Farewell To Arms 2 Essays - Literature, English-language Films

Farewell To Arms 2 A Farewell to Arms (2) World War II propels the characters in A Farewell to Arms. Fredrick Henry's actions are determined by his position until he deserts the army. It is during his escape Henry resolves that he is through with the war, a war in which he really has no place, and decides that all he wants is to be with Catherine. Henry doesn't seem to be agonizingly concerned with matters of right or wrong in the war and it seems, in fact, separate from him. Even when he is injured it doesn't appear that he is really a part of the war, which surrounds him. He maintains a distance from it and this distance isn't really closed until Aymo is killed by his own army, he discovers that Bonello is only staying with him out of respect, and he is almost killed as a spy. After this he resolves to desert the army and be reunited with his love, Catherine. Fredrick and Catherine are playing the ?game? of love, both for different reasons, but eventually move to play it as a team. Henry is role-playing to regain the sense of order he has lost when he realizes the futility of the war and his lack of place in it. Catharine is role-playing to deal with the loss of her fianc? and to try to find order in the arena of the war. When they are able to role-play together, ? the promise of mutual support? is what becomes so important to them as they try to cope with their individual human vulnerability. Floating down the river with barely a hold on a piece of wood his life, he abandons everything except Catherine and lets the river take him to a new life that becomes increasingly difficult to understand. The escape to Switzerland seemed too perfect for a book that set a tone of ugliness in the world that was only dotted with pure love like Henry's and Cat's and I knew the story couldn't end with bliss in the slopes of Montreux. In a world where the abstracts of glory, honor, and sacrifice meant little to Fredric, his physical association with Catherine was the only thing he had and it was taken away from him long before she died. The love that Fredric and Catherine had for each other was more than could be explained in words and Fredric makes it known that words are not really effective at describing the flesh blood details. Their love during an ugly war was not to be recreated or modeled even as much as through a baby conceived by their love. The baby could not be born alive because their love was beautiful yet doomed so that nothing could come out of it. History

