Factors Affecting Antipsychotic Medication Compliance

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

Ilisu Dam Project Development

Ilisu Dam Project Development The proposed Ilisu Dam is a single project under the umbrella of the massive Southeastern Anatolian Project (Guneydogu Anadolu Proje) or GAP. The GAP was a major development endeavour for Turkey and aimed to develop projects using the power of the two largest rivers in Asia, the Tigris and Euphrates, that run begin in Turkey and run through to the Arabic Gulf. GAP was conceived to meet Turkey’s rising energy needs by the construction of 22 irrigation dams and 19 hydroelectric plants, harnessing the hydroelectric potential energy contained in these two massive rivers (Stern, 2004). The GAP attracted international attention due to its focus on the human effects of the project and attention to sustainability. International credit agencies from the Canada, USA Japan, UK and other European governments along with the World Bank stepped forward to fund the project which they see as one being integral to the socio-economic development of Turkey which is an important US partner and is aspiring to join the EU. Certain aspects of the GAP, specifically the Ilisu Dam, have come under attack from citizens groups concerned about the social and political ramifications of the dam and the project is currently on hold after major sponsors pulled out and completion date has been pushed from early 2000 to 2010. This paper will examine the proposed dam and the issues that surround it. Turkey was once part of the Ottoman Empire emerged from the demise of that empire and was inaugurated as a nation in 1923 under Mustafa Kemal who was later honoured as the â€Å"Father of the Turks†. Under his authoritarian leadership the Anatolians of the region saw improvements in social and economic status. The nation enjoyed a peaceful transfer to democracy in the 1950s though has since seen several military coups but always with a peaceful transfer back to democracy (CIA World Factbook. 2005). The nation borders the Black and Mediterranean Seas and its neighbours include Bulgaria, Greece to the West and Georgia, Armenia, Iran, Iraq and Syria to the East. The country is a member of the UN and NATO since the 1950s and is seen as a leading nation in the Asia region. There have been recent conflicts with separatist Kurds in the South Eastern portion of the nation. The Kurdish separatist movement is known as Congress of Kurdistan (KGK) or the communist PKK and have links with Kurds in bordering Iraq and Syria (CIA World Factbook. 2005). The nation has been adopting major environmental and social reform in hopes of being admitted to the rapidly expanding EU. The GAP is aimed at developing the south eastern 8 Anatolian provinces which are home to the majority of the Kurdish population of the nation. The project is the largest ever development project Turkey has ever undertaken and seeks to improve the lives of nearly 10% of the Turkish population (Ilisu Engineering Group, 2001; Stern, 2004). The south eastern part of Turkey is a poverty stricken area plagued by low income, violent instability and inequality (Morvaridi, 2002). The area’s faming consists of low-mechanization with few cash crops and the region suffers from aridity despite the presence of major rivers like the Tigris and Euphrates. The region also suffers from the Kurdish separatist movement which has attracted the attention of the Turkish and this has been compounded by the militants fleeing Iraq due to the recent US and UK invasion. The focus of the GAP is to develop the energy potential of the region while providing irrigation for crop growing to the region. Historically most of the development in Turkey was concentrated on the North and Western regions of the nation, leaving the South and East to languish in obscurity. This lack of investment in the region could be a driving reason behind the Kurdish separatist movement. It is Turkey’s national interest to tap the resources of this region and hopefully quell the separatist movement by funnelling development funds into the area to improve the lives of its inhabitants. The GAP has already begun to pay off as other projects other than the Ilisu Dam have already been completed. GAP related dams already account for more than 15% of Turkey’s energy needs and has potential to reach 22% (Kaygusuz, K, 1999). The final goal for land irrigation is 20% of Turkey’s total irrigable land which is nearly 1.7 million hectares of land United States Department of Agriculture Foreign Agricultural Service, 2005). In the region of Sanliurfa – Harran, agricultural benefits are being seen with huge increases in cash crop production (mainly cotton), the establishment of new industries such as beef along with development of textile industry which is raising the standard of living in the region (Northwest Texas International Trade Center, 2004). Energy production is the other prong of the pitchfork of progress that is GAP. In 2002 Turkey’s energy consumption peaked at 126.9 billion KWh. Due to industrialization, development and population growth this figure is projected to rise to 265 billion KWh by 2010 and to 528 billion KWh by 2020 (Stern, 2004). Turkey has scarce fossil fuels so a major source of energy for the nation is hydroelectricity which accounts for 40% of Turkey’s energy needs (Stern, 2004). GAP was conceived to help meet these rapidly increasing energy demands and if GAP does not relieve some of the energy strain put on the nation then other sources of energy must be found. The politics of the GAP are tricky as other nations lie down stream of Turkey on the Tigris and Euphrates. Iraq and Syria are dependent on the flows from the two rivers and by Turkey assuming control of these cross-border water resources tension has been created due to rights to access of the water. Turkey has to be sure to manage the water resources of these rivers in such a way as to not disadvantage the residents of these nations lest they risk war. The GAP falls into the realm of sustainable development as it aims to use a renewable energy source for a long term benefit to the people of the region. The standard definition for sustainable development was generated by a report produced by a United