ) six meaningful words selected from Malayalam Articulation Test ( Mayadevi, 1990 ) which consisted of force per unit area consonants and ; ( 3 ) a standard Malayalam Reading Passage ( Anita, 1999 ) were used. Instrumentality: The recordings were carried out at address scientific discipline research lab of the infirmary. The address samples for the survey were recorded utilizing Sony digital recording equipment ICD-U60 placed 10 centimeters off from the talker ‘s oral cavity. This recorded address samples were fed into the Praat package ( Version 5.1.43 ) digitally and sampled at 16K Hz, 12 spot quantisation and Praat book was used to pull out the VLHR parametric quantity. Procedure: All participants were instructed to bring forth three tests of sustained vowels ( /a: / , /i: / and /u: / ) for a minimal continuance of 5 sec ; six selected word list from Malayalam Articulation Test ( Mayadevi, 1990 ) and to read a standard Malayalam Reading Passage ( Anita, 1999 ) at their comfy pitch and loudness degree. A sum of 720 ( 3 vowels*6 words*1 sentence*40 topics ) items were acoustically analyzed to pull out VLHR parametric quantity. The voice spectra was derived utilizing fast fourier transform ( FFT ) with Praat package for all the address samples recorded and averaged for farther analysis. Acoustic information was analyzed in conformity with the prescribed protocols for VLHR ( Lee et al. , 2006 ; 2003 ) . VLHR was calculated by spliting the spectrum into a low frequence power subdivision ( LFP ) and a high frequence power subdivision ( HFP ) . The mean spectrum was divided into low frequence and high frequence parts utilizing a cutoff frequence of 600 Hz by utilizing Praat book ( Lee et al, 2009 ) . The equation for VLHR is as follows: VLHR= 10 A- log10 ( LFP/HFP ) . VLHR was used to cipher values on sustained vowel undertakings ( /a: / , /i: / , /u: / ) , six meaningful words and a sentence from standard transition were used and it was expressed in dubnium. Statistical analysis: The information was subjected to statistical analysis utilizing SPSS ( Version 17 ) . The mean and standard divergence values of VLHR for address samples were calculated and tabulated for each topic. Analysis of Variance was used on the information to find the important difference between the groups and address samples.Consequence:VLHR for voice undertaking: For voice undertaking, the average VLHR values for /a/ , /i/ & A ; /u/ was 12.79 dubnium, 16.79 dubnium and 16.81 dubnium for topics with cleft roof of the mouth and for normal topics it was 4.14 dubnium, 9.59 dubnium and 6.93 dubnium severally. Consequences showed that high forepart vowel /i/ had the highest VLHR value followed by high back vowel /u/ and low mid vowel /a/ for both the groups. Table 1 and Graph 1 depicts the mean and SD of VLHR. Results of ANOVA indicated important difference between group I and group II subjects for all the vowels ( F= 50.389 ; p=0.000 ) . Voice undertaking Group I Group II F value Mean South dakota Mean South dakota /a/ 12.79 2.15 4.14 2.86 F=50.389 P & lt ; 0.005 /i/ 16.7 3.61 9.59 2.51 /u/ 16.81 4.83 6.93 4.32 Table 1: Mean and SD VLHR values for group I and group II subjects for voice undertaking. Graph 1: Represents the average values of voice undertaking for /a/ , /i/ and /u/ for Group I and Group II subjects. VLHR for word list: Table 2 represents the mean and SD values of VLHR for words for cleft roof of the mouth and normal topics. In word list undertaking, the mean VLHR value for dissected roof of the mouth topics was 10.21 dubnium and for normal topics it was 3.53 dubnium. Consequences showed higher average VLHR values for cleft roof of the mouth topics than the normal capable values for all the words selected for the survey. On statistical analysis, consequences revealed a important difference between groups ( F=60.34 ; p=0.000 ) . Word List Group I Group II F value Mean South dakota Mean South dakota Word 1 11.70 4.20 5.47 3.5 F=60.34 P & lt ; 0.005 Word 2 9.422 4.56 3.55 1.84 Word 3 10.69 4.86 2.70 1.82 Word 4 11.26 5.01 2.94 1.30 Word 5 9.14 4.92 2.55 2.02 Word 6 8.88 3.29 3.96 2.38 Overall Mean 10.21 4.58 3.53 2.47 Table 2: Mean and SD VLHR values in dubnium for group I and group II persons for word list undertaking. Graph 2: Represents the average values of word list undertaking for group I and group II subjects. VLHR for transition reading: For transition reading undertaking, the mean VLHR value for dissected roof of the mouth topics was 9.68 dubnium and for normal topics it was 2.31 dubnium. Table 3 and Graph 3 shows the VLHR values for transition reading undertaking for group I and group II subjects. Consequences showed important differences for groups ( F=48.54 ; p= 0.000 ) for transition reading. Passage reading Group I Group II F value Mean South dakota Mean South dakota 9.68 2.31 F=48.54 ; P & lt ; 0.005 Table 3: Mean and SD VLHR values in dubnium for group I and group II persons for transition reading undertaking. Graph 3: Represents the average values of transition reading undertaking for group I and group II subjects.Discussion:Vowel /a/ had important lower VLHR values compared to vowel /i/ and /u/ . This consequence of the present survey supports the findings of Neumann & A ; Dalston, 2001 and Lewis et Al, 2000. The higher VLHR values obtained may be due to the articulatory positions assumed during the production of these vowels. The low mid vowel /a/ is a unfastened vowel which creates comparatively small opposition to airflow out of the oral cavity. Therefore the maximal energy is transmitted through the unwritten pit and therefore comparatively lower VLHR values compared to vowel /i/ and /u/ values ( Lee et al. , 2009 ) . Whereas in instance of cleft roof of the mouth persons because of velopharyngeal insufficiency there might be more of nasal energy flight which is indicated through the higher VLHR values than normal topics for voice undertaking. The consequences besides support the fin dings of Moore & A ; Sommers ( 1973 ) who reported the greater grade of nasality on high vowels as the high vowels make greater demand upon the valving map i.e. , higher points of posterior guttural wall/ velar contacts, tighter velopharyngeal seals and greater velar jaunt. Higher VLHR values obtained in dissected roof of the mouth topics were similar to other surveies. Similar consequences were obtained in topics with rhinal obstruction after intervention for rhinal congestion ( Lee et al, ( 2003 ) , in palatine fistulous withers and velopharyngeal inadequacy topics ( Lee et Al ( 2009 ) . The consequences of their survey revealed higher VLHR values and important differences between VLHR values, hypernasality tonss and nasalence steps. In contrast to the old surveies, Vogel et Al ( 2009 ) compared VLHR and one 3rd octave analysis in cleft roof of the mouth kids to mensurate hypernasality. Consequences concluded that merely one 3rd octave spectra analysis differentiated hypernasal address between cleft roof of the mouth and normal kids. The major difference obtained between these two surveies ( Lee et al, 2009 ; Vogel et al. , 2009 ) may be because of the methodological analysis employed to pull out VLHR and the pathological status and age of the topics participated in their survey. The ground attributed for higher VLHR values for word list and transition reading undertaking may be due to the acoustic characteristics of the pharyngeal topographic point of articulation, notably low frequence noise energy chiefly in the chief formant part ( i.e. , the part of F1 and F2 ) . The form of the vowels was non good defined, peculiarly because nasaliztion has greatly reduced the amplitude of F2 so that this formant is hardly apparent in the spectrograph. Another common site of articulative compensations, the voice box, besides tends to be associated with acoustic energy in the chief formant part. Thus both guttural and laryngeal compensation contribute to comparatively low-frequency acoustic construction for consonants. These speech compensations hence are characterized by diminished or absent cues in some spectral parts but by extra cues in other spectral parts. Overall survey consequences showed statistical important difference between the groups for all the address samples collected. The average VLHR values in dubnium were higher for cleft roof of the mouth topics compared to that of normal topics. The consequences are in consonant rhyme with the findings of Lee et al. , ( 2003 ; 2009 ) whereas in disagreement with Vogel et al. , ( 2009 ) . The higher VLHR values obtained in the present survey may be attributed to the belongingss of increased low frequence energy i.e. , rhinal formant and reduced high frequence energy i.e. , anti resonance of rhinal voices in cleft roof of the mouth topics because of velopharyngeal insufficiency which was absent in normal topics ( Chen, 1996 ; Kent, Weismer & A ; Duffy, 1999 ) . Thus addition in the amplitude of frequences between F1 and F2 every bit good as lessening in the amplitude above F2 have been linked to hypernasality and these alterations were thought to be captured via VLHR ( Lee et al, 2009 ) . Decision:The purpose of the present survey was to observe the differences in VLHR for address samples between cleft roof of the mouth and normal topics. Consequences revealed that the VLHR values were higher for cleft roof of the mouth topics for all the address samples analyzed. The important difference obtained may be because of the belongingss of increased low frequence energy and reduced high frequence energy of rhinal voices in cleft roof of the mouth topics. Hence, we conclude that VLHR parametric quantity is sensitive plenty to observe rhinal voices in cleft roof of the mouth topics and can be implemented as a everyday clinical tool for nasality measuring. And besides the sensed success of surgical or curative intercession in dissected palate topics can be measured quantitatively with the VLHR parametric quantity extraction. Further surveies can be carried out with more figure of participants and besides in other Indian linguistic communications to set up normative.