Questions and Answers on International Capital Budgeting Essays

Questions and Answers on International Capital Budgeting Essays Questions and Answers on International Capital Budgeting Paper Questions and Answers on International Capital Budgeting Paper 1. Why should the required rate of return for a capital budgeting problem be project specific? Doesn’t the firm just have to satisfy an overall cost-of-capital requirement? Answer: The required rate of return for a capital budgeting problem is project specific because the firm is viewed as a portfolio of projects owned by the shareholders. It is the shareholder’s perspective that matters, and it is their opportunity cost that gives the required rate of return for a project. The question that the managers should ask is the following: If the shareholders were to receive the cash flows from the project directly, what risk would they associate with the cash flows? Notice that this immediately suggests that the required rate of return should be project specific and that it should reflect the market risk that continues to be present when an investor holds a large, well-diversified portfolio. 2. What is the conceptual foundation of the flow-to-equity approach to capital budgeting? Answer: In the flow-to-equity approach to capital budgeting, the after-tax cash flows that are available to be paid to equity holders are discounted at the levered equity required rate of return. Hence, the interest costs of debt are subtracted from the earnings of the firm in considering the amount of tax the firm will owe, and the interest payments that the firm must make are taken out of the residual free cash flow. The discount rate for these levered equity flows therefore must reflect the fact that equity is a residual claimant on the cash flows of the firm. 3. What is the weighted average cost of capital? Answer: The weighted average cost of capital (WACC) approach to capital budgeting involves forecasting the all-equity free cash flows of the firm and then finding the value of the levered firm by discounting the all-equity free cash flows at an appropriate WACC. It is a one-step procedure for finding the value of the operating assets plus the value of the interest tax shields. The weighted average cost of capital is the weighted sum of the after-tax required rate of return on the firm’s debt and the required rate of return on the firm’s levered equity. The weight for the after-tax rate of return on the firm’s debt is the ratio of the market value of the debt to the market value of total assets. The weight for the rate of return on the firm’s levered equity is the ratio of the market value of the equity to the market value of total assets. Once the total value of the firm is found, the market value of equity is found by subtracting the market value of the d ebt from the value of the levered firm. 4. Should a firm ever accept a project that has a negative NPV when discounted at the weighted average cost of capital? Answer: One reason we like the adjusted net present value approach to valuation is that it specifies all of the possible sources of value for a project. The WACC approach works well for projects that will support a certain percentage of leverage and that have no other associated features, such as interest subsidies or growth options that might add value to the project. If the only cash flows from the project are the ones that are being discounted and there are no other sources of value, other than the interest tax shields that are included in the WACC analysis, then the WACC approach finds the market value of the levered project. If this is negative, the project should be rejected. 5. Can you do capital budgeting for a foreign project using a domestic currency discount rate? Explain your answer. Answer: The answer to the question is yes; you certainly can do capital budgeting for a foreign project using a domestic currency discount rate. You just have to be careful to match the cash flows with the discount rate. One fundamental principle of capital budgeting is that the discount rate should reflect the currency of denomination of the expected cash flows that are being discounted. If a foreign project is providing expected future foreign currency cash flows, these can be discounted to the present using a foreign currency discount rate that reflects the riskiness of the project. The domestic currency present value of this foreign currency present value can then be determined by converting from the present value of foreign currency into the present value of domestic currency using the spot exchange rate. Alternatively, one can generate expected future domestic currency cash flows in future years by converting expected future foreign currency cash flows into expected future dome stic currency cash flows using expected future spot exchange rates. These expected future domestic currency cash flows should then be discounted to the present using an appropriate domestic currency discount rate. 6. Why might it be important to use period-specific discount rates when doing capital budgeting? Answer: We know that risk free spot interest rates are the appropriate discount rates for cash flows from risk free pure discount bonds. If the term structure of spot interest rates is not flat, that is, if it is upward sloping or downward sloping, using the same discount factor for all the cash flows of a risky project will not be correct. If the term structure is upward sloping, and you use the single long-term rate as the base for your risk adjusted discount rate, you will needlessly penalize the earlier cash flows from the project because short-term spot interest rates are lower than long-term spot interest rates. Conversely, if the term structure is downward sloping, and you use the single long-term rate as the base for your risk adjusted discount rate, you will be incorrectly enhancing the value of the earlier cash flows from the project because the short-term interest rates that should be used to discount near-term cash flows are higher than the long-term rates that should be used to discount longer-term cash flows. 7. Why is it necessary to consider forecasts of real currency appreciation and depreciation when doing an international capital budgeting analysis? Answer: The most important reason to consider forecasts of real currency appreciation or depreciation is that it is likely that a change in the real exchange rate will affect the cash flows of the project. Remember that a real depreciation of the domestic currency makes domestic exporters more profitable and domestic importers less profitable. Also, real appreciations typically reverse themselves somewhat slowly, so that knowledge of the current situation is necessary to know whether the future expected changes in the real exchange rate are going to enhance or detract from the cash flows of the project. Finally, if forecasts of nominal exchange rates are being made with uncovered interest rate parity, these will be somewhat different than forecasts based on relative purchasing power parity. If the market thinks that there will be a real appreciation or depreciation in the future, forecasts of nominal exchange rates based on relative purchasing power parity will not be correct. 8. What is the rate of return on invested capital? How is it calculated? Answer: The rate of return on invested capital is the free cash flow of the firm divided by the firm’s total assets. If the firm is earning its weighted average cost of capital, the rate of return on invested capital should equal its WACC. If we think of an investment that the firm is making, the rate of return on capital expenditure is the incremental free cash flow divided by the CAPX. Here again, it is important for the firm to do investments in which the rate of return on invested capital equals or exceeded the WACC – otherwise the firm is destroying value. 9. If you borrow a foreign currency, what interest deduction would you receive on your taxes? Answer: When you borrow in a foreign currency, you get an interest deduction for the domestic currency value of the foreign interest that you pay. 10. If you borrow a foreign currency, are there any capital gains taxes to worry about? Answer: If you borrow in a foreign currency, there are capital gains taxes to worry about. If the domestic currency has appreciated relative to the foreign currency between when the initial borrowing took place and when the principal is being repaid, it takes less of the domestic currency to repay the foreign currency principal than the amount of domestic currency that you had access to when you borrowed. Thus, you are repaying less than you borrowed and that capital gain is income to you and is taxed by the fiscal authorities. Conversely, if the domestic currency has depreciated relative to the foreign currency between when the initial borrowing took place and when the principal is being repaid, it takes more of the domestic currency to repay the foreign currency principal than the amount of domestic currency that you had access to when you borrowed. Thus, you are repaying more than you borrowed and that capital loss is deductible for tax purposes. 11. Why might a manager accept a high-variance, low-value project instead of a low-variance, high-value project? Answer: Shareholders only gain in good states of the world, and if the variance of the firm is higher, they gain more in those good states. Holders of debt get paid their full amount in good states of the world, and they get the value of the firm in the bad states of the world. By accepting a high variance project, managers may be able to shift some value from bondholders to shareholders. In such a situation the manager is said to have engaged in asset substitution. 12. Why would a manager not accept a positive net present value project? Answer: The value of the project accrues to the firm as a whole. Thus, if the firm has risky debt in its capital structure, some of the value of the project will accrue to the bondholders, and the remainder will accrue to the equity holders. The increase in the value of equity may be less than the equity holders must contribute to finance the investment in the project. Hence, a manager acting in the interests of the shareholders would forego such a project. This situation is referred to as an underinvestment problem.

