End Stage Renal Disease ESRD Health And Social Care Essay

End Stage Renal Disease ( ESRD ) is defined as an irreversible nephritic failure which needs to have nephritic replacing therapy ( RRT ) or undergo long term dialysis [ 1 ] . There are three types of nephritic failure replacing therapy which are hemodialysis ( HD ) , peritoneal dialysis ( PD ) and nephritic graft. In Malaysia, Continuous Ambulatory Peritoneal dialysis ( CAPD ) patients are increasing from 1525 patients in twelvemonth 1999 to 1744 patients in December 2008, an addition of 12 % [ 2 ] . Malnutrition is really common in end phase nephritic disease patients on care dialysis [ 2 ] . In Malaysia, national information showed that merely 13 % of CAPD patients are good nourished where serum albumen is above 4.0 g/dL [ 3 ] . Majority of patients ( 87 % ) undergoing CAPD are malnourished. Protein energy malnutrition ( PEM ) is one of the most prevailing complications looking in patients undergoing dialysis and it is associated to high morbidity and mortality [ 4,5 ] . Malnutrition is an of import factor associated with increasing hazard of mortality in Chronic Kidney Disease ( CKD ) patients. Hence, it is of import to measure the nutrition position of patients. Screening for malnutrition is an of import constituent of dietary pattern and improves the ability to prioritize intercession to those most at hazard [ 6 ] . Early acknowledgment and intervention can give better outcome [ 7 ] . Nutrition showing is a executable option for placing patients at hazard of PEM [ 4 ] . Screening tools are largely designed for general intents every bit good as for specific topics as aged, institutionalised person and hospitalized patients [ 4 ] . There are several showing tools available for CAPD patients. These are Malnutrition-inflammation mark ( MIS ) , nutritionary hazard showing ( NRS ) , Malnutrition Universal Screening Tool ( MUST ) , Malnutrition Screening Tool ( MST ) , geriatric nutritionary hazard index ( GNRI ) and capable planetary appraisal ( SGA ) . Among them, none was antecedently studied for usage in Malayan chronic kidney disease patients on dialysis. The dietitian plays an indispensable function in nutritionary showing. In Malaysia, entree to dietitian is limited in most dialysis Centres. Hence, nurses will play an indispensable function to place the malnourished patients. On the other manus, a comprehensive nutritionary appraisal is time-consuming and requires both subjective and nonsubjective opinions from the tester. Therefore, important preparation is necessary to guarantee consistent consequences among assorted testers and periods of appraisal. Therefore, there is a demand for a simplified nutritionary showing tool which can be used by dieticians or nurses that can be performed easy.1.1 Objective1.1.1 Main ObjectiveTo place a simplified nutritionary showing tool which compares good with the Malnutrition Inflammation Score ( MIS ) , Subjective Global Assessment ( SGA ) and with assorted single nutritionary steps for Continuous Ambulatory Peritoneal dialysis ( CAPD ) .1.1.2 Specific aimTo depict the human ecology, anthropometr y, biochemical analysis features and dietetic form of CAPD patients. To depict the per centum of malnourished patients harmonizing to BMI, serum albumen, MSGA, and MIS. To formalize the usage of MIS and mSGA in CAPD patients against anthropometric ( BMI, Triceps Skinfold, computed Mid Arm Muscle Circumference ) and biochemical ( serum albumen ) appraisals ; To compare the usage of simplified tools: NRS, MUST, MST and GNRI showing tools in CAPD patients.Chapter 2: Literature Reappraisal2.1 Overview of kidney mapKidney maps to modulate organic structure homeostasis system [ 8 ] . Kidney plays a critical function in keeping circulatory and organ system functional homeostasis. Other than that, kidney is the site of synthesis of some endocrines and an of import catabolic site for several polypeptide endocrines. ( Table 2.1 ) Table 2.1: Components of kidney map Elimination of metabolic waste merchandises ( urea, creatinine, uric acid ) Elimination and detoxification of drugs and toxins Care of volume and ionic composing of organic structure fluids Acid-base ordinance Regulation of systemic blood force per unit area Production of erythropoietin Control of mineral metamorphosis through endocrinal synthesis ( 1,25-dihydroxycholecalciferol and 24,25-dihydroxycholecalciferol ) Degradation and katabolism of peptide endocrines ( insulin, glucagon, parathyroid endocrine endocrines ) and low-molecular-weight proteins ( ?2-microglobulin and light ironss ) Regulation of metabolic procedures ( gluconeogenesis, lipid metamorphosis ) Beginning: Mitch ( 2009 ) [ 8 ]2.2 Causes of kidney failureThere are two types of kidney failure which are acute kidney failure and chronic kidney failure. Acute nephritic failure is defined as sudden decrease of glomerular filtration rate ( GFR ) or loss of kidney map which is reversible [ 9 ] . Table 2.2 shown causes of acute kidney failure. Chronic kidney failure is defined as structural or functional abnormalcies of the kidney for more than 3 months [ 10 ] . It is an irreversible advancement of kidney harm. The causes of chronic kidney failure are shown in Table 2.2. Table 2.2: Causes of kidney failureAcute Renal FailureChronic Renal FailureAcute cannular mortification ( Trauma ) Nephrotoxicity ( antibiotics and drugs ) Infection Urinary piece of land obstructor Acute glomerulonephritis Diabetess Mellitus Uncontrolled high blood force per unit area Familial disease of kidney Obstructive Uropathy Inflammation or infection of kidney Beginning: KDOQI, 20012.3 Nephritic failure and dialysisGlomerular filtration rates ( GFR ) is an first-class step of filtrating capacity of the kidneys. GFR have been used to quantify the degree of kidney map [ 10 ] . There are 5 phases of GFR degree from phase 1-normal, to present 5-severe. A lessening in GFR precedes kidney failure in all signifier of progressive kidney disease [ 10 ] . In phase 5, where GFR is less than 15 ml/min, it is considered as terminal phase nephritic failure ( ESRD ) . Phase of chronic kidney disease was shown in Table 2.3. Table 2.3: Phases of chronic kidney disease Phase GFR Description 1 90-130 ml/min Kidney harm with normal or higher GFR 2 60-89 ml/min Mild lessening in kidney map 3 30-59 ml/min Moderate lessening in kidney map 4 15-29 ml/min Severe lessening in kidney map 5 Less than 15 ml/min End phase nephritic failure Beginning: KDOQI There are three types of intervention for nephritic failure which are kidney organ transplant, hemodialysis ( HD ) and peritoneal dialysis ( PD ) [ 9 ] . Peritoneal dialysis can foster split into three methods, including uninterrupted ambulatory peritoneal dialysis ( CAPD ) , automated peritoneal dialysis ( APD ) and combination of CAPD and APD [ 9 ] .2.4 CAPD processIn Continuous Ambulatory Peritoneal Dialysis ( CAPD ) , semi permeable membrane of the peritoneum is used as the filtration membrane [ 9 ] . A catheter is surgically implanted in the venters and into peritoneal pit. In CAPD, the dialysate is left in the peritoneum and exchanged manually [ 9 ] . A dialysate battalion is connected to the catheter while another tubing is connected to an empty battalion outside to have the waste fluid merchandises. A high-dextrose concentration dialysate is instilled into the peritoneum by the catheter. The dialysate diffusion carries waste merchandises from the blood through the peritoneal membrane and into the dialysate [ 9 ] . The waste merchandises and dialysate work interdependently via osmosis to transport out the waste merchandises. The waste fluid merchandises are withdrawn and discarded. Exchanges of dialysate are done for four to five times a twenty-four hours [ 9 ] . There are different concentrations and volumes of dialysate used which depend on the patient ‘s status.2.5 Nutrition demands for CAPD patientsIn peritoneal dialysis, Calories absorbed from glucose in the dialysis fluid are included in the computation of dietetic energy consumption. Approximately, 90 % of glucose is absorbed during dwells over 8 hours a twenty-four hours and 70 % is absorbed during short dwell [ 11 ] . Therefore, the sum of saccharide absorbed should be calculated to forestall overconsumption of ene rgy particularly for diabetes patient. From KDOQI 2000, the energy demand for chronic peritoneal dialysis patients who less than 60 old ages of age is 35 Kcal/kg organic structure weight per twenty-four hours [ 2 ] . For those who above 60 old ages of age, 30 to 35 kcal/body weight per twenty-four hours is recommended due to more sedentary life style [ 2 ] . Protein need in peritoneal dialysis patient is higher than hemodialysis patient. Peritoneal protein losingss average approximately 5 to 15 g/24 hours [ 2 ] . Generally, dietetic protein demand is to keep positive N balance and prevent malnutrition. Dietary protein more than 1.2 g/kg BW/day associated with impersonal or positive N balance [ 12,13 ] . KDOQI 2000 suggest that 1.3 g/kg BW/day protein for peritoneal dialysis patient and at least 50 % of protein should be from high biological value ( HBV ) [ 2 ] . Continuous Ambulatory Peritoneal Dialysis ( CAPD ) patients have higher cholesterin, triglyceride, LDL and lipoprotein degree [ 14 ] . The abnormalcy of lipid profile for CAPD patients is due to loss of protein from dialysis fluids and soaking up of glucose from dialysis fluid [ 14 ] . Therefore, 25 to 35 % of fat from entire Calories is recommended for CAPD patients [ 15 ] . Calcium and P are mineral demand in our organic structure to keep bone wellness. Conversion of vitamin D from inactive signifier to active signifier is impaired due to kidney failure [ 16 ] . When vitamin D lack develops, it may take to faulty enteric soaking up of Ca. In contrast, phosphorus elimination becomes restricted because of reduced cannular map. Therefore, dietetic phosphate limitation is necessary. Harmonizing to KDOQI guideline, 800-1000mg phosphate per twenty-four hours is recommended [ 2 ] . Furthermore, add-on of unwritten phosphate binder is besides needed to command serum phosphate degree [ 16 ] . The grade of Na sensitiveness is increasing exponentially with declined kidney map [ 17 ] . Nevertheless, sodium limitation can assist to command blood force per unit area. Excessive Na consumption may do thirst and increase fluid gained which in bend cause oedema [ 9 ] . Malaysia Medical Nutrition Therapy ( MNT ) guideline recommends 1500mg of salt intake per twenty-four hours and no add-on salt in cookery. Suggested unstable consumption is up to 1500ml per twenty-four hours [ 15 ] . CAPD patients may be hypokalaemic due to potassium loss during dialysis procedure. Therefore, potassium limitation is non necessary for CAPD patients. Persons with CAPD peculiarly have vitamin lack [ 18 ] . Hence, vitamin addendum is recommended for CAPD patients. Table 2.4 shows the recommended alimentary consumption for CAPD patients. Table 2.4: Recommended foods intake for CAPD patientsFoodRecommendationKilogram calories 35 kcal/kg BW/day for & A ; lt ; 60 old ages old 30-35 