Complete the Ethical Lens Inventory Essay

Over the past few years I have been in the ‘finding myself’ phase. I have always been a person to be analytical and constantly working things through in my head. As of recent, I have been meaning to find purpose and meaning for all things humane. I would guess in the pursuit of happiness as they say. I often find myself wanting to reach out and see what I can do in my own pursuit to help others along the way. After taking the Ethical Lens game I can most definitely identify myself with the Rights and Responsibility lens. At a young age, I was attracted to my neighborhood church. I remember waking up to dress and walk myself there, to be around others in the community coming together for united purposes. After reading this specific lens focuses its ideals as said ‘through Nature or given by God’ as the way for man kind to strive to abide. A secondary value of this lens is loyalty. Nowadays, I find myself having to think about how far one should take loyalty. I have been in many debates on fairness to others. Defending friendships or family to the point where I’ve lost a few friendships from debating what I thought was right in a situation and came off too strong. That point leads to my blind spot, which was identified in this exercise as the ‘Belief that motive justifies method’. Looking back I can agree that I have hurt people unintentionally with what I thought was fair but being too pushy or as said in the inventory, having the risk of being too bossy. Also, I find often have to send myself reminders of not to be so judgemental of others when they don’t live up to the expectations I believe they should have for their lives. Yes I know ‘I have some nerve’. I am glad this was also pointed out as a risk in the inventory as my vice. The Ethical Lens Inventory now solidifies areas in my life that I now know for sure deserves immediate attention if I want to move forward and have succesful relationshi ps. I have never taken an ethical inventory in such detail as  this. I am grateful for this experience to identify my strengths and weaknesses in this unique exercise.

A report that reflects on Person Centred Therapy

I reflected on Person-centred Therapy (PCT) as the comparative model because of the conflict that exists between this and Cognitive Behavioural Therapy (CBT). The conflict is historical, political and from personal experience. In therapy twenty years ago I became frustrated with my counsellor’s person-centred approach. I challenged my counsellor to provide me with more support and help. I therefore had preconceived ideas of PCT which may be similar to stereotypical thinking of these models. It was excessively warm, completely non-directive and only reflected back to the client, which I found frustrating.I understand now it was because my coping style was externalised and I had no control over external events, which suited a more direct counselling approach. So, how would this influence my practice as a counsellor? In theoretical terms and in observed practice I appreciated the benefits of PCT for its empathetic understanding and for clients who require a non-directive approach to gain emotional awareness. Presenting issues that can be helped by PTS are bereavement, drug and alcohol issues, depression, panic and anxiety, eating difficulties, self-harm, childhood sexual abuse (Tolan and Wilkins, 2012).I have used the model affectively for bereavement and sexual abuse as an offer of a direction would have been inappropriate and incongruent at the time. My preconceptions of CBT were solution focused, challenging and that low intensity based interventions ignore the client’s past. I feel competent in using certain behavioural intervention in my practice and challenge maladaptive thinking patterns in sessions. CBT is a medical model and although we have been taught the disadvantages to diagnoses, CBT is seen as the treatment of choice for many presenting problems due to the amount of empirical evidence available.These are anxiety disorders, panic, phobias, obsessive-compulsive disorder, PTSD, bulimia and depression as identified by NICE (NICE, 2008, Acc essed online 27/06/201). This report reflects on the appropriate use of the models. Stereotypes have some element of truth, but at the same time, are not the truths. I wanted to understand the similarities and parallels while respecting the fact that, in practise, I use both models. I didn’t want to do a bit of each badly, but use a model in full at the appropriate time and understand my reason for doing so (Casemore, and Tudway, 2012).Both PCT and CBT are deeply rooted in the same philosophical underpinning of humanism, existentialism, and both are phenomenology particularly to the nature of suffering. However, there are differences in the understanding and interpretation of the philosophy. Both approaches view a person as continually seeking growth and self-actualisation. There are incompatible beliefs between the models. (Casemore, and Tudway, 2012). PCT observes that seeking growth and self-actualisation is a way of being and in itself therapeutic.Rogers’ professed that there were six necessary conditions for therapeutic growth that alone were sufficient to lead to a fully functioning person. The individual is the own expert who can determine their own journey of their reality and can heal themselves with the core, being the relationship itself. The structure of the self includes self-concept and introjected beliefs. PCT communicates acceptance of the client’s own experience and encourages then to identify alternate choices. It is a continual journey of self-awareness and knowledge, with the drive always towards growth (Mearns & Thorne, 2012).CBT views growth and self-actualisation as a shared goal of therapy to be reached with a set of tools, to be implemented in therapy. CBT’s view comes from Ellis who defines a person as irrational and rational. In CBT terms ‘dysfunctional beliefs’ are similar to ‘introjected beliefs’ and led to distortion in the self-concept. The irrational cause’s distress a nd rational directs the individual to fully functioning. CBT primary belief is self distortion and the process of cognitive dissonance.Interventions such as the ABCDE framework are used to challenge and dispute irrational thinking and are aimed at increasing client’s self-awareness and self-understanding. CBT sees the relationship as more collaborative and facilitates new learning. An individual’s construct of reality is dimensional and irrationality stops the client from changing. Therefore, a person’s drive is not always towards growth (Casemore, and Tudway, 2012). A similarity of both approaches is the understanding of self-worth and unconditional self-acceptance. The nature of suffering is seen the same. Humans are flawed, imperfect and we cause our own disturbance.Both see the client as the expert in the relationship. Authenticity is of great importance to both PCT and CBT as is the therapeutic relationship. It is the emphasis on the process of change, to b ecome oneself, where the differences in two models lie (Castonguay, & Hill, 2012). From a PCT perspective a client discovers some hidden aspect of them self that they weren’t aware of previously and moves towards a greater degree of acceptance of self by being prized by the therapist (unconditional positive regard), have a sense of realness (genuineness) and listen to them self (empathy).A client moves towards seeing new meaning. These changes are characteristic of therapeutic movement. The client moves along a continuum from rigid structure to flow which can be seen in the seven