Nations commission in 1987 entitled Our Common Future which is better known as the Brundtland Report after the head of the commission. The definition of the phrase sustainable development is wide ranging and open to subjective interpretation but Our Common Future (1987) defined it as: Sustainable development is development that meets the needs of the present without compromising the ability of future generations to meet their own needs. From Our Common Future (Bruntland, 1987) This report generated much response as world leaders began to respond to the issues tackled in the report. The environmental movement began in earnest with the 1960s with the publication of Rachel Carson’s landmark book Silent Spring. (Carson, 1962). The emergence of a demand of environmental responsibility from global citizens was often at odds with economic development planning and a compromise was necessary. Development in 3rd world nations was unchecked and often at the expense of environmental resources. Companies, unable to dispose of environmentally hazardous waste in 1st world nations, looked to pawn it off on 3rd world nations. Economic development was at the forefront of 3rd world nation’s development policies as deforestation, overfishing, herbicide and pesticide application raged rampant with little thought paid to environmental ramifications. An example of this was the 1972 United Nations Conference on Human Environment which was held in Stockholm, Sweden. At this conference the goal was to tackle the problem of acid rain problems of northern Europe. The nations pushing for a solution that addressed the industrial development roots of the problem were strongly opposed by the Soviet-led Block of 77 which accused the nations of pushing an eco-agenda and refused to cooperate (WSSD, 2000). However a positive outcome from this conference was birth of the United Nations Environment Programme (UNEP). Through the 1970s and 1980s the UN began to fund more initiatives focused on conservation and human environment issues (IISD, 2002). Public initiatives began to spawn environmental non-government organizations (ENGOs) such as the Environmental Defence Fund in 1967, International Institute for Environment and Development in 1971 and the Worldwatch Institute in 1984. These major environmental policy groups are still active and important today. Major environmental disasters such as Bhopal, India and Africa’s starvation in the 1980s brought further attention to human and environmental development (IISD, 2002). In 1992 the World Summit on Sustainable Development was held in Rio, Brazil. This marked a major effort by the world’s nations to tackle human development in the context of environmental issues and try to develop a model of development that was sustainable. Sustainability can only come about without the degradation of natural capital that provides the necessary requirements for human life. It has been determined that a healthy population is dependent on a healthy environment. Links are often drawn between human health and environmental health outside the realm of needs production as poisons in the environment negatively affect human health as evidenced by historical use of pesticides and their effects. Further conferences on sustainable development in 1997 (Rio+5) and most recently Rio +10 in Johannesburg 2002 has further developed the notion of sustainable development. Due to public pressure corporate social responsibility has become a focus for corporations based in the developed world and this is further evidenced by the emergence of ethical investment funds which critically screen the companies they invest in. Dam construction was a popular activity in the first half of the 20th century and experienced a peak in building activity in the 1970s (WCD, 2000). It is not that the usefulness of the dam in providing energy, irrigation and flood control has passed; it is that there are fewer rivers that are left to be damned and social and environmental awareness of issues surrounding dam construction has increased. However dam construction continues as it is an important source of energy and nations are forced to meet the energy requirements of their citizens. More than 20% of the world’s energy supply comes from dams and more than 60 countries depend on hydroelectricity for greater than 50% of their total energy needs (WCD, 2000). The World Bank still funds dam construction but less than in the past with 1.3% of the bank’s funds going toward dam-related projects and 0.9% being spent on the construction of new dams (The World Bank, 2000). In 2000 the World Commission on Dams (WCD), a United Nations research body, released a landmark report entitled Dams and Development – A New Framework for Decision-Making. This research was undertaken in response to the new realizations on the effects of dams and the role they could play in sustainable development. The report noted that nearly 1/5th of the world’s energy was generated through hydroelectricity and that 1/6th of the global agriculture was dependent on irrigation from dammed rivers. It has been estimated that global levels of hydroelectric generation, which is largely carbon-neutral, precludes the need of an extra 4.4 million barrels of oil a day (WCD, 2000). If all dams were decommissioned and destroyed the damage to humankind would have enormous and alternatives would have to quickly be found to provide the benefits that we glean from dams. There are several high profile dams being constructed globally today. The larger projects like the Three Gorges Dam project in China and the Narmada Dam project in India. These dams are large and multi-purpose aiming to help these nations meet development needs of energy and irrigation. Though dams have been integral to social and economic development there are costs as well. Large dam projects typically involve the displacement of people living near the river upstream of the dam. The WCD (2000) estimated that between 40 and 80 million people have been displaced by dam building often with little or no compensation. Water and Conflict Fresh water is a requirement for life as we know it. Humans are made up of more than 70% water and can live only days without a source of drinkable water. Clean water is needed for drinking as well as for