Green Logistics and Corporate Initiatives Research Paper

Green Logistics and Corporate Initiatives - Research Paper Example The concept and awareness about the green logistics have evolved over time. Earlier it was a matter of public policy agendas which was forcefully implemented by environmental pressure groups that focused on the mitigation of damages caused by the transportation system. Later on it gained more importance as the businesses realized their responsibilities towards the environment and wider society perspective stressing upon the need of sustainable development for the future. Additionally the scope of green logistics has expanded over time, it not only includes the physical distribution of finished goods but it also deals with the entire transportation system including integrated logistics which includes storing, warehousing and handling systems etc. and the supply chain management which includes interaction with upstream suppliers and downstream customers. (Ann, Button, Hensher.340) The modern researches unlike the traditional ones take into account the environmental effects of all the a ctivities of the supply chain. The traditional system while only recognized the forward distribution and logistic system, a ‘reverse’ logistic system has also been introduced over time which led to a new dimension of sustainable and green logistics. This involves movement of waste, used materials including toxic and hazardous goods for recycling and disposing purposes. This whole concept has created new markets for recyclable products and its movement. (McKinnon, Alan C.243) Reverse logistics is a modern concept in logistics which is now regarded as part of green logistics. This involves processing, planning, and utilization of resources from the point of consumption to the point of origin, unlike the traditional logistics concepts which focus on movement from point to origin to consumption only. These will usually involve activities like transportation and collection, storage, reprocessing, recycling, reusing or disposal etc. This topic has been a center of attention f or many types of research and work has been done to determine the drivers and constraints in reverse logistics and how techniques like speculation and postponement can be used to develop a better reverse green logistics. As the volume of waste is growing the government regulations for its recycling, reusing or disposing of are tightening too. (Farahani et al.206)

Service Recovery Effects on Customer Satisfaction Essay

Service Recovery Effects on Customer Satisfaction - Essay Example Further, the research results showed that their was a correlation between service recovery and customer loyalty. 1. Introduction The concept of service recovery is both a business function and a critical focus point from the marketing perspective. The hotel industry is majorly based on offering intangible services and this makes service recovery an important business strategy. Essentially, service recovery entails the measures that an organization puts in place to respond to failures in service delivery. The hotel industry is prone to several variables that make it necessary to put in place service recovery strategies. Therefore, the effect of service recovery on customer satisfaction and loyalty becomes an important topic of research. To gain insight into this topic, the researcher used questionnaires to collect data which was used to analyze the impact of service delivery on customer loyalty and satisfaction in the hotel industry. 1.1 Research Aim This report aims to examine the im pacts of service recovery on customer satisfaction and loyalty in the hotel industry. ... 2. Literature Review 2.1 Service Recovery According to Keith (2008), service recovery is the well thought out process solving the issues of aggrieved customer and returning the customer to a state of satisfaction with the product or company. Service delivery can also be thought of as the set of actions a firm takes as a response to poor service quality (Andreasson, 2000). Therefore, service recovery can be considered as the response of a firm to its clients after a product or service failure with the intention of appeasing the aggrieved client and maintain their business value. The ultimate goal of service recovery is to ensure that clients maintain their business relationships with the firm that caused them the initial problem. In every organization, things occur that may have undesired effect on the customer. Hence, a company needs to have systems in place to implement corrective measures whe n things go wrong. The ultimate test of a company’s commitment to quality service is how it handles issues concerning instances of provision of below per services (Craig. 1999). He further argues that organizations need to put in place effective recovery strategies to win back a customers trust after instances problems in service delivery. Service recovery strategies are necessary to ensure that the service failures do not fit into a pattern of failure which might have devastating effects on the business enterprise (Berry 1995). Some studies indicate that excellent initial service is much better than relying on service recovery. However, other studies point out that service recovery has a greater impact on the customer than even the initial service.