stages of therapeutic change. Rogers’ term was ‘organismic experiencing’ which was interpersonal in the therapeutic relationship through unconditional positive regard and intrapersonal within the client accepting a new experience into their awareness (Castonguay, & Hill, 2012). In PCT, the process of change there are different corrective experiences for a client.For me practising with a client group from a women’s refuge I use PCT and Rogers’ condition-of-worth. The incongruence between the self-concept and authentic self is evident due to the abuse. This creation of a false self is corrected with unconditional positive regard, empathy and genuineness. Process Theory is where, change in the experience of feelings and the recognition that the client is the creator of their own construct occurs. The therapeutic change has a developmental sequence.There is a change in the client’s manner of experiencing feelings and recognition of being the creator of their own constructs, accepting responsibility and in relating to others openly and freely. This is compatible with the condition of worth. A person moves with acceptance to a fully functioning person. The person’s overall ‘way of being’ is changed. Relating to a congruent therapist, the client learns to be open and congruent themselves (Castonguay, & Hill, 2012). Unblockin g or Focusing is where the self-correcting, self-healing process of the organism is blocked.The person can’t refer inwardly, focus on feelings or articulate meaning. They have a rigid self-concept. Empathic listening within the therapeutic relationship opens the issue to re-examination and unblocks the person self-healing process. There is an interaction between the feeling and the attention the client brings to create a new meaning. This is Gendlin’s felt sense, an unexpected feeling of flow. The client becomes an active self-healer who has been felt heard and understood (Castonguay, & Hill, 2012).In practice building ‘Meaning Bridges’ – new understanding which identifying introjects imposed by others who imposed external systems of value has been paramount because of the external pressure that have be imposed through a close relationship. Internal opposing voices can be accepted, examined and resolved through compromise and collaborative solution. Until now, I saw this as CBT but can now see this as PCT with Rogers’s necessary and sufficient conditions of therapeutic change all that is needed for the process of change and this change occurs without engaging in cognitive process, but in the moment (Castonguay, & Hill, 2012).I am able to draw personal parallels from watching Rogers’ session with Gloria. Gloria wanted an answer from Rogers. In the session she found it for herself, even though she actively interpreted that he had helped her to the decision; even though he hadn’t. She makes the decision of honesty for herself. Although non-directive, Rogers’s session had a focused, this was of self-healing and self-direction. Refuting the belief that the person-centred way is only to reflect back to the client. The warmth from the counsellor is also part of the process of condition of worth.This helps me challenge my preconceived ideas and understand what is happening in practice. In practise, I am awa re from a CBT perspective the therapeutic approach can teach clients new skills. The therapist is regarded as more of a coach. The client benefits from new skills and perspectives which facilitate the learning and have a sense of efficacy. I have used CBT to look at specific problem behaviours and conceptualise them as having cognitive, affective, behavioural and physiological elements each of which can have a legitimate target for intervention and can be check for validity (Castonguay, & Hill, 2012).The process of change occurs in practice as old ways are challenged through exposure exercise, behavioural experiments and cognitive restructuring techniques. Change occurs in the therapeutic setting or outside in a person everyday life. It may require repetition to produce a lasting effect and reduce maladapted patterns. This is where CBT and PCT are similar as this requires a strong therapeutic alliance, but CBT literature takes this as a given and may be a reason it is criticised. Cl ients are taught emotional regulation and basic functioning skills, such as problem-solving skills, breathing relaxation and active coping.Specific interventions are then used to motivate and foster the therapeutic relationship, such as cost benefit analysis, daily thought records, and in vivo exposure. Aligning client’s goals with interventions in a formulation develops the therapeutic alliance and collaborates with the client, with hypothesis-testing strategies used to undergo the process of change [Casemore, and Tudway, 2012). CBT is focused on corrective experiences and facilitates through interventions rather than challenging a client.It respects the importance of the therapeutic relationship and uses Rogers’ core conditions but does not see the conditions as sufficient. In-depth schema focused CBT takes the therapy to a deeper level and deals with past issues, than the low intensity offered by the NHS. Again my preconceptions are challenged for the benefit of my practice. I can see how the two models are not rivals, as Roger Casemore and Jeremy Tudway suggest in their book Person-centred Therapy and CBT, and that sibling as a metaphor works well (Casemore, and Tudway, 2012).For me, the therapeutic relationship and the advanced empathy required in PCT are important in my practise along with the core conditions in order to create change. Rogers’ believes interventions as wrong, from a philosophical point of view, as the client always having to lead the therapy. This is because Rogers sees a person as having limitless potential. For me, CBT in offering intervention and gentle coaching helps a client on their journey to self-healing and a seed can be planted and therapeutic change can happen outside the counselling session.I support the views not all humans have the same drive and there is an unconscious element to being rational or irrational. It is a more real idea and not as optimistic as Rogers. It is observation of this therapeutic change and this idea that supports the use of CBT in my practise (Casemore, and Tudway, 2012). The BACP ethical framework has been written with Rogers’ core conditions in mind. Therefore, PCT offers the client and the therapist the need to fulfil the principles of self-care, of being trustworthy and providing autonomy.As to the personal moral qualities the PCT requires the therapist to have advanced empathy. CBT has been criticised for focusing too much on the intervention and not being of beneficence. In CBT extra competence in the implementation of the intervention is required, so the criticism of the technique becoming the therapy cannot be applied . In writing this report and in my practise, I feel the difference are enough not to combine the models, but that each model can go into the same toolkit and used separately in the same session with a client.With the collaborative element in mind and further reading I am interested in the approach by Mick Cooper and John McLeod. The pluralistic perspective which believes individual clients would â€Å"benefit from different therapeutic methods† used at â€Å"different points in time†. Therapist would â€Å"work collaboratively† with clients. â€Å"Help them identify what they want from therapy† and how this can be achieved. It leaves the question of the process of therapy integration in practice open for debate. (Cooper, and McLeod, 2010, Assessed Online26/06/13).