farming, industry, sanitation and household uses. Unfortunately fresh water is scarce on Earth and its distribution uneven. With the majority of fresh water resources concentrated in a few nations the need for shared management of water resources is obvious. Turkey is a water poor nation as are its neighbours Syria and Iraq (WCD, 2000; Stern, 2004). The Tigris and Euphrates are two of the main sources of water for these two nations and they have their sources in Turkey. In a river system such as this the actions of the users upstream have an impact on those downstream. Since rivers do not follow nationally contrived boundaries this can cause conflicts between nation-states as one nation, acting within its own borders, can have significant impact on other nations. It was just this sort of trans-boundary environmental issues that incensed the UN to act and create bodies to help manage and resolve such issues. Acid rain, smog, ozone and pollution are all similar in that though no national borders are trespassed, damage it still felt by other nations. New solutions and methods are needed, and are being develo ped by ENGOS, industry and government, to tackle problems such as these The Ilisu dam project was approved in 1982 and because of the date of approval the project is not automatically subject to the Regulation on Environmental Impact Assessment which is current Turkish environmental policy (Ilisu Engineering Group, 2001). However due to the scope of the project and the international attention it attracted an Environmental Impact Assessment Report produced by a consortium of international experts under the moniker of the Ilisu Engineering Group was commissioned by the Turkish authorities and firms involved in construction of the dam. The Ilisu Dam will consist of a reservoir with a surface area of 313 km and a volume of 10.4 billion cubic meters. The power station will have a capacity of 1,200 MW and is expected to be capable of producing 3,800 GWh of power per year (Ilisu Engineering Group. 2001; Stern, 2004). The dam will transform the local environment, inundating land that is typically arid, causing a shift in the ecology of the area. Resettlement of the Kurdish people in the Anatolian regions is the main source of resistance to the construction of the dam. It was determined that approximately 183 settlements will be affected, 82 would be inundated entirely and 101 would be affected by flooding (Stern, 2004; Morvaridi, 2002). Exact numbers of people are unavailable because conflicts in the region have driven people out of their villages and have encumbered census takers from obtaining accurate estimates of population. The estimates range from 30,000 to 70,000 people, mostly Kurds, losing homes or land or both. Under Turkish law these people would be allotted cash compensation or an offer of resettlement under Turkish law (Morvaridi, 2002). This compensation plan becomes much more complicated when it is realized that many of the people living in the region do not hold deeds to their land and many have expanded their land without government planning permission (Morvaridi, 2002). Determining who would be eligible for compensation would be a long and painful bureaucratic process that would undoubtedly leave many people unsatisfied. Some have claimed that this project is part of a Turkish plot to expatriate the Kurdish people from their native lands. Human rights NGOs mobilized on behalf of these groups and were able to influence the international financiers into relenting on their backing. However the dam’s constructors and the Turkish government point to the social and economic benefits to the people of Turkey and the direct benefits to the people of the Anatolian provinces. The construction of the dam will bring jobs, training and an influx of money to a previously impoverished region. The availability of ample fresh water for irrigation, possibility of a fishery and tourism opportunities also bear consideration. The possibility exists for real economic and social benefit to the region if the project is handled properly with attention paid to women’s rights and economic opportunities, education and investment in long term planning (Ilisu Engineering Group. 2001). Cultural Issues A second major objection to the dam is archaeological potential of the area. The proposed site has seen much history pass through the area. Mesopotamia was centered here, the Romans conquered the area and the Silk Road wove through what is now South Eastern Turkey. Access to the area was previously restricted due violent conflicts between the Turks and the Kurds but in the lull archaeologists have began excavating the area. One site in particular is Hasankeyf which has visible archaeological evidence dating to 2000 years ago and the ruins may evidence a settlement dating back to 7th century B.C.E (Young, 2000). The excavation of Hasankeyf began in 1986, was stopped in 1991 due to civil strife, and excavation resumed only recently with a laughable grant from the Turkish government of  £15,000 from the Ministry of Culture. The government is spending only  £76,000 in exploring the area agriculturally before the dam is built, a meagre effort at best. Even the Ilisu Engineering Group revealed that some of the worst damage of the dam would be in the loss of untold archaeological treasures (Ilisu Engineering Group. 