Nosocomial Diseases Annotated Bibliography Example | Topics and Well Written Essays - 1000 words

Nosocomial Diseases - Annotated Bibliography Example Giving such a thorough overview is useful in tackling most of the basic knowledge needed to fully answer the thesis statement, as well as providing information on the specific prevention tactics that clinical staff can take. This peer-reviewed paper gives information provided by the Center for Disease Control (CDC) on nosocomial infections. This gives an official perspective on how to deal with the infections as well as their prevalence in medical environments. The definitions also cover the various diagnostic tests that need to be used to confirm the presence of a nosocomial infection as well as the infectious agent, which is important in ensuring the correct course of action is taken. This paper is not very useful in answering the question. The first problem is that it is over 25 years old, and epidemiology is a rapidly changing subject, and nosocomial infections are on the increase. It could have a purpose in arguing the thesis, if combined with more current epidemiological paper, because the thesis mentions the fact that hospital acquired infections are a rising trend. This source is only good in context. Again, this research paper is quite old, but does give an overview of the trends in the types of microbe that are involved in nosocomial infection. This paper gives a lot of scientific knowledge about the nature of the infectious agent and how they are likely to evolve and mutate to cause more problems in the hospital environment. It also warns against the over-use of antibiotics, something that we see today is causing a number of issues in producing antibiotic-resistant bacterial strains which are commonly seen in nosocomial infections such as MRSA. Although the information here should be taken with caution, it does provide some interesting perspectives. This is a clinical reference text and therefore can be used to provide