kcal/kg BW/day for & A ; gt ; 60 old ages old Protein 1.3 g/kg BW/day, 50 % HBV Carbohydrate 50-60 % of energy consumption Fat 25-35 % of energy consumption Sodium 1500 mg/ twenty-four hours Potassium 3-4g adjust to serum degree Fluid Up to 1500 ml/day Phosphate 800-1000 mg/day Calcium Calcium from diet and phosphate binder non transcend 2000 mg/day Vitamin B: Thaimine Vitamin b2 Vitamin b6 Vitamin bc Addendum to run into recommended day-to-day consumption Vitamin C Supplement up to 60-100 mg/day Beginning: Malaysia Medical Nutrition Therapy guideline, 20052.6 Malnutrition among CAPD patients2.6.1 DefinitionLack of protein and energy consumption or both is mentioning as protein-energy malnutrition ( PEM ) [ 19 ] . PEM is a status ensuing from long-run unequal consumption of energy and protein which can take to blowing of organic structure tissues and increased susceptibleness to infection [ 19 ] . PEM is strongly linked to malnutrition and mortality rate in person who undergoes care dialysis [ 2 ] . CAPD patients are more prone to malnutrition compared to HD patients. In CAPD, protein lost during dialysis procedure will ensue in protein lack and cause malnutrition [ 2 ] .2.6.2 PrevalenceBy the terminal of twelvemonth 2008, there are 3836 patients who are new to dialysis out of entire 19000 patients. The entire dialysis prevalence rate in December 2008 is 680 [ 3 ] . Patients who undergo CAPD are increasing twelvemonth by twelvemonth. Chronic kidney disease patients who underg o CAPD were 1744 patients out of entire 19221 patients in December 2008. The gender distribution is male ( 55 % ) and female ( 45 % ) from a entire 18856 patients [ 3 ] . The primary cause of nephritic disease is diabetes mellitus ( 55 % ) followed by high blood pressure ( 7 % ) from entire 3836 new dialysis patients on twelvemonth 2008 [ 3 ] . Protein-energy malnutrition ( PEM ) is really common among patients with advanced chronic nephritic failure ( CRF ) and those undergoing care dialysis ( MD ) therapies worldwide [ 2 ] . K/DOQI guideline proposed that, both work forces and adult females patients undergoing maintenance dialysis to accomplish BMI of at least about 23.6 kg/m2 and 24.0 kg/m2, severally. There are 14 % of CAPD patients who are scraggy ( BMI & A ; lt ; 18.5 kg/m2 ) . In Malaysia, malnutrition among dialysis patients is of great concern as it remains to be one of the strongest forecasters of morbidity and mortality [ 2 ] . There are 87 % of CAPD patients have serum albumin degree ( & A ; lt ; 4.0g/dL ) which assigned as malnourished [ 3 ] . Table 2.5 shows the categorization of serum albumen degrees. Table 2.5: Categorization of serum albumens degreeStatusSerum albumin degreeWell nourished 4.0 g/dL Mild undernourished 3.5 – & A ; lt ; 4.0 g/dL Moderate undernourished 3.0 – & A ; lt ; 3.5 g/dL Severe undernourished & A ; lt ; 3.0 g/dL Beginning: KDOQI, 20002.7 Factors doing malnutrition among CAPD patientsThere are multiple factors that cause malnutrition in these patients [ 2,20 ] . They are chiefly categorised into three causes: unequal dietetic consumption, disease conditions and intervention or dialytic factors. Inadequate dietetic consumption will take to malnutrition among dialysis patients. Altered gustatory sensation esthesiss caused by unequal dosage of dialysis, emotional hurt, anorexia and unpalatable prescribed diets ensuing in patients ‘ hapless unwritten consumption, and later impair their nutritionary position [ 20 ] . Disease status is besides a factor causes malnutrition in dialysis patients. Uremia is the most of import subscriber to inadequate nutrition in CAPD patients. As the Glomerular Filtration Rate ( GFR ) declines, azotemic toxins accumulate, taking to sickness and diminished appetite. Patients on dialysis have exposed to chronic inflammatory province will increase hypercatabolism and loss of thin organic structure mass when there is negative nitrogen balance [ 2 ] . Inflammation caused by infection, periodontic disease and familial factor will besides take to hapless nutrition intake [ 20 ] . Ascitess patient is at higher hazard of PEM. Ascites is another disease status doing protein loss more than 30g per twenty-four hours particularly after peritoneal dialysis induction. However, the sum of protein loss will decrease over clip [ 20 ] . In dialysis intervention, unequal dialysis might bring on anorexia and decreased gustatory sensation sharp-sightedness [ 20 ] . In add-on, dialysis promotes blowing by taking foods such as aminic acids, peptides, protein, glucose, water-soluble vitamins, and other bioactive compounds, and promotes protein katabolism, due to bioincompatibility [ 2 ] . In CAPD patients, redness of catheter site, bioincompatibility of dialysis solution will impact the nutrition position [ 20 ] . Besides, dialysis therapy may besides take to peritonitis. Transportation of K and azotemic toxin down a concentration in peritoneal capillaries will do protein loss. Furthermore, peritoneal inflammation will do ‘leaky ‘ in peritoneal capillaries and prolong peritoneal redness ensuing in release of cytokine and protein loss, which in bend influence patient ‘s nutrition position. Intra-peritoneal force per unit area is another factor impacting dietetic consumption. An addition in intra-abdominal force per unit area will take to symptoms of decrease in dietetic consumption and early repletion by delayed gastric emptying [ 20,21 ] . The most holds in stomachic voidance happened in those with smaller organic structure surface country [ 22 ] . Gastric emptying clip is associated with adequateness of foods ingestion. Last but non least, psychological factor will besides impact patient ‘s nutrition position. Psychological load causes loss of appetency in CKD patients, ensuing in a diminution of nutritionary position [ 20 ] .2.8 Nutrition Screening2.8.1 Purpose of testingHigh prevalence of CAPD patients with hapless nutritionary position is associated with inauspicious results [ 20 ] . Early sensing of malnutrition patient can diminish the hazard of inauspicious result of hapless nutrition. Therefore, it is critical that a validated and accurate tool used to place those malnutrition patients. Nutritional appraisal acts as an indispensable and introductory clinical process in nutritionary direction [ 4 ] . K/DOQI 2000 recommends nutrition appraisal should be performed routinely with combined method such as anthropometric measurings, organic structure composings measurings, biochemical measurings, dietetic appraisals and subjective appraisals [ 2 ] . However, most of these processs are time-consuming and cumbersome, even when a adept dietician is involved [ 4 ] . Therefore, a simplified and user friendly testing tool is needed for others wellness professional to observe malnutrition among the patients.2.8.2 Introduction of showing toolsThere are entire 6 showing tools will be used in this survey: Malnutrition-inflammation mark ( MIS ) , nutritionary hazard showing ( NRS ) , Malnutrition Universal Screening Tool ( MUST ) , Malnutrition Screening Tool ( MST ) , geriatric nutritionary hazard index ( GNRI ) and modified subjective planetary appraisal ( MSGA ) . The SGA and MIS tools are the gilded criterion showing tools which have proven in many surveies [ 2,23 ] . However, MSGA is used in this survey alternatively of SGA. MSGA is more nonsubjective, easy and practical that utilizing quantitative marking system if compared to SGA which is utilizing semi-quantitative marking system [ 24 ] . Whereas, MIS is validated and proven by Kalantar-Zadeh et. Al ( 2001 ) as a dependable tools to place malnutrition patient particularly in inflammatory province [ 23 ] . A survey by Yamada K. ( 2008 ) obtained the mark from several testing tools such as NRS, MUST, MST, GNRI and Mini nutritionary Assessment-Short Form ( MNA-SF ) and comparing the MIS testing tool as the mention criterion. Among the five showing tools, consequences shown GNRI was the most accurate showing in placing hemodialysis patient at nutritionary hazard. However, this survey did non included CAPD patients [ 4 ] . MSGA is a modified quantitative subjective planetary appraisal which modified utilizing the constituents of conventional SGA by Kalantar-Zadeh and co-workers, 1999. MSGA is a to the full quantitative hiting system with mark from 1 ( normal ) to 5 ( really severe ) . MSGA consists of seven variables including weight alteration, dietetic consumption, GI symptoms, functional capacity, comorbidity, hypodermic fat and marks of musculus cachexia. This survey had shown a relationship between malnutrition mark and the combination of MAMC, BMI, serum albumen and TIBC. MSGA is an nonsubjective, dependable and easy tools which can execute in proceedingss compare to SGA. However, the survey did non include any CAPD patients [ 24 ] . Malnutrition-inflammation mark ( MIS ) was another testing tool developed by Kalantar-Zadeh and co-workers in twelvemonth 2001. It is a utile tool to mensurate nutrition and redness on care hemodialysis ( MHD ) patients. This tools was developed utilizing seven constituents in SGA and added three new elements which are body aggregate index, serum albumen degree and total-iron binding capacity with mark 7 ( normal ) to 35 ( terrible malnourished ) . Kalantar-Zadeh and co-workers proved it is a good tool in foretelling mortality every bit good as nutrition, redness and anaemia in MHD patients. [ 23 ] Nutrition hazard showing ( NRS ) is developed by Kondrup and co-workers in old ages 2002. This tool was designed to steps current possible undernutrition and disease badness patients in order to measure whether tools was capable to separate patients with a positive clinical result from those who non profit from nutrition support. The consequence proved this screening tool is able to separate positive consequence and those who are likely to profit from nutrition support. It scored 0 ( absent ) to 3 ( terrible ) . [ 25 ] Malnutrition Universal Screening Tool ( MUST ) was designed to observe protein-energy malnutrition and the hazard of developing malnutrition in grownup patients. There are three independent standards use in this tool which is BMI, weight loss mark and acute disease consequence mark which mark from 0 to 2. The entire tonss is added and delegate into one out of three classs including 0 ( low hazard ) , 1 ( medium hazard ) and & A ; gt ; 2 ( high hazard ) . Stratton and co-workers concluded that MUST was a speedy and easy performed tool. [ 26 ] Malnutrition Screening tool ( MST ) was developed to observe hospitalized grownup ague patients at hazard of malnutrition by Ferguson and co-workers. It consisted of two inquiries sing appetency and recent unwilled weight loss. The information showed a relationship between patients who are high hazard of malnutrition harmonizing to MST with low average value of nonsubjective nutrition parametric quantities and longer length of infirmary staying. Ferguson and co-workers proposed MST as a simple, speedy, validated and dependable tool to observe malnutrition. [ 27 ] Geriatric Nutrition Risk Index ( GNRI ) was developed by Bouillanne and