2001). Political Issues The construction of the Ilisu dam would require the water flow to be suppressed in the construction of the dam. Even the slowing of the flow of the river has consequences for the downstream inhabitants in Syria and Iraq. The people of these countries rely on the river for sanitation, industry and personal use and as the rivers are already over taxed any further reduction will surely have negative consequences on the people of these regions. With the construction of the Ilisu dam reservoir there is the potential that Turkey can fully cut Iraq and Syria off from the flows of these vital rivers. In the coming years when the crisis over water deepens this could be an ill-advised political tactic for Turkey to dominate these nations. Due to the volatile nature of the region it is hoped that it does not come to this. However in 1997 the UN approved the Convention on the Non-Navigational Uses of Transboundary Waterways with a vote of 103: 3. The convention was aimed at preventing damage to international waterways with emphasis on peaceful resolution and prior notification between nations. China, Burundi and Turkey all rejected the treaty (Bosshard, 1998). Dam Alternatives The main focus of the dam is to meet Turkey’s energy needs. In the way of natural energy resources Turkey is scarce. To match the 1,200 MW output of the dam numerous coal, lignite or oil plants would need to be constructed which will have a negative impact on the environment of the region and the globe. In the Ilisu Engineering Group’s 2001 Environmental Impact Assessment the group concluded that it would be necessary to import and consume over 2,500 tons of oil per day, releasing 3 million tons of CO2 per year. A coal plant would do much the same. Photovoltaic technology is not advanced or cost-effective enough to possibly take the place of such a large MW project with the costs being three times per kilowatt what hydroelectricity would cost (Ilisu Engineering Group. 2001). Wind projects are under consideration in Turkey but it will take the construction of wind farms as well as the GAP to meet Turkey’s energy needs in the coming decade. The major avenue for reducing the need to build the dam is in increasing energy efficiency. The Ilisu Engineering Group’s report pointed to this avenue as a necessary one for exploration as Turkey’s energy needs continue to grow. Current Status and Future The Ilisu dam’s future is uncertain as major international funding fell apart over concerns of the dam’s social and ecological impact. In November 2001 the British construction firm Balfour Beatty backed out of the deal as the UK export credit agency pulled its support due to public pressure. Another construction company, Impregilo of Italy, also pulled shortly afterwards and the Swiss bank UBS did the same less than 6 months later (BBC, 2002) Through Turkish government still plans on carrying on the project the lack of financial backing makes it impossible to go forward. For the time being the project is on hold. Recommendations A baseline study of wildlife and ecology with the intention of creating reserves nearby for displaced species. Adequate funding and time for proper exploration of Hasankeyf and investigation of other potential sites. Negotiation with Syria and Iraq on the use of the river. Finding a solution that benefits these nations is vital to the dam’s construction. A plan for compensation of people displaced by the dam. Compensation will need to be based on more than proof of land ownership and a census of the area will be necessary to determine the scope of the compensation plan. Negotiation with the Kurdish people of the region, guaranteeing them a greater say in the compensation funds from the dam and in the monetary benefits to be gained from its construction. Moves to further improve the existing energy infrastructure to ensure maximum benefits are garnered from the dam. Development of industry and agriculture in the area to aid in the development of the region. The Ilisu dam is a highly controversial project is a necessary part of Turkish development, providing energy for tens of thousands of people. Dams, though notorious for displacement of people and conversion of landscapes, are a multi-purpose high energy yielding alternative to fossil or nuclear power generation. In terms of sustainable development they are a much better option than fossil fuel and provide the best energy option until wind and photovoltaic energy technology improves. The dam is controversial and for good reason. The Turkish government must take into account the many parties that will be affected by the dam and work to mitigate their concerns. However without this dam Turkey will be hard pressed to meet energy needs and be able to develop for the social and economic benefits of their people. The Ilisu dam may not be an ideal solution to Turkey’s energy needs but it seems to be the best currently available. Bibliography BBC. 2002. Swiss bank quits Turkish dam project. Available from http://news.bbc.co.uk/1/hi/world/europe/1844465.stm>. Last accessed April 25th, 2005. Bosshard, P. 1998. Ilisu a Test Case of International Policy Coherence. Berne Declaration, November 1998. Available from http://www.rivernet.org/turquie/ilisu.htm>. Last accessed April 25th, 2005.  © Copyright of European Rivers Network Bruntland, G. (ed.), 1987. Our common future: The World Commission on Environment and Development, Oxford, Oxford University Press. Carson, R. 1962. Silent Spring. Houghton Mifflin, Boston. Ilisu Engineering Group. 2001. Ilisu Dam and HEPP Environmental Impact Assessment Report. IISD. 2002. Sustainable Development Timeline. Available from http://www.iisd.org/rio+5/timeline/sdtimeline.htm>. Last accessed April 25th, 2005. Kaygusuz, K. 1999. Energy and water potential of the Southeastern Anatolia Project (GAP). Energy Sources ; Vol. 21 ; Iss: 10 ; PBD: Dec 1999. Morvaridi, B. 2002. Social Review of the Ilisu Dam Resettlement Action Plan. UK Export Credit Guarantee Department. Northwest Texas International Trade Center. 2004. Gap Irrigation Project In Turkey.  © Northwest Texas International Trade Center 2000-2004. Available from http://www.nwtitc.org/gapturkey.htm>. Last accessed April 24th, 2005. Last Updated 02/06/2004. Stern, S. 2004. International Project Finance: The Ilisu Dam Project in 2004 and the Development of Common Guidelines and Standards for Export Credit Agencies. Journal of Structured and Project Finance. New York: Spring 2004.Vol. 10, Iss. 1; p. 46. The World Bank. 2000. Statistics on the World Banks Dam Portfolio. Available from http://www.worldbank.org/html/extdr/pb/dams/factsheet.htm>. Last accessed April 25th, 2005. United States Department of Agriculture Foreign Agricultural Service. 2005. Southeast Anatolia Project (GAP). Available from http://www.fas.usda.gov/remote/mideast_pecad/turkey/turkey.htm>. Last accessed April 24th, 2005. WSSD. 2000. Towards Sustainable Development: A Guide To The Process Towards The U.N. World Summit For Sustainable Development. Johannesburg, 2002 WCD. 2000. Dams and Development – A New Framework for Decision-Making. Young, P. 2000. Hasankeyf: A city in Peril. History Today; Nov 2000; Vol. 50 Iss 1. pg. 3.