An Assessment of Nhif Utilization in Kiwanja Market

AN ASSESSMENT OF THE UTILIZATION OF NHIF BY RESIDENTS OF KIWANJA MARKET, KAHAWA WEST LOCATION, KASARANI DIVISION IN NAIROBI. Presented by: Ann Mwangi Registration number: I30/2160/2006 A research proposal submitted in partial fulfillment of the requirements for the award of the degree of Bachelor of Science (nursing and public health) in the school of health sciences of Kenyatta University. February, 2010. DECLARATION STUDENT’S DECLARATION This proposal is my original work and has not been presented for any academic award in any other University or college. Signature†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ Date†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. Name: Ann Mwangi Registration number: I30/2160/2006 SUPERVISOR’S DECLARATION This proposal has been submitted for review with my approval as a university supervisor. Signature †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. Date†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. Name: Mrs. Makworo Department: Nursing sciences. ABBREVIATIONS AND ACRONYMS NHIF National Hospital Insurance Fund MOH Ministry of Health CAP Chapter HMOs Health Management Organization UNICEF United Nations Children’s Fund KIPPRA Kenya institute for public policy research activities and analysis OPERATIONAL DEFINITIONS Health care- Goods and services used as inputs to produce health. In some analyses one’s own time and knowledge used to maintain and promote health are considered in additional to conventional inputs. Used synonymously with Medicare in this study. Health maintenance organization (HMOs) –It is a managed care plan that integrates financing and delivery of a comprehensive set of health care services to an enrolled population. HMOs may contract with or directly employ health care providers. Social insurance – It’s a government insurance programme in which eligibility and premiums are not determined by the practices common to private insurance contracts. Premiums are often subsidized and there is typically redistribution from some segments of the population to others. Health care financing- Refers to paying or funding of health care services provided or to be provided. It is not Medicare per se that consumers want but health itself. Medicare demand is a derived demand for an input that is used to produce health. Health care consumers do not merely purchase passively from the market, but instead produce it, spending time on health improving efforts in addition to purchasing Medicare input. ABSTRACT The National Hospital insurance Fund (NHIF) is an important aspect of healthcare financing through social health insurance in Kenya. It was established by the government of Kenya (GoK) in 1966 as a social insurance fund. At its inception, the NHIF was meant to assist GoK employees to gain access to higher quality private hospitals, thereby relieving congestion in the free public hospitals. The NHIF has mainly focused on the formal sector employees in the past around four decades. This has left those employed in the informal sector. This study is attempts to analyze and understand the demand for social health insurance of the informal sector workers in Kiwanja market by assessing their perceptions and knowledge of and concerns regarding National Hospital Insurance Fund. It will serve to explore how more informal sector workers could be integrated into the NHIF scheme. The research design to be used will be a descriptive cross-sectional study. The area of study is Kiwanja market in Kahawa west location. The study population will include Kiwanja residents above 18 years of age, and employed in the informal sector. The sample size will be 76 as determined using a standard statistical formula and the respondents selected through cluster sampling. A structured questionnaire will be used to collect data. Pretesting of the data collection tool will be done in Kihunguro area in Ruiru. The data collected will be entered, coded and keyed into variables using SPSS version 12- computer software and excel computer packages. Quantitative data will be analyzed using SPSS version 10 computer software. Presentation of quantitive information will be done using statistical packages (graphs, charts, tables and pie charts). The findings, conclusions and recommendations of this study will be very important in formulating awareness campaigns and educational materials that will enable the residents of Kiwanja in the informal sector of employment to realize the significance of NHIF programmes in financing their healthcare. TABLE OF CONTENTS DECLARATIONii ABBREVIATIONS AND ACRONYMSiii OPERATIONAL DEFINITIONSiv ABSTRACTv CHAPTER ONE1 1. 0 INTRODUCTION1 1. 1Background to the study1 1. 2Statement of the problem4 1. 3Justification of the study5 1. 4 Research questions5 1. 5 Objectives of the study6 1. 5. 1 Broad objective6 1. 5. 2 Specific objectives6 1. 6 Research assumptions6 1. 7Significance of the study6 CHAPTER TWO7 2. 0 LITERATURE REVIEW7 2. 1 Social health insurance7 2. 2 Healthcare financing through health insurance in Kenya9 2. 2. 1 The National Hospital Insurance Fund (NHIF). 10 2. 2. 2 Membership to NHIF10 . 2. 3 Mode of Payment11 2. 2. 4 Benefits and cover11 2. 2. 5 How to access benefits11 2. 2. 6 Accredited hospitals12 2. 2. 7 Milestones12 2. 2. 8 The future of NHIF12 2. 3 Factors influencing utilization of social health insurance services. 13 2. 3. 1 Feasibility analyses of social health insurance14 CHAPTER THREE20 3. 0 RESEARCH METHODOLOGY20 3. 1 Research design20 3. 2 Study area20 3. 3 Stud y population20 3. 4 Inclusion and exclusion criteria20 3. 4. 1 Inclusion criteria20 3. 4. 5 Exclusion criteria20 3. 5 Sampling technique and sample size21 3. 5. 1 Sample size determination21 . 5. 2 Sampling technique22 3. 6 Data collection procedures22 3. 6. 1 Research instruments22 3. 6. 2 Pre testing22 3. 6. 3 Data collection process22 3. 7 Data management23 3. 8 Limitations of the study23 3. 9 Ethical considerations23 REFERENCES24 WORK PLAN FOR THE STUDY. 26 BUDGET27 APPENDICES28 INSTRUMENT FOR DATA COLLECTION (QUESTIONNAIRE)28 CONSENT FORM31 MAP OF STUDY AREA32 CHAPTER ONE 1. 0 INTRODUCTION 1. 1Background to the study The concept of National Hospital insurance Fund (NHIF) is an important aspect of healthcare financing through social health insurance in Kenya. In a developing country like Egypt, the Health Insurance Organization (HIO) is prominent among many health institutions involved in health financing and provision, and a key player in the country’s health sector reform programme. It was established in 1964 as the institution in Egypt responsible for social health insurance, providing compulsory health insurance to workers in the formal sector (Abd et al. , 1997). One of the overall goals of the Government of Kenya is to promote and improve the health status of all Kenyans by making health services more effective, accessible, and affordable. Therefore health policy in the country revolves around two critical issues, namely: how to deliver a basic package of quality health services, and how to finance and manage those services in a way that guarantees their availability, accessibility and affordability to those in most need most health care (Kimani, Muthaka, and Manda, 2004). On achieving independence in 1963, the Government of Kenya (GoK) committed itself to providing â€Å"free† health services as part of its development strategy to alleviate poverty and improve the welfare and productivity of the nation (GoK press, 1965). This pledge was honored in 1964 with the discontinuation of the pre-independence user fees, and the introduction of free outpatient services and hospitalization for all children in the public health facilities. Services in the public health facilities remained free for all except those in employment whose expenses were met by their employers (Owino, W. and Were, M. , 1998). Through financial support from the central government, strategies were developed to expand the health infrastructure and support the entire health system. The GoK established NHIF in 1966 as a social insurance fund. At its inception, the NHIF was meant to assist GoK employees to gain access to higher quality private hospitals, thereby relieving congestion in the free public hospitals. The NHIF has mainly focused on the formal sector employees in the past around four decades. This has left those employed in the informal sector. Structural reforms and poor economic growth have increasingly pushed labor into the informal and small scale agriculture sectors where livelihoods are often insecure and incomes are low and uncertain (Kimani, Muthaka, and Manda, 2004). As a way of reaching out to those in the informal sector and the poor, the government plans to transform the current NHIF to National Social Health Insurance Fund (NSHIF). The aim is to ensure equity and access to healthcare services by the poor and those in the informal sector, who have been left out for the last forty years that the NHIF has been in existence. It is also expected that the new scheme will increase healthcare services utilization, which has suffered under cost sharing, by extending benefit package to also cover outpatient care. The current cost sharing will be replaced by pre-paid contribution into the new scheme (Kimani, Muthaka, and Manda, 2004). The principal choices for financing a health care system are: general revenues, social insurance funding, and private insurance financing and out of pocket payments. General revenue financing here refers to a system of revenue collection through a broad based tax. All or portion of this tax may be dedicated to the health care system . general revenues may be raised at the federal, state, provincial, or local levels. According to the United Nations system of national account, 1993, Annex IV par. 4. 