co-workers in twelvemonth 2005. GNRI was used to observe patients at hazard of malnutrition and related to mortality and morbidity. Nutrition position indexs including albumen, weight and WLo was used to cipher GNRI mark. It had four classs of nutrition related hazard which are no hazard, low hazard, moderate hazard and major hazard categorized by utilizing GNRI mark. This survey showed a strong relationship between albumen and GNRI. It is a simple showing tool for foretelling mortality and morbidity hazard particularly in hospitalized aged patients. [ 28 ]Chapter 3: Materials and Methods3.1 Study designThis research was a cross-sectional survey which done amongst 50 CAPD patients in Hospital Kuala Lumpur ( HKL ) . The research has been approved by the IMU Joint commission Research and Ethics. This research was to place a suited simplified testing tool to observe malnourished patients on CAPD. Six available showi ng tools were tested on patients ‘ nutritionary position. The diagram shows the flow of the survey.3.2 Sample sizeParticipants were chosen by utilizing convenient trying method at the Nephrology unit in Hospital Kuala Lumpur ( HKL ) . The sample size computation was based on the prevalence of malnutrition CAPD patients as reported in National Renal Registry, 2006. ( Z ) 2 P ( 1-p ) e2 Sample size computation, Ns = = ( 1.96 ) 2 ( 0.87 ) ( 1-0.87 ) ( 0.10 ) 2 = 43.4 50 patients Where Z = Z0.95 = 1.96 is read from a standard normal distribution tabular array. Where P = Prevalence of malnutrition CAPD patients = 0.87 ( 87 % ) Where E = Estimated trying mistake = 10 % Therefore, 50 patients were recruited for this survey.3.3 Capable choiceThe inclusion standard of this survey were participants recruited must be above 18 old ages old and undergoes at least 6 months of care dialysis. Participants who admitted in wad or hospitalized were categorized into exclusion standards.3.4 Sampling methodParticipants recruited by utilizing convenient trying method. There were in entire 50 participants in this survey. Participants available at the CAPD unit at informations aggregation period were approached and invited to fall in the survey.3.5 Methodology3.5.1 Questionnaire designThe questionnaire consisted of 8 sectors to obtain information on participants ‘ personal inside informations, socioeconomic background, medical history, drug profile, CAPD prescription, appetite, lifestyle history and dietetic informations. Information was obtained through interview. This is shown in appendix 1. A ) Personal inside informations This subdivision covered inquiries on personal information of the participant ‘s name, gender, age, day of the month of birth, ethnicity, matrimonial position, instruction degree and employment. B ) Medical history Information on cause of kidney failure, intervention history ( continuance, history of kidney graft and parathyroid secretory organ remotion ) and co-morbidities of the participant is obtained. C ) Drug profile This subdivision covered informations on the medicine prescription and besides information of multiple addendum taken and traditional medical specialty. D ) CAPD prescription Information was obtained on figure of exchanges done in one twenty-four hours and the concentration, type and volume of dialysate usage per exchange. Tocopherol ) Appetite Participant ‘s current appetency was questioned by utilizing a graduated table of ranking which included good, just, hapless and really hapless. F ) Physical activity The frequence of exercising and the grounds for non exerting were asked. G ) Dietary Data Food readying, eating wonts and any allergic reaction of nutrients were specified in this portion. H ) Hospitalization Subject ‘s hospitalization ground and surgery history was asked. 3.5.2 Anthropometric informations ( Appendix 3 )3.5.2.1 Height and weightParticipant ‘s tallness and weight was obtained from the medical record. Three measurings of participant ‘s station dialysis weight were recorded at first hebdomad for 3 old months from December 2010 to February 2011. The 3-month weight informations provides the information of topic ‘s weight position ( weight addition or weight loss ) for testing tool constituent. Body Mass Index ( BMI ) will be calculated from topic ‘s tallness and weight, utilizing the undermentioned expression: BMI = Body weight ( kilogram ) / Height2 ( M2 ) *KDOQI 2000 recommended that the BMI of care dialysis patient to be at least 24-28 kg/m2. Table 3.1: Categorization of BMI cut off point for grownupCategorizationBMI ( kg / M2 )Underweight & A ; lt ; 18.50 Normal 18.50 – 24.99 Corpulence 25.00 Corpulent 30.00 Beginning: Adapted from WHO, 1995, WHO, 2000 and WHO 2004.3.5.2.2 Mid arm perimeter ( MAC )Mid arm perimeter was performed with mensurating tape ( preciseness  ± 0.1 centimeter ) . Landmarking was done on the center of acromiale and radiale. Cross manus technique was used to mensurate the perimeter.3.5.2.3 Tricep skinfold ( TSF )Triceps skinfold was performed with Harpenden Skinfold Caliper ( John Bull, British Indicators Ltd. England ; preciseness  ± 0.1 centimeter ) . Landmarking was carried out prior to skinfold measuring.3.5.2.4 Mid arm musculus perimeter ( cAMA )Mid arm musculus perimeter is a computation derived from mid arm perimeter ( MAC ) and Tricep skinfold ( TSF ) : MAMC ( centimeter ) = MAC ( centimeter ) – [ ? – TSF ( centimeter ) ] Calculate mid arm musculus country ( cAMA ) provides a more accurate appraisal of musculus mass by gauging bone-free arm musculus country, corrected with gender differences. Calculate mid arm musculus country, cAMA = [ ( MAC ( centimeter ) – ? – TSF ( centimeter ) ) 2 ] / 4 ? – 10.0 ( work forces ) = [ ( MAC ( centimeter ) – ? – TSF ( centimeter ) ) 2 ] / 4 ? – 6.5 ( adult females ) Table 3.2: Cut off point of arm musculus perimeter ( AMA )PercentileClass 5th Wasted & A ; gt ; 5th but ? 15th Below norm & A ; gt ; 15th but ? 85th Average & A ; gt ; 85th but ? 95th Above norm & A ; gt ; 95th High musculus Beginning: Frisancho AR. 1990. Anthropometric criterion of the appraisal for growing and nutritionary position. 3.5.3 Biochemical informations ( Appendix 4 ) Serum albumen, serum beta globulin, serum Total Fe binding capacity ( TIBC ) , serum cholesterin, serum creatinine, Kt/V and serum carbamide were obtained from participant ‘s latest blood trial consequence. Table 3.3: Cut off point biochemical value Biochemical constituents Normal scope Serum albumen & A ; gt ; 4.0 g/dl Serum Tranferrin Serum TIBC Serum Cholesterol Serum Creatinine Serum Urea Kt/V & A ; gt ; 1.7 3.5.4 24 hours dietetic callback ( Appendix 5 ) Dietary consumption was obtained utilizing 24 hours dietetic callback. Participant ‘s dietetic consumption of 1 weekday and 1 weekend were recorded. Dietary appraisal tools ( bowls, spoon, matchbox and cup ) were shown to the topic at the first interview subdivision. The subsequent information aggregation was done through phone call. Food functioning size recorded was converted to unit gm and analysed via Nutrient composing of Malayan Food ( Tee E Siong, 1997 ) and Nutritionist Pro. Programme.3.6 Screening toolA sum of 6 showing tools were used in this survey.3.6.1 Modified Subjective planetary appraisal ( MSGA )This tool was designed by Kalantar-Zadeh group in twelvemonth 1999. This testing tool was developed by utilizing the constituent of conventional SGA and consists of seven variables: weight alteration, dietetic consumption, GI symptoms, functional capacity, co-morbidity, hypodermic fat and marks of musculus cachexia. Each constituent was scope from 1 ( normal ) to 5 ( te rrible ) . The entire mark used to find the nutrition position of the patient.3.6.2 Malnutrition-inflammation mark ( MIS )MIS was developed by Kalantar-Zadeh et. Al 2001 based on 7 constituents of SGA method and 3 extra constituents of BMI, serum albumen and serum TIBC. The medical history buttockss weight loss during the predating 6 months, dietetic consumption, GI symptoms, functional capacity ( nutritionary related functional damage ) , and co-morbidity including figure of old ages in Dialysis ; while physical scrutiny assesses loss of hypodermic fat and musculus cachexia. Each constituent was scored from 0 to 3, the entire mark of all 10 constituents ranged from 0 to 30 ( higher figure indicates more terrible ) .3.6.3 Nutrition hazard showing ( NRS )Nutrition hazard showing ( NRS ) was developed by Kondrup and co-workers in old ages 2002. The concluding tonss were categorized into absent, mild, moderate or terrible malnourished with a entire mark 0-6. It contain of two testing c onstituents, initial and concluding showing. There were four variables included in initial screening- BMI, recent weight loss, alterations in nutrient consumption and wellness status. In concluding showing, two chief constituents were tested by each hiting 0 ( absent ) to 3 ( terrible ) . The entire mark was added and one extra mark for participant above 70 old ages old.3.6.4 Malnutrition Universal testing tool ( MUST )MUST was developed for multidisciplinary usage by the Malnutrition Advisory Group of the British Association for Parenteral and Enteral Nutrition. MUST consists of 3 independent constituents which are current weight position measured by BMI ( mark: 0 to -2 ) , unwilled weight loss ( mark: 0 to -2 ) , and acute disease consequence bring forthing no nutritionary consumption for & A ; gt ; 5d ( mark: 0 or 2 ) . The amount of these 3 tonss was calculated.3.6.5 Malnutrition testing tool ( MST )The MST was developed by Ferguson et. Al 1999 had been used for acute infirmary patients ; it incorporates 3 constituents which are weight loss ( mark: 0 or 2 ) , sum of weight lost ( mark: 1-4 ) , and hapless nutrient consumption or hapless appetency ( mark: 0 or 1 ) . The entire mark was calculated for each patient.3.6.6 Geriatric nutrition hazard index ( GNRI )The GNRI was developed by modifying the nutritionary hazard index ( NRI ) for aged patients. This index was calculated from the serum albumen and organic structure weight by utilizing the undermentioned equation: GNRI = [ 1.489 – albumen ( g/dL ) ] + 41.7 – ( organic structure wt/ideal organic structure wt ) ]3.7 Statistical AnalysisAll the information was analysed by utilizing Statistic Merchandises and Services Solution, SPSS ver. 18.0. Each variable is presented as the mean  ± Standard Deviation ( SD ) . Descriptive frequence trial was used to prove the distribution of the variables among gender. T-test was besides used to show the correlativity between the variables. P & A ; lt ; 0.05 was considered as statistically important. Sensitivity, specificity, positive prognostic value ( PPV ) and negative prognostic value ( NPV ) were used between testing tools and nonsubjective variables. Crosstab was used to transport out the sensitiveness and specificity trial. Formula of computation: Sensitivity = true positives/ ( true positives + false negatives ) Specificity = true negatives/ ( true negatives + false positives ) Positive prognostic value ( PPV ) = true trial positives/all trial positives Negative prognostic value ( NPV ) = true trial negatives/all trial negatives