The Theme of Blindness in King Lear Essay examples -- English Literatu

The Theme of Blindness in King Lear In the tragedy King Lear, the term blindness has an entirely different meaning. It is not a physical flaw, but the inability of the characters to see a person for whom they truly are. They can only read what is presented to them on the surface. King Lear, Gloucester and Albany are three prime examples characters who suffered most by having this flaw. Lear was by far the blindest of the three. Because Lear was the King, one would expect him to have superb reasoning skills, but his lack of insight kept him from making wise choices. This is the flaw that led to his downfall. Lear's first big mistake was letting himself be fooled by Regan and Goneril, and giving them his throne. For they did not love him at all, he could not understand the depth of Cordelia's love for him. He banished her from the kingdom without one thought to what she had said. Lear's last words to the only daughter that truly loved him were; ".....for we/ have no such daughter, nor shall we ever see/ that face of hers again. Therefore be gone/ without our grace, our love, our benison." (Shakespeare 1, 1. 262-265) Lear's blindness also caused him to banish Kent, one of his most loyal followers. Kent tried to stand up to Lear in Cordelia's honor, but Lear would not listen to what Kent was trying to tell him. To Kent's opposition; "This hideous rashness, answer my life, my judgement,/ Thy youngest daughter does not love thee least;" ( 1,1. 150-151) Lear responded with, "Kent on thy life, no more." ( 1, 1, 154) "Out of my sight!" ( 1, 1. 157) This is a good example of Lear's lack of insight. He was being too stubborn to see that Kent was only trying to do what was best for Lear. After Kent had been banished, he ... ...for Goneril blinded him from the evilness that she possessed. He was blind from the fact that Goneril was having an affair with Edmund, and planning to have her husband killed. Fortunately Edgar, devised a plan to cure Albany's blindness. A letter outlining Goneril's plan, was all that Albany needed to see. After reading the letter Albany came to his senses and confronted Goneril; " O Goneril,/ You are not worth the dust which the rude wind/ Blows in your face!" ( 4, 2. 29-31) Unlike Lear and Gloucester, Albany did not suffer from his bout of blindness, he lived to become the leader of which was once Lear's kingdom. In King Lear, blindness is a theme portrayed by the main characters of these plots. Throughout the play Shakespeare is saying that the world cannot be seen with eyes only. It is a combination of mind, emotion and heart. True sight comes from within.

The History of Kingston Penitentiary :: Canada

The History of Kingston Penitentiary Kingston Penitentiary is located on the shore of Lake Ontario in Ontario, Canada. It has served as the main symbol of punishment in Canadian society. Penitentiary Houses were first created in Great Britain in 1779. It was on June 1, 1835 that Kingston Penitentiary formerly known as the Provincial Penitentiary admitted its first six inmates. It represented a new world of confinement that removed the convict from his community and regimented his life. It introduced society to a new notion of punishment and reform. (Curtis et al, 1985) People expect a penitentiary to hold inmates, especially dangerous ones, for as long as the court determines they should serve. Kingston Penitentiary has been doing that for many years. But it has also dedicated to the reform of inmates. What that means has changed dramatically over time. (Curtis et al, 1985) The first inmate to enter Kingston Penitentiary was Mathew Tavender who was sentenced to serve three years for grand larceny. He was placed in cell number four and was put two work as a stonecutter two days later. He was whipped on August 30, 1835 which was three months after his arrival, along with inmate number two, John Hamilton. John Hamilton was sentenced to three years for felony. He was made a stonecutter on his third day and then a mason. Both he and Mathew Tavender were whipped together which may imply they tried to make contact with each other, this was strictly forbidden. Inmate number three was Edward Middlehurst who was sentenced to five years for grand larceny but was actually released. He was the first carpenter at the penitentiary but after a year got sick and was moved to another cell. He is not on record on the roster after he was sick for three months, so whatever he had must have been contagious. He may have received a pardon which was a common way to deal with sick convicts. It was felt that it was better for diseased people to stay outside of the prison walls so the sickness would not spread to the others. The penitentiary was not equipped to deal with death because it had no cemetery but still had to pay for a gravedigger if someone died on the inside. John O'Rourke, inmate number four was sentenced to five years for grand larceny. He received his first rawhide beating two short weeks after his arrival.