111, an insurance programme is designated as a social insurance programme if at least one of the following three conditions is met: a) Participation in the programme is compulsory either by law or by conditions of employment. b) The programme is operated on behalf of a group and is restricted to group members. c) An employer makes a contribution to the programme on behalf of the employee. National Hospital Insurance Fund (NHIF) is therefore a social insurance financing in Kenya. NHIF’s core function is to collect contributions from all Kenyans earning an income of over Ksh 1000 ($12) and pay hospital benefits out of the contributions to members and their declared dependants (spouse and children) Whilst ensuring that Kenyans of all walks of life have access to quality and affordable healthcare, NHIF operates under the social principle that â€Å"the rich should support the poor, the healthy should support the sick and the young should support the old. 2. Statement of the problem The GoK established NHIF in 1966 as a social insurance fund. At its nception, the NHIF was meant to assist GoK employees to gain access to higher quality private hospitals, thereby relieving congestion in the free public hospitals. The NHIF has mainly focused on the formal sector employees in the past around four decades. This has left those employed in the informal sector (Republic of Kenya, 2003a). There exists an information gap on informal sector Kenyans utilization of NHI F services, in instances where studies focus on informal sector employees, NHIF is a social health insurance and an important aspect healthcare financing in Kenya that is often neglected or not fully explored. Majority of studies carried out; focus on utilization of NHIF services across general Kenyan population irrespective of the employment sector. This has led to formulation of healthcare financing programmes that do not address the specific needs of Kenyans in the informal sector. More so, tools of analysis by most relevant studies are limited to univariate and bivariate analysis falling short of examining the net effect of selected background and intermediate factors negatively impacting healthcare accessibility and utilizations by workers in the informal sector of employment. The study is designed to assess the level of knowledge and utilization of NHIF in Kiwanja market because it is an area whose majority of residents are in the informal sector of employment. 3. Justification of the study Taking into considerations the existing information gap on utilization of NHIF services by informal sector employees, it is important to undertake this study in Kiwanja market to establish the awareness level and its use. Kiwanja market is a densely populated area behind Kenyatta University. Majority of Kiwanja residents are in the informal sector. The study is designed to identify the potential hindrances of utilization of NHIF services in Kiwanja residents in the informal sector and ways of how to remove them. The study seeks to explain and provide a systematic body of knowledge that can be explored for appropriate policy formulation, to act as an eye opener and reminder to both the NHIF management team, and other stakeholders to raise the utilization of NHIF services by the informal sector in Kenya. Knowledge deficit regarding NHIF benefits and use to finance health care contributes greatly to the high mortality and morbidity rates due to poor health seeking behavior (Inke et al. 2004). Provision of information and raising awareness on NHIF benefits and use will reduce significantly the number of pregnant women delivering at home due to lack of funds to pay for hospital delivery. 1. 4 Research questions The research questions for the study will be: a) How informed are the members of Kiwanja market about NHIF benefits? b) Wha t percentage of Kiwanja market residents use NHIF services and are in the informal sector? 1. 5 Objectives of the study 1. 5. 1 Broad objective To assess the awareness on NHIF benefits and utilization of NHIF services by Kiwanja market residents. . 5. 2 Specific objectives a) To find out the knowledge level of Kiwanja residents about NHIF. b) To determine the number of Kiwanja residents who are NHIF beneficiaries. 1. 6 Research assumptions The residents of Kiwanja market are knowledgeable about health care financing, they are aware about NHIF benefits but they do not use it because they think it is only meant to benefit those people in the formal employment sector. 7. Significance of the study This study aims at finding out if Kiwanja residents utilize NHIF services. In addressing the objectives, the study will identify the level of utilization of NHIF services, factors influencing its utilization and come up with ways of addressing any shortcomings that will be identified and help in improving NHIF services utilization. The findings, conclusions and recommendations of this study will be important in formulating awareness campaigns and educational materials that will enable the residents of Kiwanja in the informal sector of employment to realize the significance of NHIF programmes in financing their healthcare. This study attempts to find out the awareness on NHIF benefits and use by residents of Kiwanja market. It will therefore benefit the residents of Kiwanja and empower them to acquire their human right of health care. CHAPTER TWO 2. 0 LITERATURE REVIEW 2. 1 Social health insurance The concept of health insurance was first proposed in 1694 by Hugh the Elder Chamberlen from the Peter Chamberlen family. In the late 19th century, â€Å"accident insurance† began to be available, which operated much like modern disability insurance. This payment model continued until the start of the 20th century in some jurisdictions (like California), where all laws regulating health insurance actually referred to disability insurance. During the 1920s, individual hospitals began offering services to individuals on a pre-paid basis, eventually leading to the development of Blue Cross organizations. The predecessors of today's Health Maintenance Organizations (HMOs) originated beginning in 1929, through the 1930s and on during World War II (Weber, 1994). A health insurance scheme is social when it subsidizes the poor, the elderly and the sick, and when it promotes equity and access to everyone and not for profit. The core values in social health insurance embody a concern for the plight of the poor. In social insurance financing, health services are paid for through contributions to a health fund. The most common basis for contributions is payroll, with both the employer and the employee paying a percentage of the salary. In general, membership to a social health insurance schemes is mandatory, although it can be voluntary to certain groups such as the self-employed. The health fund is usually independent of the government but works within a tight framework of regulations. Premiums are linked to the average cost of treatment for the group as a whole, not to the expected cost of care for the individual (Conn , 1998). While there is no universally accepted definition of what â€Å"social insurance† is, Kraushaar and Akumu (1993) outline some broad characteristics, which are generally agreed upon. These are: a) Coverage is generally compulsory by law ) Eligibility for benefits is derived from contributions having been made to the programme c) The benefits for one individual are not usually directly related to contributions made by that individual but often those benefits aim to redistribute income between different income groups. This redistribution is usually from the rich to the lower income groups or from those with few to those with many dependants. Equity of benefits regardless of payment is the rule. d) There is generally a plan or the financing of benefits that is designed to be adequate in the long term. ) Governments manage nearly all such social insurance organizations. f) Revenues go fully and unchallenged to health and are not controlled by the treasury in a given country. Conn and Walford (1998) explain the rationale for health insurance in a low-income country with the following three arguments: a) Attracting additional money for health. This is so because health insurance is perceived as an additional source of money for healthcare. Consumers are more enthusiastic about paying for health insurance than paying general taxation as benefits are specific and visible. ) Getting better value for money because consumers are more able and prefer to pay regular, affordable premiums rather than paying fees for treatment when they are ill. c) Improving the quality and targeting of healthcare. Historically, HMOs tended to use the term â€Å"health plan†, while commercial insurance companies used the term †Å"health insurance†. A health plan can also refer to a subscription-based medical care arrangement offered through HMOs, preferred provider organizations, or point of service plans. These plans are similar to pre-paid dental, pre-paid legal and pre-paid vision plans. Pre-paid health plans typically pay for a fixed number of services. The services offered are usually at the discretion of a utilization review nurse who is often contracted through the managed care entity providing the subscription health plan. This determination may be made either prior to or after hospital admission (Weber, 1994) 2. 