Martin Luther King Essay

America was experiencing a situation of chaos in the 1950s when the African Americans and the people of color began to rise for the fight of equality and freedom, and racial differences were realized. Initially, blacks and colored were widely discriminated. There were separate restaurants for white and the colored; separate educational institutes and likewise, separate hotels and motels and other public places. Blacks were not given employments on the basis of race and color and the ratio of black working men was almost negligible. They were not even given the right to vote. Cases of police violation on blacks were tremendous. As a result, gradual frustration began bottling up in the blacks. Finally, much to their relief, a decision by the Supreme Court, Brown v. Board of Education was issued in favor of the blacks. This decision given on May 17, 1954, recognized the discrimination against blacks in the field of education and declared that separate educational institutes resulted in unequal educational opportunities. Thus, it ordered all states to combine the blacks and white into same classrooms. However, the country, particularly the Southern part of America, was reluctant in carrying out the court order and hence, many years passed but the order failed to be put into operation. That is when Martin Luther King Jr. appeared. King had been working for equality and justice of blacks for a long time and was one of the prominent leaders in this movement. In order to spring the court order into action and protest for freedom, King along with other more than 250,000 individuals led a march to Lincoln Memorial on August 28, 1963, also known as the March on Washington. This rally included many other eminent characters such as actor Sidney Poitier, and labor leader Walter Reuther. All these influential heads addressed the audience and expressed their feelings individually; however, it was King’s speech; ‘I have a dream’ marked a landmark in civil right movement history. (Wikipedia, 1) About Martin Luther King Jr Born in January 15, 1929, in Atlanta, Martin Luther King was the son of Reverend Martin Luther King, Sr. and a brother of two siblings. He earned his Bachelors degree in 1948 in sociology and then completed his Bachelor of Divinity degree afterwards. In 1955, he did his PhD from Boston University. Afterwards, he became a Baptist minister but then turned his focus towards the civil rights movement and fighting for the freedom of the blacks. He contributed to the establishment of the Southern Christian Leadership Conference and also led the Montgomery Bus Boycott. He was the orator of the memorial speech ‘I have a dream’. He received Nobel Peace Price for his efforts to eliminate racial discriminations. He was also declared â€Å"Man of the Year† by Times Magazine. King was shot dead on April 4, 1968 in Lorraine Motel in Memphis. Martin Luther King Jr. Day was later established in his memory. (Wikipedia,1) Analysis of the Speech Style There is an element of emotional appeal in King’s speech. Rich in vocabulary, it is drenched in symbolism. The speech begins with an attention-grasping phrase and positive connotations. In fact, in the entire speech, whenever the future of blacks is mentioned, King has used strong and healthy words reflecting hope and an optimist approach. The first half of the speech; however, exposes the horrible reality the blacks faced. It narrates the story of thousands of blacks who were divested of their basic rights because of their coloring. King has made use of several phrases to describe the gloomy life of African Americans such as â€Å"the life of the Negro is still sadly crippled by the manacles of segregation and the chains of discrimination. † (Alvarez, 339) King’s background as Baptist also came useful in his speech as it reminds many of the blacks’ Baptist sermons. It contains references from Bible; for example, his sentence, â€Å"It came as a joyous daybreak to end the long night of their captivity’ in the second stanza indicates to Psalm 30:5. Other allusions are found from Amos 5:24 and Isaiah 40:4. † (Wikipedia, 1) At the same time, the speech also reflects the Abraham Lincoln’s style in his Gettysburg Address when he uses the term, ‘Five score years ago’. (Public broadcasting service,1) Here again, the purpose of alluding to Lincoln in the commencing lines of speech is symbolic that is, he refers back to a leader who had fought the Southern states over the issue of slavery. In this way, King is reminding the whites that the slaves of in the 19th century and the blacks of 20th century shared a similar tragedy and the same repressive power. After emptying out his feelings of sorrow and despair for the African Americans, the speech then moves to the phase mirroring hope and about demanding their rights. Here, King uses the term ‘check’ to refer to their rights. (Heath, 146) His expressions such as ‘bank of justice’ and ‘riches of freedom’ compel any man of heart to melt and feel their pain. (Heath, 148) They are also an evident of his literacy exposure and knowledge which was rare in blacks at that time. Plus, these words depict a feeling of hope thriving in the speech. The way King demands for blacks’ right is purely beautiful and saintly as he says, ‘And so, we’ve come to cash this check’. (Alvarez, 352) Next, the speech emphasizes the significance of democracy and need to work together to achieve that state of democracy. Here, ‘Now is the time’ has been accentuated four times in the entire paragraph to demonstrate the critical requirement of acting promptly, without any further delay. (Alvarez, 355) He then refers this discrimination as a weakness of America that needs to be removed in order to achieve the nation’s mutual objectives. Here, King has used the technique of reaching the subconscious by using such words such as ‘children of God’ which itself defines that all blacks and whites are brothers. (Wikipedia 1) Hence, in this way, he didn’t have to say it directly and the message was also conveyed. While he talks of brotherhood and the need to put aside the differences and work together, he also issues a warning for the conflicting parties of the consequences if such circumstances failed to occur and promises the nation that they will struggle to fight and rebel until they were not granted their rights. This is evident from this sentence, ‘The whirlwinds of revolt will continue to shake the foundations of our nation until the bright day of justice emerges. ’ (Alvarez, 338) Nevertheless, King was against violence and sermonized the message of peace. Hence, the main objective of King in this rally was also to communicate his message in a non-violent manner. After encouraging the blacks to continue the fight, the speech moves to its second half – the part about his dream –an American dream. Here, ‘I have a dream today! ’ is repeated at intervals to indicate that the dream must be accomplished immediately and not in some future time. The most popular phrase of this speech ‘I have a dream’ is repeated eight times. (Wikipedia, 1) In this part of the speech that is about his dream, he has offered the image of a united country; a country free of discrimination and hatred; a liberal state. This part is highly rhetorical and lulls the audience into another world the world he yearns to create. His words carry such weight that the audience is bound to share his dream even if they deny it. At the end of the speech, he has named several different states of America. The reason was to make it clear that they want respect, dignity and equality in not just some parts of America but in fact, the entire country. This point was explicitly a clear indication for the Southern states. The concluding stanzas contain a stimulating phrase, ‘Let freedom ring! ’ and ‘Free at last! ’ (Alvarez, 351) The absorbing aspect of this speech is its rhythmical flow. The speech begins with a background of the black citizens’ existing situation and the crisis they are facing. It then proposes the solution to their dilemma; followed by the explanation of the reason of why this solution should be implemented. For this part, King uses number of tools such as facts and emotional appeal. At the end, in order to provoke the feeling of urgent execution of his solution, he shares with the audience a stirring dream i. e. his vision of the ideal situation that would prevail if his proposed solution was put into practice. Techniques Used The climax of the speech is distressing yet uplifting. The beginning stanzas reveal the sad state of blacks in America but the approach of the speech is highly optimistic and inspires the blacks to continue their struggle and the whites to bury their axes and embrace their black brothers. The technique of anaphora has been widely employed. Anaphora is the repetition of same word or phrase again and again at the beginning of sentences. For example, the most extensively used anaphora, also the title of this speech, is ‘I have a dream’. Similarly, other examples of this tool are ‘One hundred years ago’, ‘Let freedom ring’, and ‘With this faith’, along with many others. (Wikipedia, 1) The speech is filled with metaphors. For instance, ‘long night of their captivity’ refers to their sufferings and ‘nation’s capital to cash a check’ points to their purpose of protest. At the same time, ‘this nation will rise up’ is again an indication of the coming revolution. Similarly, ‘I have a dream that my four children’ refers to the black community in reality and the word my gives it a personal touch. (Heath, 160) In fact, King has personalized the entire message by using the words you, my and me. The wealth of this speech is its exquisite vocabulary. Words are skillfully manipulated in such a way that they attach a new meaning to every phrase. The popularity of this speech also owns to this factor. In addition, the quantity and quality of information and words reveal King’s extensive research done before delivering the speech, plus his vast knowledge since it contains references from the Bible, The Gettysburg Address and the US Declaration of Independence. (Public broadcasting service,1) Hence, King has used various techniques and tools in this address including facts, anaphora, metaphors, motivation, visualization, arguments and persuasion. The entire speech is highly figurative and symbolic. In fact, the rally outside the Lincoln’s Memorial is symbolic in itself: they were standing outside the steps of Lincoln Memorial i. e. the memorial of a leader who abolished slavery in the Southern states. (Wikipedia, 1) Conclusion The most distinguished fact about this march was its non-violent approach and this speech is its leading example. While its majority of audience was black; its main target was the white people. While he talked of revolution; his speech contained a message of peace. It was able to answer the meaningless questions of the opposing parties and warn them of the consequences of denying the blacks their rights without any form of hostility. In other words, it instilled in the whites a feeling of guilt and humbleness which proved to be enough to achieve their objective. At the same time, it prodded the colored citizens to keep their hopes high and not to rest until they were ‘free at last! It also motivated President Kennedy to extend his support for this issue. The context of the speech and of the surroundings also became one of the reasons for the popularity of the speech. His speech articulated the feelings of all colored citizens and his voice became the voice of all black citizens. To sum up, King’s speech ‘I have a dream’ touches the depth of the hearts and captures the minds. Its words were able to bring tears in the eyes at that time and carry a captivating effect on the readers even today. With tools such as anaphora and metaphors employed, the speech holds an air of charisma. It shakes the souls of the slumbering and the unjust alike. All in all, the linguistic power of the speech is what makes it stand out from the rest and gain the status of one of the most influential speeches ever delivered. Bibliography Alvarez, Alexandra. â€Å"Martin Luther King’s ‘I Have a Dream’: The Speech Event as Metaphor,† Journal of Black Studies 18 1988: 337-57. Heath, Robert. â€Å"Black Rhetoric: An Example of the Poverty of Values† Southern Speech Communication Journal 39 1973: 145-60

Why Is Xenia Such an Important Theme in the Odyssey?