Affirmative Action Essay -- essays papers

Affirmative Action Affirmation Action In Today Society: Myths and Facts As America nears the end of the twentieth century, we still face many lingering problems that stand unresolved. One of the most pressing and difficult problems is that of human relations, or to many, the trigger word race relations. For over 225 years America has been trying to fulfill the promise of the founders of this nation that â€Å"All Men Are Created Equal†, yet we still see institutionalized injustices and discrimination. Therefore, this paper attempts to look at one controversial issue that was implemented to correct previous human relation injustices of our nations. This issue is Affirmative Action. To examine affirmation action, this paper looks at the origin of affirmative action programs, U.S. Supreme Court affirmative action debate, employment and affirmative action, and finally myths and facts about affirmative action. I hope that through this paper these issues can be presented to gain a better understanding of affirmative action in today’s society. Affirmative action is a policy assigned to increase representation of women and minorities in business, educational institutions and government. It origin lies in the legislation that came out of the civil right movement of the 1960’s. The Civil Right Act of 1964 was passed, which forbids discrimination unions, employment agencies, and business employing more than 25 employees. However, the tasks for enforcement of this law had been immense and extremely difficult. In an endeavor to redress the systematic discriminations of the past, especially against blacks, remedial programs often called "affirmative action" were undertaken by educational institutions, unions, and governments. These programs required a percentage of minorities – group (racial minority and women) representation goal and a timetable for accomplishment of that goal. The basic premise was to level to playing ground for minorities. Almost, immediately from its inception affirmative action program has been controversy. The process of minority goals and percentages created a powerful† â€Å"white backlash†. Critics charge that the ratios are not goals but quotas and that affirmative action programs really call for reverse discrimination (discrimination against white males). Resolution of this conflict is difficult. While it is true that some minority group ... ... doors by themselves. In a perfect world program such, as Affirmative Actions would not be needed. Personnel decisions would be basis upon each individual’s abilities and qualifications, without regards to gender or ethnic group. However, we are far from a perfect world. As long as we have prejudices, hatred, and discrimination in society, programs of Affirmative Action will be necessary. Bibliography: Coleman, James William, and Cressey, Donald R. Social Problem. 5th ed. Harper Collins College Publishers. New York. 1993. 188-190 Levenson, Alec R., and Williams, Darrell L. Interracial America: Opposing View, â€Å" Affirmative Action Combat Unintentional Racism†, Greenhaven Press Inc., San Diego, 1996, 154-158 Bender, David and Leone, Bruno. Work: Opposing Viewpoints, â€Å"Affirmative Action Promotes Equality†, Greenhaven Press Inc., San Diego, 168-176 Collier’s Encyclopedia. CD-ROM. Sierra Home, 1998 Reflective in Race Relation, Online, www. Elibrary.com, 18 Feb. 1999 Coleman, Jonathan. Long Way To Go: Black & White In America, Atlantic Monthly Press, New York, 1997 Carter, Stephen L., Reflections of an Affirmative Action Baby, Basic Books, New York,

After Hope And Change

Despite winning reelection, President Obama had joined a group of three to her previous incumbents (Eisenhower, Wilson, and Clinton) who had all entered office origin anally with a united government in their very first term and then won reelection with a did vided government. Obama had lost his seats on the House of Representatives. Will on was the only other president in history to lose more seats than President Obama. The novel speaks on how five incumbent presidents since 1 896 had lost reel action and then begins to explain why those same factors didn't apply to President Obama.Us memorize the four arguments the authors make. There are multiple reasons Barrack Beam's 201 2 presidential reelection was slight victory although he won reelection, it was fairly close in the polls. The opponent NT Mitt Rooney didn't have a proficient performance when he had to present his plan NSA on if he was to be elected, not only did this show some of his flaws as a speaker but al so as a candidate . Rooney had way too many weak points that Obama was able to TA eke advantage of to convince the American people he was still their best option. R money pushed his few advantages way too far.He stayed on one topic the entire Tim e and would mindlessly talk about that same subject, which was a flaw on his part especial Y close to the elections. If Mitt Rooney had given better speeches and realized some of his mistakes before elections, the outcome may have been different in 2012. Summarize the arguments that the authors made concerning the results from the 2012 elections and what they may tell us about the 2016 elections. The first point made by the authors uses statistics to predict that the president till election in 2016 will be a battle for the most swing states.In 2012, Barrack Obama had gained the states that he won in his previous election. These states had also been the as me couple dates that the last three democratic presidential candidates had also won as well. Rooney had also won the states that previous republican candidates had won as well. There were only n,vow states that had changed between the 2008 and 2012 elections. Became use of how the republicans have lost the last two presidential elections (Including the 201 2 elections), they have some serious work to do and they must pull off swinging multiple s dates in the 201 6 elections (something that hasn't happened in half a century).The second point of the chapter speaks on the changes in demography. In bet when the ears of 2008 and 201 2 percentages of the ethnic groups that vote democrat increased very high. These voter increases were very noticeable with an increase in youth h support, especially for democrats. Without any explanation the numbers of ethnic race s that vote republican dropped. The very republican