2 Healthcare financing through health insurance in Kenya Health insurance in Kenya has been provided by both private and public systems. The main objectives of the he health systems have been to insure Kenyans against health risks that they may encounter in future. Health insurance is considered private when the third party (insurer) is a profit organization (Republic of Kenya, 2003a). In private insurance, people pay premiums related to expected cost of providing services to them. Therefore people who are in high health risk groups pay more, and those at low risks pay less. Cross-subsidy between people with different risks of ill health is limited. Membership is usually voluntary. Public health insurance in Kenya is provided by the National Hospital Insurance Fund (Kimani, Muthaka, and Manda, 2004). 2. 2. The National Hospital Insurance Fund (NHIF). The NHIF was established in 1966 under chapter (CAP) 255 of the Laws of Kenya to be run by an Advisory Council appointed by the Minister of Health. The NHIF was established in 1966 under CAP 255 of the Laws of Kenya to be run by an Advisory Council appointed by the Minister of Health. It catered for salaried employees earning Kshs. 1, 000 and above per month, making a monthly contribution of Kshs. 20/= . In 1972 an amendment was made to incorporate voluntary members (self-employed) at a monthly contribution of Kshs. 0/=. In 1998, Cap 255 was repealed and replaced by the NHIF Act No. 9 of 1998 which transformed the fund to a State Corporation managed by an all inclusive Board representing various stakeholders and interest groups (Republic of Kenya, 2003a). 2. 2. 2 Membership to NHIF Membership to NHIF is open to all Kenyans aged 18 years and above earning a monthly income of kshs. 1000 or an average yearly income of kshs. 12, 000. There is no upper ceiling for the age. 2. 2. 3 Mode of Payment Employers effect deductions and remit to the fund by cheque or cash, and E-banking. Members in the informal sector pay in any of the NHIF offices Kshs. 160 per month for informal sector members. Members in the informal sector pay in any of the NHIF offices. All payments should be received by the 9th of the following month. For retirees/self employed persons payment for the year may be paid upfront; quarterly, semi-annually and/or annually. 2. 2. 4 Benefits and cover a) It covers all admission cases with few exceptions such as circumcision with no medical checkup required. b) Covers member, spouse and children under the age of 18 year. ) Children over 18 yrs and in learning institutions are also covered d) It covers for 180 days of hospitalization in a year. NHIF pay a daily rebate which ranges from Ksh. 400/= to Ksh. 2, 200/= Foreign claims. The number of other spouses is not limited and depends on the ability to pay for them. 2. 2. 5 How to access benefits Through presentation of the following to hospital on admission: Current NHIF Card- both manilla and photo card , Certificate of Contributions Paid (CCP) receipt and the national Identity card. The accredited hospitals deduct the daily rebate X number of days of hospitalization from the incurred bill. While for the contracted hospitals under category A, the entire bill is made by the Fund, the Fund reimburses member for costs incurred to the extent of the daily rebate if for one reason or another he /she is unable to use the card in Hospital. All claims should be received within 90 days after hospitalization. 2. 2. 6 Accredited hospitals Four hundred and fifteen health care providers have been enlisted across the country to provide services to NHIF beneficiaries under various contracts. Accreditation by NHIF is based on certain set standards and criteria for purpose of NHIF benefits. Quality Assurance and Standards Department consistently monitors the quality of services. 2. 2. 7 Milestones Increased rebates up to a maximum of 2,200 depending on hospital accreditation. It has an extensive branch network with 27 branches, satellite and window offices. It offers decentralized services, computerized operations and services and has a quality assurance and standards department in place. 2. 2. 8 The future of NHIF NHIF in future will use magnetic stripe card in hospitals to access benefits, introduction of diversified product lines, and further expansion of branch network. The ministry of health has designed a mandatory social health insurance scheme which seeks to transform the NHIF into a National Social Health Insurance Fund (NSHIF) to provide health insurance cover to both outpatients and inpatients. The main objective of the fund is to facilitate the provision of accessible, affordable and quality healthcare services to all its members irrespective of their age, economic or social status (Republic of Kenya, 2003c). 2. 3 Factors influencing utilization of social health insurance services. In most economically advanced countries, adequate social security laws are basically taken for granted. However, it often took many decades for social security systems to benefit all or major parts of the population in those countries. In the area of social health protection, for example, it took Japan 36 years to move from the enactment of the first health insurance law to the final law establishing nation-wide social health insurance. In the United Kingdom, a similar time period was needed to achieve its universal tax-based system (Inke et. al. 2004) Social Health Insurance (SHI) is not a widely adopted health financing mechanism in Africa. While there are many countries that operate a health insurance scheme for civil servants and/or private sector employees only some of these include features of a SHI, its appeal to cover larger parts of the population has been growing. Countries including Ghana, Nigeria and Rwanda have passed SHI laws. Earlier on, Kenya investigated the feasibility of SHI and Lesotho and Swaziland are doing so now. One distinct feature is that it does not call exclusively on public finance, but instead spreads the responsibility of health care financing among households and the private sector as well. From that point of view, tax-based systems in Africa are particularly challenged: the overall tax base may need to be strengthened, tax compliance may require improvement, and then a sufficient allocation towards health would have to be called for. Still, social health insurance is not a panacea either. It requires that an important organizational apparatus be put in place and that many actors in society shoulder critical responsibilities, such as the willingness and ability to contribute to the SHI scheme and then to comply with its regulations, thereby accepting a certain degree of financial solidarity (Kimani Muthaka ,and Manda, 2004). Aiming at universal health coverage for its 9. 5 million populations, Rwanda has spearheaded the development of a number of schemes that together constitute its SHI system. The three most important ones are the Rwandaise d'assurance maladie (RAMA), the Medical Military Insurance (MMI) and the Assurances Maladies Communautaires (AMCs). The RAMA social health insurance is compulsory for government employees and voluntary for private sector employees. Its contribution rate is 15% of basic salary (shared equally etween employee and employer). MMI covers all military personnel, who pay a contribution rate of 22. 5% of basic salary (5% paid by employee and 17. 5% by government). AMCs are community-based health insurance schemes whose members are mainly rural dwellers and informal sector workers in both rural and urban areas. They make up the majority of the population; by the end of 2007 about 5. 7 million Rwandans were covered by AMCs. Members usually contribute 1000 Rwandan Francs (1. 5 US$) per person per year which is matched by the government (Stilglitz, J. E. , 2000) 2. 3. 