Why is Xenia such an important theme in the Odyssey? Explain your views and support them with details from the poem. (45 marks) The concept of guest hospitality was extremely important in ancient Greece. Evidence that Xenia was integral to Greek society can be found in the fact that Zeus, the king of the Gods, was also portrayed as the God of Xenia. Xenia created an obligation for the host to be hospitable to their guests, and conversely, the guests had their own responsibilities too. If either the host or the guest was to break a Xenia rule, there would be severe penalties dealt by Zeus and also by society.Some basic Xenia rules were that the guest could not insult the host, make demands, or refuse xenia. Additionally, the host could not insult the guest, fail to protect the guest, or fail to be as hospitable as possible. It was also customary for gifts to be given to the guest, or for a gift exchange to be conducted between guest-friends. The host-guest relationship was very compli cated and placed equal burden on both. This custom of xenia also held a burden of trust, where both the guest and host would have to rely on custom in regards to personal safety.This trust was reinforced by both fear of word getting out that the host had provided improper xenia, and fear of retribution by the gods, since one never knew when a traveller might actually be a god in disguise (for example, in book 1 when Athene disguises herself as Mentes and receives hospitality from Telemachus), come to test the level of your xenia. All travellers were seen as sent by Zeus and under his protection, so giving proper xenia was also a way of showing respect for the gods, especially Zeus in the form of Xenios. Xenia offers a moral ground in the Odyssey.Greek religion did not have strict moral regulations like modern Catholicism etc, and the Gods possessed a level of humanity and humility (for example, they had flaws, such as Achilles heel). Xenia imposed moral regulations in ancient Greece . It also allows Homer to convey whether characters are ‘good’ or ‘bad’, characters that show bad Xenia are almost portrayed as amoral. An example of poor Xenia in the Odyssey is Penelope’s Suitors. The suitors steal and plunder Odysseus' hall, feast on his food, take his maids to bed and all the while, each trying to take Penelope's hand in marriage.When Odysseus returns, he knows all about the suitors, and schematically kills all of them with no mercy. As the suitors showed bad Xenia, Odysseus is considered heroic for killing them. This is also an example of retribution for bad Xenia. Homer also uses Xenia as a literary device in the Odyssey. Without Xenia, much of the plot would be invalidated; Xenia customs explain many events in the Odyssey. For example, Xenia explains why Penelope and Telemachus didn’t just ask the suitors to leave rather than putting up with them.Xenia also explains why, during the battle of Troy, Glaucus and Diomedes r efuse to fight: they discover their ancestors had a Xenia bond. Traveling in Homer’s time was much more extensive and lengthier than in modern times. The less advanced methods of transportation used in Homeric times, such as by boat or by foot, were much slower than modern forms of transportation. Because of this, many more nights were spent away from home in many different locations. Also, there were not hotels or inns where travellers could pay and stay the night.Even if there were, travellers probably could not afford to pay for every night they were gone. Because of this, travellers had to rely on the hospitality of others for shelter, food, and protection. Without Xenia, Odysseus wouldn’t have been able to return home to Penelope. Xenia was also a universal way for Homer to state character’s status and wealth in the Odyssey. As it was frowned upon for aristocrats to engage in trade or commerce, Xenia was one of the only ways for Homeric heroes to acquire we alth. All hosts are obligated to provide their guests with the best food, accommodation and comfort they can.For example, Menelaus’ guests are offered water from a golden jug into a silver basin and wine served in golden cups. The xenia gifts characters give are also a statement of wealth, as well as a way of acquiring wealth, for example, when Telemachus acquires a silver krater, a wedding dress, a golden cup and other elaborate gifts from his stay in Sparta. In the Odyssey, Xenia is also shown to be one of the hallmarks of a civilised society, allowing us to judge the societies that Odysseus visits by their attitudes to xenia.For example, the Cyclopes are well informed about Xenia, yet disregard it because they have no fear of the God’s retribution. This tells us that the Cyclopes live in a formidable and amoral society. Even the Gods are shown to respect Xenia rules, for example in Book 5 when Calypso gives hospitality to Hermes. Good xenia is shown to have good rep ercussions for both the guest and the host: for example, Odysseus’ stay on the island of Calypso, where he is met with exceptional hospitality. Odysseus received this hospitality well and continued to please Calypso.Only at the end did he ever try to refuse her hospitality and leave, and even this caused no serious problems. Here we have an example of the guest-host relationship working well. Calypso is provided with a companion, even if it was not permanent, and Odysseus was provided with shelter, provisions, and protection for his men. In the end it proves to be a beneficial situation for them both. Xenia also provides a system of retribution in the Odyssey. Those shown to disregard the rules of Xenia often meet violent ends, and in turn, those shown to show good Xenia reap the benefits of this.An example of retribution for bad Xenia is when the Cyclops decides to eat rather than welcome Odysseus and his crew, and the men respond by poking his eye out. This event does not b other the gods at all. The father of the Cyclops, Poseidon, is only upset by the event because it was his son who was hurt. Zeus even praises Odysseus after the event by claiming that, â€Å"There is no mortal half so wise† (Homer, p. 3). This statement proves that violence was an acceptable answer when a host was not gracious. It also shows how the Gods justified violence as a result of bad Xenia.Overall, Xenia is a majorly important theme in the Odyssey. Not only is it used as a literary device by Homer, as it provides an explanation for many aspects of the plot and provides the poem with continuity as well as a way for Homer to portray characters as heroes and villains. Xenia also tells us a lot about ancient Greek society, as it provided a moral grounding and allowed travellers to go from place to place. Examples of Xenia in the Odyssey allow us to judge which characters are wealthy, famous, good, bad, monstrous and evil.

MULTICULTURAL BUSSINESS MANAGEMENT & Global leadership Essay

MULTICULTURAL BUSSINESS MANAGEMENT & Global leadership - Essay Example ome decided to outource jut certain part of their organization. The telecommunication indutry wa advancing, but Global Communication wa being left behind. I have created thi analyi to how the problem and potential olution Global Communication ha dealt with along with the ethical dilemma faced by the takeholder and the end tate viion of the company. My paper will include the comprehenive gap analyi for Global Communication; what i going with them at thi point in time and where the company i trying to be, regaining the reputation of being one of the larget, progreing global tool throughout the telecommunication indutry. Global Communication uffer from the tre of the indutrie and trying to maintain competition while oberving their tock price falling. The tockholder are preuring Global Communication to correct the problem, along with coming up with new innovative way to keep the conumer wanting to do buine with Global Communication. Thi analyi i deigned to how optional olution to Global Communication preent tribulation, rik management for the uggete d alternative olution, the optimal olution and finally the implementation plan to deal with the problem. ituation Analyi Iue and Opportunity Identification everal iue are acknowledged for Global Communication throughout the ituation. ... Competition i one of the reaon why Global Communication tock ha falling o dratically. Another iue Global Communication faced i the uproar of the employee and union worker becaue of the layoff that are planned. Global Communication leaderhip team came up with thi ingeniou plan to of moving ome of the technical call center to India and Ireland which hould reduce unit cot for handling call by nearly 40%. Although the move will ave Global Communication money, they did not think about the ending cot in human capital. In addition to the other iue provided, Global Communication i having communication problem within. Global Communication i an organization that i conidered one of the bet for taking care of the employee need to make ure they at leat addre all the iue. "By improving deciion making, knowledge management, employee need and coordination; company can progre and retain the name in the communication indutry. Workplace communication ha a ignificant effect on organizational performance (Mchane & Glinow, 205). "Firt organization depend on the ability of people to coordinate their individual work effort toward a common goal (Mchane & Glinow, 25). Global Communication i faced with economic iue in which the leaderhip team i trying to apply trategic planning to retructure the company and make it properou again. Although they have trategically planned a olution, the leaderhip team i having difficultie conveying the new plan to the employee. Local, long ditance and international market are all competing for the ame buine. New calling feature and uite of local and long ditance ervice helped, but the indutry uffered a huge blow at the hand of the cable companie, who tepped in to provide complete olution

David Hume's An Enquiry Concerning Human Understanding Essay

David Hume's An Enquiry Concerning Human Understanding - Essay Example On the other hand, Hume tells of ideas as being part of a copy principle from impressions, which means that ideas are derived from impressions and they directly correspond to the impression from which they are derived, to create a complete image of both. This he goes to state that ideas are thoughts, beliefs or memories that are directly connected to our memories, which may not serve as much of a distinction between the two, as it ties or binds the two aspects tightly. This is to mean that we construct ideas from impressions, where the mind looks at three crucial factors prior to generating an idea; resemblance, contiguity and effect (Landy 120). In the case of ideas, the issue of the mind using resemblance shows a clear application of impression, especially reflection, to come up with ideas, as it requires the mind to relate to different factors and find the merging point, or even establish the relationship between the two. This is again applied in the case of cause and effect as it requires one to establish the relationship between two or more aspects in order to comprehend how they affect each other. This application requires the use of sensation and reflection, which are both aspects of impression, to generate ideas crucial for any part of thinking. Hume also shows a difference between the two by the use of the earlier mentioned vivacity, where impressions are far much stronger as compared to ideas. This is because impressions are real and occur as first hand experiences, before they are played by the mind to retrieve ideas through reflection, which makes impressions more powerful than ideas. Another difference provided between impressions and ideas is that it man is liable to have difficulty in distinguishing between ideas and will even make mistakes about ideas. This, however, does not apply to impressions or is rather difficult to face, as impressions are highly distinct and can be told apart at any given time based on their powerful nature, and especial ly the concept of vivacity based on reflection and sensation. In addition, impressions can stand on their own, while ideas do not, but only serve to build further on impressions as an idea enriches what one perceives, but not how it is perceived. This is to mean that ideas assist in the construction of concepts, in which an example of a dog is given, impressions are applied based on direct sensations and ideas are developed, where the mind associates all impressions of a dog and creates an overall impression or idea of what a dog is, as well as its properties (Lacewing 1). In order to back his claim that ideas are copies impressions, Hume goes into the issue of the copy principle, which in the first place is used to distinguish between ideas and impressions. As such, he describes ideas as being dependent on impression, as one cannot construct knowledge or concepts from scratch without a hint of sensation and reflection. This means that one must have an impression of the concept from which ideas are to be developed, as ideas are part of the mental entity impression. With this in mind, Hume supports his claim by stating that for ideas to be in existence, there is a

Techniques of Effective Discipline Term Paper Example | Topics and Well Written Essays - 1250 words

Techniques of Effective Discipline - Term Paper Example But if an employee fails to respect these rules, the employee’s behavior needs to be corrected. The entire purpose of discipline is to improve the employee’s behavior, and hence in turn improving work performance. This relationship is considered the most important factor that governs effective discipline in the work environment. If a manager gets along well with his employee and they develop an understanding, life in the workplace becomes fairly easy. A good manager would take time to go through the work of the employee and would not hesitate to give positive as well as negative feedback. This would motivate the employee to improve and actually perform better. For example: if a manager were to give negative feedback, point out mistakes and rebuff the employee, everytime he submitted an assignment, and not compliment the employee for submitting it before the deadline or even when he did a good job , then obviously the employee would be extremely demotivated and would not try to improve. Hence, it is extremely essential for the manager to be supportive, helpful and encouraging so that the employee strives to do a better job. Whenever an employee makes a mistake the manager should explain what went wrong and then guide the employee on how to correct the mistake. This not only motivates the employee but it could help to make him enjoy his work. Positive reinforcement is one of the primary techniques in effective discipline and one the most successful one. It is a known fact that people work harder and better when they are rewarded for doing something right than when they are punished to do something wrong (B.F.Skinner, 2011). If an employee has never been late to work or has always submitted his assignments on time, the manager should praise him in the monthly meeting so that he keeps up the good work. Not only that, other employees might learn from