votes that dropped during the elect On W ere surprisingly white males. This made an impression that the youth were in co melt support of Obama. This is important because in the futu re it would seem that they will go on to support the democrats.At the same time it is very possible that the turn UT was quite low in the 201 2 race turnout for many favorable republican categories w as quite lower than expected. Minorities refused to vote for Mitt Rooney simply because SE their identity with him was almost nonexistent if he would become the next preside .NET. This very fact coupled those not in support of Obama, this led to people not voting at all, which severely hurt the republican parry's chances of winning the race. Minor ties can always change their mind on who they will vote for or even if they should vote at all depending on the status of the economy at that time.That very fact may lead o the republicans doing better with appeal to the minorities in the 2016 elections, a ND they could sway them, especially if no democrat could like President Obama. The final point discusses the reasoning of both democrats and republicans. D emaciates have always been focused on social justice, and the use of more federal govern moment plans, and redistributions policies. Democratic policies will be in full support of those whose jobs are given to by the government and those who receive benefits FRR mom the government (welfare, healthcare, etc).Meanwhile, the republicans are focuses on lowering taxes from the government, dividend liberty in the economic arena, a achieving a small federal government. The Democrats Will have those who chi goose to receive benefits from the government policies gravitate to their side, while re publicans will always focus on bringing rich businessmen who support themselves to the Eire side. Many republicans have joined the party because they are tired of an overpower erring federal government and paying high taxes.Chapter 2 Questions What were the issues and characteristics of politics arising from President b mama's first term hat figured in the 201 2 election. Give brief summaries Of what was involved I n these issues and the positions that Democrats and Republicans held in order to demonstrate t hat you have a general understanding of these issues. The unemployment rate during the recent recession was very shaky going up and down during the years of 2010, 2011 , 2012. There was a brief boom of jobs created during this period, this would end up disintegrating within a short period of time.Demo rats had originally said that during the time of President Beam's first term that he ha d actually ordered the high unemployment rate in America. Republicans were found to have said that because of how slowly the improvement of the economy has been, press dent Beam's policies in office slowed down the natural progress of improving the economy. This made their case for the recession being one of the longest ever. The flourishing of the nationwide deficit and debt rolled over onto President Beam's first term in 2008. In the â€Å"Obama era†, the national debt never fell below the amount off trillion dolla rs.The average in the first term was 1. 33 trillion dollars. This peer entangle was appalling because no one could have possibly predicted such a number a coo plea yea RSI before Beam's election. The overall federal spending amount of the GAP ha d increased nearly 5% from 2007 to 2012. Republicans went on to say that Barrack Obama presidency was the true cause of all of the spending. To counter that statement NT, Democrats had responded saying that an increase in the deficit was just as UN avoidable as the last President who happened to be a republican (George W.Bush) who ha d originally put America in this very predicament. Political popularization had become a big problem during Beam's first term. In such a divided government, reaching an agreement between both democrats and re publicans was extremely difficult. What did the 2010 midterms reveal about politics nationally? It was revealed that the American people were heavily in support of Republican NSA Simply because President Be am's first term had not been the best in the â€Å"popularity y contest†. It exposed many of the ideologies of the American people with the unveiling of a now completely divided government.How did President Obama improve his political position leading into the election? President Obama began to improve his political position by lowering the socio I security tax by two percent of the original price in December of 201 1. This was to been fit lower income workers whose payroll tax was more than their income tax. Such a pop were play in office proved that Obama was in support Of the lower and middle classes and that unlike republicans the upper class wasn't a priority. The Occupy Wall Street Movement that began in mid September 2011 also boo Existed President Obama.The movement/ strike blamed the top â€Å"one percent' of the country (Rich) for all the problems with the current economy. The movement also bell paved that he 1% has benefited while the rest of the country is in suf fering. Obama had decided that he was indeed support of those who weren't wealthy which politically is a strong decision because it accounts for 99% of the nation President Obama benefited from the reports of his speech after the beginning Eng of The Occupy Movement stating that the unemployment rate had actually fallen fro m 9% to 8. % within the time period of early December 2011 to late March 2012. Chapter 3 Questions What reasons do the authors give as to why it was unlikely that Mitt Rooney would win the nomination? It was very unlikely that Mitt Rooney would end up winning the nomination f president because he was seen as â€Å"an uncomfortable fit† because he only fit n one of the three factions of the GOP.He appealed to many of the old school republicans with his strong corporate background in big business, but was considered to be very weak with the other two factions of the GOP (social and Christian conservatives care about t he laws of abortion, same sex marriage, and other concerns). The book describes two structural changes that had an impact on the amino Zion process: Republicans limiting winner aka all primaries until after April 1 and the changes in the laws regulating campaign finance. Summarize both changes and the effect they ha d on the nomination campaigns.