1 Feasibility analyses of social health insurance Since 2002, the WHO has been involved in technical advisory work especially on assessing the feasibility of SHI in Kenya, Lesotho and Swaziland in collaboration with national experts from those countries. In each country we analyzed the financial, organizational and political feasibility. Below we present some of the highlights of this work that should help us in formulating general guidance (Inke et. al. 2004) In Kenya, one basic financial scenario was that of gradual implementation of universal health coverage: coverage by a possible National Social Health Insurance Fund (NSHIF) would reach 62% of the population after 10 years, with further expansion in the second decade of SHI implementation. An important feature is that such a scenario would only be conceivable with sizable government subsidies. Without such subsidies, access to health car e among low-income households would be jeopardized, as the contributions From formal sector employees and civil servants would be insufficient to cross-subsidize the needed health care of the poor. External donors' financial support, however, could alleviate this extra financial burden on government. In fact, a variant of the basic scenario assumes that external donors would finance the provision of antiretroviral therapy, which would reduce the required government subsidies by about 20%. As far as the organizational aspects are concerned, it was studied whether the existing National Hospital Insurance Fund, a mandatory hospital insurance scheme for the formal sector with a small part of voluntary insurance for informal sector workers, might be transformed into the NSHIF. The latter would then be governed by a Board of Trustees with representatives from civil society. It is also interesting to note that the proposed NSHIF would include a Department of Fraud and Investigation in order to check the fund's financial activities. Civil society groups and enterprises such as the Post Office would also be given a role, especially in the collection of contributions from households in the informal sector (Inke et. al. , 2004) Concerning its political feasibility, consultations were held with a great number of stakeholders and interest groups, and most were supportive of the proposed NSHIF. Only Kenya's private Health Maintenance Organizations were very critical and had doubts about NSHIF feasibility. Finally, in 2004, the Kenyan Parliament passed a law on the NSHIF. However, President Kibaki judged it still needed amendments and returned it to Parliament for further debate that is still ongoing. Nonetheless, with a long-term vision, the existing National Hospital Insurance Fund is undertaking a number of institutional changes to increase membership and extend benefits so as to be better prepared should SHI take off (Inke et al. 2004) Factors which influence the use of NHIF services in Kenya include: ignorance, socio-economic factors, cultural factors, and demographic factors. Services information availability and accessibility also determines the utilization of social health insurance. Owino and Were (1998), in their study of enhancing healthcare among the vulnerable groups in Kenya ,found out that higher levels of awareness on health insurance, was associated with gre ater use of social insurance and thus better healthcare among the vulnerable people. In another study , a poverty survey by the UNICEF and overseas development Agency in 1995/96,it was found that user fees in Kenya made visits to government facilities prohibitively costly as the poor were required to make payments to reach the registration table, instead of using social insurance rebates. Worse, after the payments, the patients were asked to provide paper for record purposes. These costs could have been covered less difficultly by NHIF or more so NSHIF were they well informed of the benefits and the ease of membership. The study by Mwabu and Wang’ombe (1995) showed that the introduction of outpatient fees in Kenya’s public hospitals reduced the demand by a large proportion, and concluded that introduction of fees, or any upward revisions should be preceded by investments to raise quality of services and a well worked system of health insurance. The people should then be well sensitized on the benefits of joining into health insurance schemes. Huber (1993) did a systematic assessment of outpatients requiring exemptions, based on data from surveys in three districts in Kenya. The calculation was based on information on the household’s ability to pay. The study established the criteria for determining ability to pay on the assumption that households do not need to pay more than 5% of their annual incomes on healthcare from their pocket fees. As a result, households with cumulative health expenditures greater than 5% were assumed to qualify for the exemptions. The main conclusion from the study was that, it is not possible to tell who cannot pay fees by personal characteristics and so all people of the entire population should be enlightened on social insurance schemes such as NHIF and be encouraged to be members even when they are self employed. In a study carried out in Kenya (coast province) by Inke Mathaue (2007), on assessment affecting health services demand: extending social health insurance to informal sector in Kenya. Inke found out that, in the sum mix of the demand-side determinants can be addressed with a well designed strategy, focusing on awareness raising and information, improvement of insurance design features and setting differentiated and affordable contribution rates. In another study done by Mwangi W. M. and Mwabu, G. M (2006) on health care financing in Kenya: simulation of welfare effects of user fee, they found out that the introduction of user selective contribution charges would improve social insurance programmes such as the NHIF. The National Hospital Insurance Fund is the most important health insurance program in Kenya. Membership is compulsory for all civil servants. As of 1990, contribution levels proved insufficient to meet hospital costs and the government was planning to broker private health insurance policies. The government is continually improving and upgrading existing health facilities and opening new ones. Private health institutions account for 60% of total medical equipment and supplies (import value). Kenya also has a well-developed pharmaceutical industry that can produce most medications recommended by the World Health Organization (republic of Kenya, 1999) In order to increase the utilization of NHIF services, we need to raise the awareness on NHIF benefits to the people of Kiwanja market majority of who are struggling to pay for healthcare from their pockets. This study therefore, sets out to assess the utilization of NHIF services and identify factors that hinder its use by Kiwanja residents. The Government of Kenya has addressed the issue of inequalities and poor performance in a number of policy documents. The efforts made under the First Health Sector Plan (1999-2004) did not contribute towards improving Kenya’s health status. In 2005, the Second Health Sector Strategic Plan was implemented. This will run until 2010. In order to improve the funding of the healthcare system and to give more Kenyans access to better healthcare, the Ministry of Health is planning to introduce a National Social Health Insurance Fund (NSHIF). This is a social insurance scheme to which everyone will contribute, without exception. CHAPTER THREE 3. 0 RESEARCH METHODOLOGY 3. 1 Research design The study will be a cross-sectional descriptive study which will assess the awareness of the residents of Kiwanja market on NHIF services and benefits. 3. 2 Study area The research will be carried out in Kiwanja market which is located behind Kenyatta University, approximately 2 kilometers from the Nairobi –Thika dual carriage highway. 3. 3 Study population The study population will include Kiwanja market residents who are in the informal sector employment, who have attained the age of 18 years and earn an income of at least one thousand shillings per month. Kiwanja market has a total population of approximately 28,000 and about 5600 households as per the records in the chief’s office of Kahawa west location. 3. 4 Inclusion and exclusion criteria 3. 4. 1 Inclusion criteria The study will include Kiwanja market residents, who are self employed or employed in the informal sector. The respondents to be included must have attained the age of 18 years and consented to be used as respondents in the study. 3. 4. 5 Exclusion criteria The study will exclude students of Kenyatta University residing in Kiwanja market, residents under 18 years of age, and those who will decline to give consent. 3. 5 Sampling technique and sample size 3. 5. 1 Sample size determination The sample size will be determined by using the standard sample size calculation formula by Mugenda and Mugenda, 2003. nf = [pic](Mugenda & Mugenda, 2003) Where: nf =desired sample size (If the target population is 10,000) =the proportion of the target population estimated to be in the informal sector taken as 50% z =Standard normal deviation which is 1. 96 at 99 % level of confidence q=1 – p=1-0. 5=0. 5 d=Degree of accuracy desired is 0. 08 (Fischer et al, 1998) n=the desired sample size (when the target population is ;10,000) N=the population of Kiwanja resident households which is 5600 n =1. 962 ? 0. 5 ? 0. 5 0. 082 =76. 64 nf= 5600=75. 60 therefore sample size=76 1+ (5600/76. 64) 3. 5. 2 Sampling technique Cluster sampling technique will be used till an adequate sample size is achieved. Kiwanja market area will be divided into four clusters of approximately 1400 households each. There will be cluster A, B, C, and D. cluster A will be on the eastern part of the safaricom booster, cluster B will be on the western part of the safaricom booster while clusters C and D will be north and south of the booster respectively. Each cluster will contribute 25% of the sample size thus 19 respondents will be issued with the questionnaires. 