Integrative Approaches to Psychology and Christianity Essay

Integrative Approaches to Psychology and Christianity - Essay Example allows for a constructive relationship between Psychology and Christian Theology, and its peaceful co-existence in the living the life God has meant us flawed humans to live. The interaction of Psychology and Theology is inevitable because of their mutual interest in understanding human nature and healing its brokenness. There have been times when their principles complemented each other, and other times when there were animosities. Integration reflects God’s desire to reconcile humanity and the larger created realm to Him (p. 81). Thinking Christians can raise metaphysical questions that harmonize with their faith, that supports and strengthens it instead of undermining it when they are introduced to well-considered and clearly articulated world and life-views. Such questioning has implications for an integrative paradigm. The book discusses various models in describing the relationships of Psychology and Christianity, ranging from the extreme Enemies paradigm which polarizes the â€Å"Secular Combatants† (psychology) and the â€Å"Christian Combatants† (Christianity), and proposes fierce loyalty to one discipline while rejecting the other. Other models like the Spies, Colonialists and Neutral Parties have tendencies to vacillate between the two disciplines. The fully integrative paradigm is the Allies. It sees the value of both camps of Christianity and Psychology, that taken together will give a fuller and more accurate picture of the truth. It is a truth that God has revealed in both the bible and in practical life. It is such a credible truth because it comes from the One who reigns supreme over both disciplines. It proposes that in seeking truth, we must study both books of God’s word (the bible, Christianity) and God’s work (the world, people, Psychology). Comprehensive study of both books will allow mutual interaction of principles which may bring us to understand that all truths is God’s truth. In the event that there are

Information Tecnology Law Essay Example | Topics and Well Written Essays - 4000 words

Information Tecnology Law - Essay Example After holding talks for a couple of years with the EU, the US, to the initial chagrin of much of Europe, was able to wrest an agreement that would bail out its companies from the rigid standard of the EU. The EU/US Safe Harbor agreement is a compromise pact that would allow US companies to receive personal data from the UK despite the finding of inadequacy of US data protection system. The EU/US Safe Harbor agreement, which almost relies on self-regulation of its member organisations, suffers from fundamental structural and procedural lapses that weaken its effect. The EU Data Protection Law The United Nations was the first international body to delve on the issue of data protection during the 20th anniversary of the Universal Declaration of Human Rights in 1968. It posed the question as to whether limits must be set in the use of electronics to protect privacy rights. Subsequently, the Organisation for Economic Cooperation and Development (OECD) drafted the Guidelines on the Protection of Privacy and Transborder Flows of Personal Data in 1980 whilst the Council of Europe came up with Convention for the Protection of Individuals with Regard Automatic Processing of Personal Data also in the same year. The non-binding OECD Guidelines preceded a heated disagreement between some European countries and the United States where the former charged the latter of intentional laxity in its data protection laws as a strategy to globalise its computer industry and the latter accused the former of protectionism through data protection. The OECD Guidelines therefore, was a compromise o f the conflicting stance of the parties. On the other hand, the Council’s treaty came about after considerations in the difficulty, especially by multinationals, in transferring personal data from one country to another because of the different procedural elements in each country. The need to harmonise these different procedural elements was the primary objective of the treaty.2 As the emergence of a European common market loomed in the horizon, the European Council finally gave in to the longtime suggestion that it comes up with a Directive that would tackle data protection. In 1990, the EC issued Directive 95/46 also known as the Data Protection Directive, which has since been described as â€Å"the most influential international policy instrument to date.†3 It was formally implemented on October 1995, with Member States given until 1998 to amend their respective laws to conform to its provisions. Whilst the Council’s earlier treaty was aimed at harmonising na tional laws on data protection, 4 the primary objective of Directive 95/46 is to protect the individual’s privacy as a basic right. This Directive is a consolidation of all efforts to obtain a uniform data protection laws in all Member States, because differences in levels of data protection hamper the free flow of personal data from one Member Country to another, which can result in difficulty in the implementation of a unified European market.5 The rights that are embodied in the Directive are put in a nutshell by Article 8 of the European Union Charter of Fundamental Rights, which took effect in 2009 concurrently with the Treaty of Lisbon. These rights are: the right to protection of personal data; the right to have personal data processed

General Investment Discussion Posts Assignment Example | Topics and Well Written Essays - 1250 words

General Investment Discussion Posts - Assignment Example Wieland (2010) denotes that a passive investment strategy has a rate of return of 7% per annum. This, Wieland (2010) denotes that is the main disadvantage of a passive investment strategy. That is, an investor will not get a high return for his or her investments. Barnes (2009) denotes that an active strategy will incorporate a method in which an investor seeks to buy bonds or stocks expecting a high return. On this basis, its main advantage over passive strategy is that an investor can acquire unlimited return. However, this method is very expensive, and there is no guarantee of success. It is important to denote that approximately 80% of actively managed stocks usually underperform (Barnes, 2009). Those that perform well are not consistent over the years. On this basis, the best form of portfolio management is the hybrid system. This is because it is a combination of the passive and active investments strategies (Wieland, 2010). On this note, the hybrid system combines the advantages of these two investments strategies, as well as mitigating their disadvantages. Toporowski (2010) denotes that one major strength of a projected P/E is its ability to explain the degree of confidence upon which investors have on a company. Toporowski (2010) further denotes that a P/E which is low in value will imply that investors do not have confidence with the company. On the other hand, a P/E which is high will denote that investors have confidence with the company. Investors will therefore purchase the various securities and stocks of these companies. On this note, the projected P/E ratio provides a guideline in which investors will know a company that performs well or not. However, the P/E ration has limitations. This is because the P/E ratio uses earnings as its indicator. It is important to denote it is possible to manipulate the earnings of a company. On this note, it is therefore

To what extend does Joint Commission International (JCI) Accreditation Essay - 1

To what extend does Joint Commission International (JCI) Accreditation standards improves healthcare facilities(2) - Essay Example Scientific enquiry or research involves a series of steps that begins with defining the problems through proper investigations using a scientific approach and devise methods to reach a suitable solution. Experts have divided this process of scientific research under eight sub-divisions. The first characteristic is purpose, which implies that every researcher should have a specific purpose for undertaking the research. This is the initial step that would enable the researcher to find suitable answers and methods to solve the problem. The next important requirement is rigor by which researchers need to be attentive and scrupulous during the research process in order to avoid any errors or bias that may affect the end results. The next requirement is testability by which a hypothesis should be subjected to proper testing processes after collection of the required data. Following the testing process the researcher should also ensure that the results obtained are replicable every time the research is conducted under similar conditions as this will ensure that the hypothesis is reproducible. The next requirement for any research is precision and confidence. Precision ensures that the results obtained from the research are relevant to the hypothesis made and the confidence levels reveal the extent to which the results are correct. In addition to the above factors, every researcher should be objective in their research by which any subjective or emotional bias should be eliminated and the study interpretation should be based on the data alone. Another important requirement is generalization of the study by which the study could be applied to any setting. Finally the study should also be simple to perform and understand rather than complex.(Sekaran, 2003). The following chapter begins with the definition of the research problem and then describes the purpose of this study, following which the study objectives are detailed and in turn the study setting is described. The research methodology that includes the sampling methods is explained and the types of data to be used, data collection and analysis are then explored. The contribution of the study is described finally. The method employed in the study is telephonic interview and use of an executive staff questionnaire with the IMC staff members. The IMC has entered into an agreement with the JCI, which has made it the first hospital in Gulf to be involved with the acclaimed organization right from the inception of a project. 3.2 Research problem Following the implementation of the JCI standards within the TQM department, several manufacturing industries have shown marked improvement in quality in different sectors across the country. Given this increase in quality improvement, the service industry, especially the healthcare industry has shown interest in implementing this concept within its purview. The Saudi health sector, both public and private, faces a variety of general challenges such as reso urce allocation and other challenges related to its nature such as the quality of services provided, cost containment and medical errors. Considering the

Information Systems Development Philosophies and Methodologies, and Essay

Information Systems Development Philosophies and Methodologies, and System Analysis - Essay Example The data is then made accessible to the doctors and the nurses and then they have the power to sort the system at the will or in accordance to the hospitals guidelines or according to emergency disasters (Lakha and Moore, 34; Turegano and Perez-Diaz, 441). The updated information is what is fed back into the original triage and made available for patients to watch on a live monitor. As more patients get into the hospital and are registered, many more will tend to have more severe cases and thus, depending on the mode of selection by the doctors to determine who should be served first, there are patients who will feel neglected. This will tend to resume the past squabbles as outlined by the previous system. The system development process is thus fairer in that the problems trying to be rooted out are partly done. To avert the problem noted in the profile, it is essential that assessment that is more practical be done in terms of the CATWOE checklist. According to Checkland and Scholes (23), in their soft systems methodology, they propose solutions, advising on CATWOE to problems that have no definitive approach. Using the analysis, it will hence be possible to tell out the possible remedies to the problems and proposed solutions. According to Wilson (1) proper judgments will depend on the

Macbeth as Tragedy Essay Example for Free

Macbeth as Tragedy Essay Shakespeare’s Macbeth is often considered one of literature’s greatest tragedies and is said to reveal much about human nature. Do you agree or disagree that the play conveys much about humanity or about the human experience? What, if anything, does the work suggest about human beings or society? Support your views with textual details and analysis. In your response, address how Macbeth’s subject matter, themes, form, or other literary elements might (or might not) be characteristic of tragedy. How do tragic qualities of the play contribute (or not) to the story’s larger message(s)? Macbeth has always been a play of interest in any age groups. I remember this play in my high school but then which school does not get involved with this play. I do agree with the statement that Macbeth reveals much about human nature. Macbeth reveals the dark side of human nature; ambition, hunger for control and power, it shows us the aftermath that it leaves behind. The play suggests the dark tendencies that lives within many of the human beings in our society; the need to succeed and annihilate their obstacles at any cost: human beings are opportunistic. Macbeth shows us how far a person will go to in order to realize their own ambitions; even to commit a killing. Free will exists in humanity and everyone has the potential for good and the commit evil deeds. The Macbeths lust for power and greed ends up in grim tragedy. Macbeth starts off as a hero; a brave warrior in the battlefield, standing behind his king and protecting his land. This is what makes Macbeth a tragic hero. Tragic hero: A main character who acts with courage but falls from high standing into catastrophic circumstances because of a weakness of character or serious misjudgment. (Clugston, 2010, page. 4. 4, para. 3). Lady Macbeth is willing to lose her soul in order to push her husbands faith to be king a reality and sooner; she asks the gods to remove all compassion and femininity and replace with cold and ruthless qualities; this symbolizes the darkness of human nature. The Macbeths had it all but failed to recognize it due to having their dark ambitions take over them; consuming them and this is the tragedy. The literary elements are the motifs, they are the hallucinations and violence; these motifs lead to tragedy end of the Macbeths.