Benchmarks And Goal Setting Education Essay

Adult scholars bring a particular set of fortunes to the tabular array when they decided to go on their instruction. Their ends tend to be really different from those of younger scholars. They tend to convey a batch of life experiences with them that affect the manner they view larning. The benchmarks that they set should be really come-at-able and mensurable so that the scholar can experience as if they are doing the advancement that they want to. Adult scholars are really goal-oriented. They want to see that they are doing advancement and have a great desire to accomplish success. Many grownup scholars feel at hazard in an educational so in order to accomplish a successful and synergistic session, facilitators must demo their regard and support for grownup scholars. Puting single ends and mensurating accomplishment is an indispensable accomplishment for many scholars today. Depending on the person, ends may be set deliberately or subconsciously. If this procedure is applied to the acquisition environment pupils should be provided with the tools of goal- scene and accomplishment monitoring. A figure of research workers have suggested that goal-setting patterns can be utile, can impact academic accomplishment and can forestall pupil abrasion. In add-on, it was suggested that supplying non merely goal-setting patterns but besides uniting these patterns with progress feedback can hold an even greater consequence on academic accomplishment than carry oning goal-setting activities entirely without benefit of teacher feedback. It has been shown that the undermentioned three chief factors, setting-goals, self-assessment of public presentation against the ends, and having teacher feedback have been most helpful for scholars in accomplishing success ( Kat o, 2009 ) . Andragogy is perchance the first acquisition theory specifically for grownups. It follows the premise that grownups learn otherwise than kids because they have had more life experiences and are autonomous. It besides holds that information must be used shortly after its presentation for grownups to accept and absorb the acquisition. Additionally, Knowles identifies several countries that define the manner grownups learn. Adult scholars have great trade of experience to add to the acquisition environment. Educators can frequently utilize this as a resource. Adults expect to hold a high grade of influence on educational subjects and how they are to be educated. Adults need active engagement in planing and implementing their educational plans. Adults must recognize the relevance of any new acquisition. Adult scholars look frontward to to holding a high grade of influence on how their acquisition will be evaluated. Adults expect their feedback on the plan ‘s advancement to be acted upon in a timely manner ( Kelly, 2006 ) . Adult scholars are really goal-oriented. They want to see that they are doing advancement and have a great desire to accomplish. Many grownup scholars feel at hazard in an educational scene. Self-esteem and self-importance can be compromised in an environment that is non perceived as safe and supportive. In order to accomplish a successful and synergistic session, facilitators must demo their regard and support for grownup scholars ( Kelly, 2006 ) . Autonomous acquisition ( SDL ) accomplishments are the frequently the foundation of womb-to-tomb acquisition. Teaching intends to accomplish at least two indispensable ends for all pupils: to increase cognition with regard to peculiar content and to develop accomplishments that will function pupils good, even beyond the environment of a specific class. It has been found that from a schoolroom experiment that was designed to measure pupil public presentation with regard to the 2nd end of skill acquisition, specifically the accomplishment of autonomous acquisition ( SDL ) was most of import ( Dynan, Cate and Rhee, 2008 ) . A successful goal-setting procedure that focuses on direction and acquisition is cardinal to good educational pattern. Puting ends allows grownup instruction pupils to stipulate what they want to carry through and provides a benchmark for both single and plan public presentation. Goal scene is an synergistic procedure that involves scholars in, placing and entering their ends, finding whether the ends are come-at-able and mensurable, making a timeline for accomplishing them based on an appropriate instructional program and relevant acquisition activities and set uping a agency for periodic reappraisal and alteration of their ends ( NRS Tips: Learner Goals and NRS Goalsaa‚ ¬ † Making the Connection, n.d. ) . The best ends that can be set normally have five basic features: Precise ends let pupils cognize what they are endeavoring for and give them a clear mark at which to take. Measurable ends allow pupils to cognize when they have achieved their ends. Accomplishable ends are those within a studentaa‚ ¬a„?s range. Reasonable ends achieve a balance between forcing pupils to their bounds and non thwarting them. Time-limited ends create due day of the months that push pupils to finish a end. A timeline should include periodic cheques on advancement ( NRS Tips: Learner Goals and NRS Goalsaa‚ ¬ † Making the Connection, n.d. ) . Establishing grownup scholar ends defines the countries in which direction and acquisition will be focused in add-on to supplying a benchmark by which plans and pupils study advancement. To function this double intent, it is indispensable to distinguish between short and long-run mileposts. It is necessary to update the studentaa‚ ¬a„?s end choice if their state of affairs alterations. It may be suited to curtail the pick of certain ends when their choice is inappropriate. Programs must supply counsel so that grownup scholars select describing ends that are sensible. Plans are encouraged to utilize common sense when assisting pupils choose ends ( Requirements for Student Intake and Description of OAE Adult Learner Assessment Policies and Procedures, 2008 ) . Physical and cognitive alterations that take topographic point as people age are of import to observe because they can hold an affect on grownup acquisition and on the ends that they set: Older pupils have slower reaction times than younger scholars. They need more clip to larn new things as they age, nevertheless, when grownups can command the gait of acquisition, they can frequently efficaciously counterbalance for their deficiency of velocity and larn new things successfully. Vision normally declines from the age of 18 to 40. After 40 there is a crisp diminution for the following 15 old ages, but after age 55 the diminution in vision occurs at a slower rate. Approximately at age 70 a individuals hearing Begins to worsen aggressively and a individual begins sing jobs with pitch, volume, and rate of response. Loss of hearing can be compensated for through the usage of hearing AIDSs, but frequently older pupils may be embarrassed by their hearing loss and experience less confident. This diminution in assurance can go a greater hinderance to larning than the physical disablement. Few changes have been found in both centripetal and short-run memory as a individual ages, but long term memory diminutions. Older grownups have a harder clip geting and recovering information and they experience troubles in forming new stuff and in treating it. Older grownups are non every bit able as younger scholars in trials of callback, but the differences between older and younger scholars in trials of acknowledgment are little or absent. When contextual acquisition methods are used, fewer diminutions have been found in the memory procedure as a individual ages. The most jobs with memory for older scholars occur with meaningless acquisition, complex acquisition, and the acquisition of new things that require reappraisal of old acquisition ( Adult Learning, n.d. ) .DecisionAdult scholars bring a particular set of fortunes to the tabular array when they decided to go on their instruction. Their ends are really different from those of younger scholars because of the fact that they have so much life experience to trust upon. The benchmarks that they set need to be non merely come-at-able but besides need to be really mensurable so that the scholar can experience as if they are doing the advancement that they want to.