3. 6 Data collection procedures 3. 6. 1 Research instruments A structured questionnaire will be used to collect data during the study. 3. 6. 2 Pre testing Pre testing of the study tool will be done at Kihunguro area in Ruiru town. 10% of the sample size will be used to test the data collection tool. 3. 6. 3 Data collection process A structured questionnaire will be issued to the respondents after an informed consent is given. The first respondent per cluster will be identified through simple random sampling technique and the next subjects will be selected by snowball sampling until a sample of 19 is obtained. Field editing will be done to the raw data obtained. . 3. 7 Data management Data categorization and coding will be carried out during preparation of the questionnaires. The data collected will be entered, coded and keyed into variables using SPSS version 12- computer software and excel computer packages. Quantitive data will be analyzed using SPSS version 10 computer software. Presentation of quantitive information will be done using statistical packages (graphs, charts, tables and pie charts). 3. 8 Limitations of the study Time will be limiting factor as the time frame for the study is short compared to the workload that will be involved in the study. Due to inadequate time and limited resources, it will be impossible for the study to be carried out in the entire Kahawa west location. This therefore will make generalization impossible because of using only one locality for the study. The researcher will also be disadvantaged in terms of personnel in that the researcher will be the only one carrying out the study with no assistants involved. 3. 9 Ethical considerations The researcher will ensure the following ethical considerations: i. Introductory letter from Kenyatta University, Department of Nursing Sciences. ii. Letter of authorization from chief of Kahawa west location.. iii. All respondents will give informed consent before being interviewed. iv. Confidentiality will be maintained. The researcher will provide feedback to the gatekeepers in the community (chief) and Kenyatta University, Department of Nursing Sciences REFERENCES 1. Abd El Fattah, H. I. Saleh, E. Ezzat, S. El-Sahaty, M. El Adawy, A. K. Nandakuma, C. Connor, H. Salah(1997). The health insurance organization of Egypt: An analytical review and strategy for reform. Technical report No 43. Bethesda, MD: Partnerships for health reform project, Abt Associates Inc. 2. Arrow, K. J. (1963). †Uncertainty and the welfare economics of medical care. † American Economic review. 3. Inke Mathauer, Guy, C, Doetinchem, O. , Joses, K, Laurent, M. (2004). Social health insurance: how feasible is its expansion in the African region, ISS, Rotterdam. 4. Kraushaar, D. (1994). † Health insurance: what is it, how it works. † Financing districts Health Services international workshop 5. Kraushaar. & O. Akumu (1993). â€Å"Financial sustainability of health programmes: the role of the national hospital insurance fund. † Nairobi: Government of Kenya. 6. Manda, Kimani. D. , (2004) Healthcare financing through health insurance in Kenya: the shift to a national social health insurance fund. Kenya Institute for Public Policy Research Activities and Analysis (KIPPRA), Nairobi, Kenya. . Republic of Kenya (2003a). The National Social Health Insurance Strategy. Prepared by the Task Force on the Establishment of Mandatory National Social Health Insurance. 8. Republic of Kenya (1999). Kenya Gazette supplement, Acts, 1999. The national hospital insurance fund Act, 1998. Nairobi: government printer. 9. Republic of Kenya, (1997). Econom ic survey. Nairobi: government printer. 10. Shaw, P. (1998) Financing healthcare in the sub-Saharan Africa through user fees and insurance. World bank 11. Stliglitz, J. E. (2000). Economics of the public sector (third edition). W. W. Norton 12. World Bank (1993). World development report 1993: investing in health. Oxford university press. 13. Techlink International (1999). A renewed NHIF: final report manual. WORK PLAN FOR THE STUDY. |Task | Months | | | |January |February |March |April | | | | | | | | | | | | |Preparation, and approval of proposal |Wk 1 | |Purchasing stationery |500 | |Transport |1500 | |Proposal preparation |2,000 | |Data collection |3,000 | |Data processing and analysis |2,000 | |Lunch |1500 | |miscellaneous |1500 | |Total |12,000 | APPENDICES INSTRUMENT FOR DATA COLLECTION (QUESTIONNAIRE) Instructions Please tick ( ) in the brackets representing the most appropriate response. Additional informational can also be given in the provide spaces or at the back of the questionnaire. 1 a) How old are you? (In complete years) 18-24years ( ) 25-34 years ( ) 35-44years ( ) 44years and above ( ) b) What is your gender? Male ( ) female ( ) 2. What is your highest level education? Never gone to school ( ) primary school ( ) secondary ( ) post secondary education ( ) 3. What is your religion? Christian ( ) Muslim ( ) Baha’i ( ) other (please specify)†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 4. What is your marital status? Single ( ) married ( ) divorced ( ) separated ( ) single parent ( ) widowed ( ) other (please specify)†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ †¦Ã¢â‚¬ ¦.. 5 a) what is your main occupation? Self employed ( ) civil servant ( ) ? 6. Have you ever heard about NHIF? YES ( ) NO ( ) b) How many dependants do you have? †¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 7. IF Yes in question 6 above, where did you hear about it? ) Heard from a friend b) I am a beneficiary or a member if NHIF c) My parents are members of NHIF d) At my place of work 8. Are you a National Hospital Insurance Fund member or beneficiary? Yes ( ) No ( ) 9. If yes in question 9 above how do you rate NHIF services in the scale below out of ten:0-3 poor ( ) 3-5 below average ( ) 5-7 good ( ) 7-10 very good ( ) 10. If no in number 9 above, please tick as appropriate the reason why you are not member or beneficiary of NHIF a) I have never heard about NHIF b) I do not know the benefits of NHIF c) There is no branch of NHIF in Kiwanja market d) I am not employed in the formal sector. 11. If you are a beneficiary of NHIF, would you like to be a member? Yes ( ) no ( ) 12 If no in number 11 above, please as appropriate the reason why. a) I am not employed in the formal sector. b) There is no branch of NHIF in Kiwanja market. c) I have to think about it first and consult my husband about it. d) The monthly contribution is too much for me. 13. If yes in number 11 above, how many beneficiaries will benefit from your cover? None ( ) my spouse ( ) my children ( ) my parents ( ) other†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. 14. Do you think that NHIF services will ease your burden of financing healthcare for you and your family and significant others? Yes ( ) no ( ) 15. Would like to be an NHIF member? Yes ( ) no ( ) 16. If yes in the above no. 15 do you know what requirements for becoming a member are? Yes ( ) no ( ) 17. If no in number 16 above, why? a) Because I have just learnt about NHIF now. b) Because I have never had a chance of accessing information about NHIF membership before. c) Because I have always thought NHIF is for those in the formal sector. d) I would like some brochures from NHIF on benefits, cover, and how to contribute to the insurance scheme. 18. If you are a member of NHIF have you ever used their services? Yes ( ) no ( ) 19. If no in the above question 18, why? ) I have never been hospitalized. b) None of my beneficiaries have been hospitalized. c) I did not know how to place my claim of cover. d) The process of accessing benefits is too long for me. 20. If yes in the above question 18, where did you use it? a) In a government facility. b) In a mission hospital. c) In a private hospital. d) In a referral h ospital such as Kenyatta National Hospital. e) Other (please specify)†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦ 20 if yes in question 18 above how did you find NHIF services? a) Average b) Good c) Very good d) Excellent Thank you very much for being a respondent and for your much cooperation. CONSENT FORM Researcher’s confirmation. I am Ann Mwangi, a Kenyatta university student pursuing a Bachelor’s of science degree in Nursing and Public Health. I am carrying out a study on utilization of NHIF services in Kiwanja market, Kahawa west location in Kasarani Division. I kindly request your permission to interview you. Confidentiality will be guaranteed. Your names will not be required. Signature of researcher†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦.. Date†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. Respondent’s consent I have been fully informed about the nature of the study and I hereby give my consent to any information which is required of me. Signature of respondent†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Date†¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦Ã¢â‚¬ ¦. MAP OF STUDY AREA [pic] ———————– Kiwanja Market