Relationship Between Childhood Well-being and Poverty

Relationship Between Childhood Well-being and Poverty Introduction This paper explores the relationship between childhood well-being and poverty. Using structural equation modelling a multidimensional picture of child well-being is developed which is linked to previous work on multidimensional poverty indicators at household level (Tomlinson et al. forthcoming). Following a brief literature review of childhood poverty and well-being research, there follows an analysis of several waves of the British Household Panel Study – a valuable source of data collected directly from children as well as adults in the same households. The paper attempts to map the experience of poverty at household level and relate it to the child’s well-being. Rather than seeing poverty as a facet of child well-being, as other researchers often do, this work conceptually distinguishes between the two and shows how they are linked. Following the literature review various structural equation models are estimated that measure different dimensions of child well-being. These dimensions are then related to other aspects of the child’s life including the experience of poverty, age and gender, household composition, income, parental education and employment status. The effects of poverty are broken down into more detailed dimensions and the relative impact of each dimension is discussed. Finally, the models are used to inform targeting strategies with respect to child welfare policy. Crucially the differential impact of various potential policy instruments is assessed through the models. Mainstream child poverty research Since New Labour took office and pledged to eliminate child poverty by 2020 a myriad of policy changes and political statements has been issued to address the problems associated with poverty and deprivation during childhood. Indeed the costs of child poverty and its immediate and future effects are becoming increasingly alarming. For instance, recent research has found that poor children are more likely to get into trouble inside and outside school and more likely to be involved in drug abuse (ONS 2002). The direct costs of this are estimated to be considerable. For example:  £6000 for a 6 month non-custodial sentence  £21000 for a custodial sentence of 6 months Cost of attending pupil referral unit:  £10000/year Drug programmes cost on average  £15000/person over a 4 year period (Source: Godfrey et al. 2004) Much of the literature relating to child poverty in the UK has focussed around two areas: first the identification of households where risk is greatest and second, the so-called ‘scarring’ of children and the transmission of disadvantage into adulthood. With respect to the former it is now well known that poor children in particular are more likely to come from the following types of household: Workless households Benefit dependent households Lone parent families Low income households Families with younger children are more likely to be poor Large families Ethnic minority households Those in rented accommodation See, for example, Hirsch (2006a), Lloyd (2006). In addition Bradshaw (2006a) has extensive breakdowns of poverty rates for different social groups with children; Platt (2007) has an analysis of ethnicity, employment and child poverty; large families are extensively discussed in Iavacou and Berthoud (2006) and so on. In other words it is no longer an issue of identifying which types of environment – from a household perspective – are important, but rather moving towards a measurement model that can assess the impacts of the various dimensions associated with poverty on the child and its well-being. This is the approach taken in this paper. With respect to the second set of literature on scarring and transmission, the impact of poverty on a child’s future life-chances has also been extensively researched. Moreover, these impacts appear to have increased as child poverty increased during the 1980s and 1990s (Fahmy, 2006). Gregg and Wadsworth (2001) have noted the increased polarisation of working versus non-working households and the effects that this has had on poverty rates. That is the growth of dual-earner versus no-earner households. Using cohort studies such as the British Cohort Study (BCS) and National Child Development Study (NCDS), a series of papers has shown that low income in childhood leads to poor educational attainment in later life. For example, see Blanden and Gregg (2004) which also provides a useful review of the US literature on this topic. Gregg and Machin (2000) and Glennester (1995) come to similar conclusions. Fahmy has also reviewed the literature with respect to youth poverty (youth being defined as being aged 16-25). The consequences of poverty identified for this group, referred to as ‘hazardous transitions’ into adulthood, include: A high probability of becoming a ‘NEET’ (not in employment, education or training – see Istance et al 1994 for an earlier study) A bad career track (Craine 1997) A reduced level of citizenship and civic participation (Dean 1997) A higher risk of homelessness (Smith 1999, see also Flouri and Buchanan, 2004) Stewart has also documented various consequences of child poverty in later life. Adding low self-esteem, low expectations, reduced educational attainment, benefit dependency and poor labour market outcomes to the list. See Stewart, (2005) and also Hobcraft (1998) and Ermisch et al. (2001). While all this work is very convincing and commendable there is relatively little literature relating child poverty in the here and now and its immediate impact on the life and environment of the child. It is almost as if this were less important than the future costs. However, there is also a growing interest in the current well-being of children and its measurement. Early literature on this is extensively reviewed in Pollard and Lee (2002). This covers definitions of well-being, the indicators developed and instruments used in the measurement process. Moreover, two recent special issues of Social Indicators Research (SIR, 2007a, 2007b) have already been devoted exclusively to the topic (and a third issue is on the way). Interestingly, one strand of this work relates to human rights which shows the level of importance now being attached to these issues. Bradshaw et al. (2007) discuss concepts of well-being which are predicated on the UN convention on the rights of the child (UNCRC). Essentially this accepts the multi-dimensional nature of well-being from at least four perspectives: first that it is non-discriminatory, second that it is in the best interests of the child, third that it relates to the child’s survival and development, and fourth that it respects the views of the child (Bradshaw et al 2007: 134). The link to poverty and deprivation is sometimes made explicit in this literature: for example, ‘child well-being and deprivation represent different sides of the same coin’, Bradshaw et al. (2007). On the other hand, US, and very recent British, research shows well-being to be related to, but not the same as childhood poverty (Land et al., 2006; Bradshaw and Mayhew, 2005) for reasons that are not well-understood, but which probably include protective behaviour by parents (e.g., Flouri, 2004) and individual resilience (e.g., Masten and Coatsworth, 1998, Masten, 2001). Thus there is confusion about the relationship between well-being and poverty. Sometimes poverty is cited as a specific dimension of well-being, and sometimes as a separate concept entirely. For example, Bradshaw et al. (2007) have developed an eightfold classification of child well-being and generated one composite summary indicator from internationally comparable data. The eight dimensions being: Material well-being Housing Health Subjective well-being Education Relationships Civic participation Risk and safety These are measured by standardised scores which are added together to form the individual indices and an overall summary index which is then used for international comparison. There is then no accepted or uncontroversial measure of child well-being. The general thrust of the debate is that child well-being must be measured along several dimensions and poverty (or particular dimensions of poverty such as material deprivation) is sometimes included and sometimes not. The approach taken in this paper is somewhat different in that the two concepts are kept completely distinct as explained in more detail below. The measurement of poverty and well-being The approach here uses two sets of measures reflecting two aspects of the situation of children living in British households. First of all we measure poverty at the household level using structural equation models. This is done along several dimensions using data from the British Household Panel Study (BHPS) and is discussed in Tomlinson et al. (forthcoming). The dimensions are: financial strain, material deprivation, the environment, psycho-social strain, civic participation and social isolation. These are combined into an overall weighted index referred to as the Poverty Index (PI). Second we use structural equation models to measure various dimensions of childhood well-being. We are restricted in the questions that are asked and cannot include all the dimensions listed by Bradshaw et al. (2007). However, we measure four different aspects of child well-being including ‘home life’ which relates to family relationships and parental control (similar to Bradshaw’s ‘relationships’ dimension), ‘educational orientation’ (again similar to Bradshaw et al.), ‘anxiety’ (based in part on Bradshaw’s subjective well-being indicator) and ‘delinquency’ (which also relates to risk and safety). However, a crucial difference with our approach is that we treat dimensions such as material well-being and housing as aspects of household level poverty rather than childhood well-being. Thus we keep poverty and well-being conceptually distinct and analyse the relations between the two. It is the association between these four measures of child well-being and the numerous measures of poverty already developed that is the ultimate focus of the paper. In summation we take a multidimensional approach to both well-being and poverty and we examine the correlates of poverty with a child’s current well-being. In this way we can assess the impacts of poverty on the child’s immediate social environment and state of mind rather than what the future might hold. Models which can link together different aspects of poverty with various aspects of children’s livelihoods will assist in developing strategies to alleviate some of these problems. In other words we identify which aspects of poverty have the most serious impacts on the child (and hence will probably affect their future life chances to the greatest extent). Using structural equation models (SEM) There are now many academics using more advanced statistical techniques to measure poverty from a multi-dimensional perspective (e.g., Jenkins and Cappellari, 2007, Tomlinson et al., forthcoming, Whelan et al. 2007a, 2007b). These techniques, such as item response theory, structural equation modelling and latent class analysis, can be used not only to analyse which families with children are actually in poverty, but also which particular aspects of this poverty are more intense (such as bad housing, material deprivation, financial strain and so on). This is the approach taken in this paper with respect to the measurement of poverty and the measurement of child well-being the two being linked together within a coherent methodological framework and then related specifically to policy and policy targeting. Like the more traditional method of factor analysis, a SEM reduces a large number of observed variables to a smaller number of factors. However, in a SEM the variables are conceptualised as observed manifestations of an underlying or ‘latent’ dimension. Each observed variable in a SEM also has an error term associated with it, allowing measurement error to be isolated and controlled for in a way that is impossible with factor analysis. But, most importantly, a SEM requires a strong theoretical justification before the model is specified. Thus the researcher decides which variables are to be associated with which latent unobserved factors in advance. There are two fundamental types of SEM used to measure or test the validity of latent concepts – first and second order confirmatory factor analysis models (CFAs). We use first order CFAs below to measure child well-being. A first order CFA simply attempts to measure preordained underlying latent concepts. The left side of figure 1 shows a simple CFA which has two latent unobserved variables: L1, material deprivation; and L2, financial strain. L1 is measured by the observed variables V1 to V4 and L2 is measured by variables V5 to V7. The single headed arrows represent coefficients or loadings in the model and are usually shown in standardised form much like beta coefficients in regression analysis. The covariance between material deprivation (L1) and financial strain (L2) is represented by the double headed arrow. The associated error terms are shown as the circles labelled e1 to e7. Using statistical techniques such as maximum likelihood estimation and making assumptions abou t the distributions of the variables and error terms in the model, the coefficients and covariances can be estimated. In all SEMs a variety of fit statistics is available to assess the validity of the models constructed (see Klein, 2005, Byrne, 2001). Usually it is assumed that the observed variables in the model are continuous and that the distribution of the variables is multivariate normal. More recently available software is beginning to allow the explicit modelling of categorical, binary and censored variables (such as MPlus which is used in this study). Models of this kind can be made as complex as necessary to describe real-world situations and employ many latent variables and various interactions between them. Covariates or controls can also be applied to the overall measurement models to assess differences between groups or to assess the impact of a particular variable on the latent concepts under consideration. Furthermore, scores can be generated for the unobserved latent variables. These scores are analogous to the factor scores obtained using factor analysis. The BHPS and the measurement of childhood well-being The analysis that follows utilizes data from the British Household Panel Study (BHPS) and follows the methods discussed in Tomlinson et al. (forthcoming). The BHPS commenced in 1991 with an initial sample of around 10,000 individuals resident in some 5,000 households. These individuals have subsequently been re-interviewed each year and the sample has also been extended to include more households from Scotland and Wales and to embrace Northern Ireland (although Northern Ireland is excluded from this analysis). The data can be weighted to provide an accurate picture of life in Great Britain at different points in time. The analysis here covers the period 1997, 1999 and 2001 (i.e. BHPS waves 7, 9 and 11) and draws on information concerning the following topics for the measurement of poverty: income, finances and benefits; stress; material deprivation; general housing and neighbourhood characteristics and social exclusion and civic participation. The level of poverty at household level is measured by the responses given by the head of household and calculated as detailed in Tomlinson et al. (forthcoming). Each individual dimension of poverty as well as an overall score (the Poverty Index) is computed via a SEM for each household with children. Households with heads under 18 years of age or over 64 years of age are excluded from the sample analysed to calculate poverty scores. We also use a unique data resource available within the BHPS and consistently applied across the three waves. Children aged between 11 and 15 within these households were also asked to complete a separate questionnaire which forms the basis for the measurement models of child well-being. Questions included relate to home life, schooling, anxiety and psychological aspects of life, social isolation and delinquent behaviour. Estimating a structural equation model of childhood well-being As with the measurement of our multi-dimensional poverty index we attempted to create measures of multidimensional childhood well-being using 1st order CFAs based on the responses given by the 11 to 15 year olds in the BHPS panel for the years 1997, 1999 and 2001. The models have been estimated separately for all three waves. Questions change significantly in other available waves and these waves have not been included in the present analysis. The four dimensions of well-being are estimated using the following variables (which are all measured as ordinal scales except the variable relating to suspension from school which is binary): 1. Home life is a measure of the children’s relations to their parents and family and how much control the parents have over them: How much children talk to their parents How much control parents exercise over TV How much the family share meals together 2. Educational orientation is a measure of how well the child is doing at school and their attitudes to teachers and so on: How much the child likes his/her teachers Whether the teachers ‘get at me’ General feelings about school Whether the child is doing well at school 3. Anxiety is a measure of the child’s psychological health and feeling of self-worth Whether the child feels unhappy Whether the child has lost sleep How useless the child feels How much of a failure the child feels Whether the child feels no good The extent to which the child feels lonely The extent to which the child is left out of activities 4. Delinquency is an attempt to measure aspects of criminal tendencies or anti-social behaviour: Whether the child has ever been suspended from school How often the child plays truant How much experience the child has with smoking cigarettes Whether the child vandalises property Whether the child has friends that use illegal drugs (there is no direct question about the respondent’s own drug use) A first order confirmatory factor analysis model was estimated to measure the four dimensions (see figure 2 for an example from wave 11) and further models developed with controls for gender and age of the child and the overall Poverty Index of the head of household. We attempted this with each of the three waves of the BHPS, but all three models gave similar results and good fit indices. The model estimation was done using MPlus 4 with the observed variables being treated as ordinal rather than continuous where appropriate. Results and discussion of the basic model The first order models produce a good fit to the data (see Table 1) and the coefficients on the observed variables are all in the expected direction and all statistically significant at the 1% level. Some error terms were allowed to co-vary as illustrated in the figure based on very high modification indices in the initial modelling attempts. Examining the latent constructs themselves and the correlations between them reveals the relationships between the various dimensions of well-being. That is educational orientation is strongly associated with parental influence and negatively associated with anxiety and delinquency. Delinquency is also positively associated with anxiety etc. (Table 1). Table 1Fit statistics and correlations for the simple models (wave 11) Fit statistics: (N=1201) Without controlsWith controls Chi-square 426.959 (79 d.f.)639.104 (130 d.f.) CFI0.9370.902 TLI0.9550.921 RMSEA0.0570.057 Correlations between latent variables in controlled model (all significant at 1%):   Home life Educational Orientation Anxiety Educational Orientation +.54 Anxiety -.18 -.36 Delinquency –.63 -.54 +.22 The controlling variables are also salient. Girls are more anxious than boys, but have better educational orientation and relations with their parents. There is no significant difference between girls and boys with respect to delinquency. The age controls show that home life diminishes with age, while delinquency increases. Children of 11 and 12 also have stronger educational orientation than their older peers. However, the most striking result is that poverty (measured by our composite multidimensional index) has a highly significant and detrimental effect on all four of the well-being dimensions. That is it contributes to anxiety and delinquency and detracts from educational orientation and home life. Thus we can show that poverty has a serious debilitating effect on child well-being in the here and now. The relative importance of poverty for each dimension of well-being is also evident. The strongest effect appears to be on home life (–0.22) followed by educational orientat ion (–0.13). The impact on anxiety and delinquency is less strong (both at 0.10), but still highly significant. Thus we can show that the overall impact of the experience of poverty appears to affect home life and education the most while still having an effect on anxiety and anti-social behaviour. However, one of the issues we wish to deal with (not least from a policy targeting perspective) is to see which sub-dimensions of poverty are the most salient with respect to child well-being. For example, as we have measured poverty in a multidimensional way, which particular dimensions have the biggest impact? In our previous measurement work we developed several indicators of multidimensional poverty. Namely the poverty index is a weighted summation of several sub-indices: financial strain based on bad finances and missed housing payments material deprivation based on the levels of material possessions in the household and whether the household could afford to do certain things the environment which is based on a combination of housing and neighbourhood characteristics social isolation based on lack of social support civic participation based on participation in civic life psycho-social strain based on stress, mental health and anxiety The most desirable way to test the effects of the various dimensions on well-being would be to include them all as covariates in a measurement model similar to that shown in figure 2. However, because the various dimensions of poverty are highly correlated with each other this presents problems for the estimation (that is there is a multicollinearity issue). Rather than attempt to do this, individual models have been estimated with each sub-dimension of poverty included by itself in place of the overall poverty index in a similar fashion to the model in Figure 2. The relative sizes and significance of the coefficients relating to the individual sub-dimensions of poverty will allow an assessment to be made as to which elements of poverty are the most serious with respect to the child’s welfare. The results are summarised in figure 3 (this is a diagrammatic summary of results from wave 11 (2001) and shows only the significant effects). The results show that different aspects of poverty have different effects on the various aspects of well-being. For example, the financial dimension affects all the aspects of well-being whereas material deprivation only affects two (being detrimental to home life and increasing delinquency). A poor environment in terms of bad housing or neighbourhood results in reduced quality of home life, increased anxiety and delinquency. By using these results it becomes clear that policy aimed at poverty reduction could in principle be targeted in particular ways that would have different benefits as far as the diverse dimensions of child well-being are concerned. Improving the environment of children – both within and outside the household – may well have a greater overall impact on well-being than improving material deprivation. On the other hand if educational performance is the main criterion then financial strain, and civic participation of the household become the key areas. If home life is seen to be the main issue then finance, material deprivation, the stress of the parents, the environment and civic participation would be the key foci. This policy dimension is returned to below. It is also interesting to note that social isolation (a measure of social exclusion) of the head of household has no bearing on the four well-being indicators. However, there are also other controlling factors that can be incorporated in the models determining child well-being besides poverty, age and gender. Using the structural equation framework with covariates allows several alternative model specifications to take into account different offsetting factors with respect to child welfare. There is already evidence from the UK that certain situations in childhood can ‘buck the trend’ in reducing the negative outcomes of child poverty. For example, Blanden (2006) has shown that parental interest (mainly the father for boys and the mother for girls) has a positive impact on adult educational outcomes. She also shows that higher educational attainment early in the child’s life has a positive impact later on as does the school’s characteristics and the social mix of the child’s school. So research has shown that there may be mediating effects (such as parenting or living in a good neighbourhood) that offset the deleterious impact of poverty and deprivation. For example, McCulloch and Joshi (2001) found using the National Child Development Survey that although poverty and living in disadvantaged neighbourhoods does correlate with lower test scores at school, the family environment and family support can offset this effect. In the US the extensive work of Aber and his colleagues has also shown that there are negative effects on child specific outcomes from poverty and material hardship and that cognitive and emotional outcomes are affected by low income and material hardship (e.g., Gershoff et al, n.d.), but that this is mediated by parental characteristics. With this idea of mediation in mind several alternative models have thus been estimated to take account of the following factors which are included as further controls in the models: Household composition (such as the presence of other children and single versus multiple adult households) Educational attainment of the household head Employment status of the head of household Income rather than multidimensional poverty indices The household composition model will enable an assessment of family relations and its impact on well-being. The education model will assess the impact of parental human capital irrespective of other considerations. While the employment and income models can be usefully compared with the Poverty Index model (in other words can income or employment status merely substitute for poverty)? These results are summarised in table 3 for wave 11 (2001). The models were essentially the same as shown in figure 2, but without including the Poverty Index as a control which confounded the income and employment status models (again because of multicollinearity). Household composition was tested by including a variable indicating whether the household was a single adult household (versus other types) and dummy variables representing the number of children in different age categories. The results show clearly the influence of adults is significant when it comes to home life and delinquency (whereas being a single adult household has no effect on anxiety or educational orientation). Single parent households are therefore at a possible disadvantage when it comes to controlling their children. Even when a control for income is included in this model in an attempt to separate out the impact of low income from single parenthood the single adult variable is still significant in the same way. The presence of other children or siblings appears to have no impact on the child respondent’s well-being. Education of the head of household also has an impact on home life and educational orientation of the child, but only where the household head is educated to a higher educational level (that is degree level). The models for employment status included variables for self-employed status, unemployed and non-employed (i.e. not working and not actively looking for a job). Clearly the household head not having a job has an effect on the child’s well-being (although this is also correlated with the Poverty Index). In the case of being non-employed (which includes housewives, the disabled, and other economically inactive people) this has an impact on all four well-being dimensions to the detriment of the child whereas being unemployed only affects home life and delinquency. Self-employment has no effect. One possible explanation for the difference between unemployed and non-employed effects might be a reflection of the impact of long-term poverty and deprivation on children. That is t hose household heads that are not economically active for one reason or another and classed as non-employed rather than unemployed may well suffer from longer periods of chronic financial hardship, whereas the unemployed may be intermittently working and thus have experienced periods where they were no longer poor. Table 3Effects of various controls on the basic well-being model with various controls in addition to age and gender of the child (wave 11). Significance level is 1%. Standardised coefficients shown.