Analysis of E-grocery Systems

Analysis of E-grocery Systems Introduction:- The literature reviews the operational and strategic analysis of E-grocery systems. There are many business models in E-grocery business. To make E-business model a sustainable one they are using different strategies in different targeted markets. Each individual model varies from one other in various dimensions such as placing of order, assembling and delivering the goods. The first part of the literature provides statistical description of online grocery industry in various geographical and measures. The second part provides review of the E-grocery industrys market and its customer base. The final part offers previous studies opinions and factors about various outcomes of e-grocery business. Industry Over View:- Over last five decades grocery business has transformed into new sector of supermarkets in UK. Many of the supermarkets changed the grocery field dramatically. These champions of consumers brought vast choices in product and price to improve their business sector. Online grocery shopping and Home delivery system has became one of major aspects in grocery industries. The revolution of technology advancement in internet promoted grocery industries to embark on new methods in retailing industry. However, many grocers have been unsuccessful to consider the advantages of how it can support grocery business. These developments lead to dismissal of complete-online supermarkets such as webvan, homegrocer, shoplink and homeruns (Ramus and Nielsen, 2005). These results demonstrate the necessity of careful crafting of e-grocery strategies which exploits internet technologys potential of increasing company profit and also customer service (porter, 2001). On one hand, strategy conceptualisation is difficult for pure-play grocery stores since companies have not tried business models before. On the other hand, formulation of strategies for clicks and bricks grocery shops requires strategies which will combine both existing retail practice and internet based shopping processes ( Teo, 2002). Online shopping or e-grocery retailing service involves customers online buying behaviour and practices, order fulfilment and delivery of order, development and maintenance of online websites to facilitate customers to enter their orders (Hong and Kim, 2004). This literature provides insight of e-groceries and the strategic methods. Development Of Home Deliveries In The UK:- In United Kingdom, from centuries home delivery of goods has been taking place. During 20th century some local door to door field sales and home deliveries were go down due to rise large number of retail centres and also availability of cheap cars, however, some other home delivery business still in existence such as milk and catalogue distribution. The innovation of large consumer products such as washing machines, dishwashers, refrigerators, televisions etc results in certain type of delivery methods after mid-twentieth century. (Spufford, 1994) The recent development of information technology has contributed many new methods to retailing sector over the internet which drastically increases the demand of home deliveries. Online shopping and home delivery became an ideal path or approach in a society where people themselves believe they are cash-rich and time-poor for grocery or household goods. E-commerce along with some other forms offers the opportunity for consumers to buy household goods from their homes and also to receive deliveries at their flexible timings rather than travelling to stores. (ibid) Grocery And Grocery Industry:- Groceries and other food retailers function each and every day, yet it is fundamental and permanent industry sectors in the business world. Everybody require food, thus everyone must and should purchase food from one or another retail outlet. Therefore, the grocery industry is a vast, fragmented and tremendously competitive environment ( Kelly Delaney et al, 2003 pp 187). â€Å"In Great Britain, food retailing industry constitutes 36 percent of overall retail turnover annually (Central Statistical Office, 1990). In United Kingdom the largest individual category of family expenditure and along with some other groups, which are partially sold in supermarkets, like household goods, tobacco and alcohols, clothing and leisure goods for a considerably large share of customer shopping (Central Statistical Office, 1991).† (Russell Aylott et al, 1998,. Pp.363) Customer Base And Market Trends:- According to Verdict (2006a), 80% of the online shoppers were of 29 to50 age group in 2002. Majority of responded shoppers were female. There are three groups of online shoppers: firstly rich and busy people who are pressed for time, secondly families with one or more young children and thirdly people who find difficulty to get into stores. The first group of people are those who have higher incomes and less time to shop. These people are normally high internet users, technology comprehend or family with dual income. These rich and busy people prefer someone to shop behalf of them. The second group are those who have got young children in their families. They constitute higher number of e-grocery shoppers. The age group of e-grocery shoppers is 29 to 50 years old with at least one young child under five years old. This group usually spend their time in cooking dinners for their family therefore they prefer shop online for regular household groceries. This category of people wants to avoid hassle situation at stores by dragging kids along with them for shopping. The final group is comparably small to other two categories. This group of people are those who find difficulty to access the store environment due to several reasons like age or physical disability. People average life span increased in recent decades comparing to 1950s and 1960s. People average life span increased from 67.8 to 77.2 in 2007 and they estimated life span is 82.4 for 2015.Aged people and physically challenged people may need little more extra help while doing shopping. They may found it as difficult to drive to supermarkets and to carry heavy household goods back to home. Online shopping will be the good alternative source for grocery shopping. Estimation Of Home Delivery Shopping Market And Market Share:- In the year 1999 the total home shopping market worth was figured  £12.36bn in UK market. The projected view for 2004 was  £24.12bn. All sectors have been experienced by considerable growth and constant increase has been expected for following 5 years as customers accept different new channels for purchasing of goods. Traditional grocery shopping is matured market. However, recent development and growth predicts that, it has been generated by potential e-commerce and majority of grocers converted a part of their business into e-grocers. UK e-shopping was  £581m worth in the year 1999 and estimated growth to  £1.53bn in 2000. Verdict research predicted there will be huge growth of 3.36% of total sales in online market and it was estimated as  £8.84bn by 2004(Nielsen, 2000). Market Trends In Home Shopping:- E-commerce growth in recent decades (excluding some declined cases) transformed old traditional companies into technology implemented new companies. Moreover, now companies are in better position to exploit and implement new technologies to business models to grow their sales and profit. In the starting days of internet technology there were comments from academic commentators that most of incumbent businesses were unwilling to try internet for sales channel. There was lack of internet knowledge and also uneven distribution of amount for physical distribution. These companies distribution infrastructure have their brand names and customer base which will help to command and access the funding, and provide stronger position to embrace e-commerce (Anderson consulting, 2000). If we consider present situation, majority of internet user are males compare to females. This socio-economic difference in internet profile user also affects online shopping. Along with these higher proportion of society contains children and youth who currently own their own computer systems and access internet more than older generation. However, research depicts that some of these variations may diminish over the growth of technology. For an example, the prediction of women internet user by the 2005 will increase by sixty percent of total UK online users. (Tesco, 2000). Many more established retailers are likely to adopt a new approach, Multichannel retail sector implementation and development, in future. Already there are alternative channel development methods by many large retailers. It will also permit retailers to create alternative channels to draw supply chains and resources from their existence channels. For manufacturing companies it will provide good opportunity to access customers directly and to formulate new methods of delivering service or product. There is an expectation of launching of new niche catalogues from major drivers in UK as growth rate penetrates. (Webb, 2000). Geographical Characteristics:- Sandoval( 2002) mentioned analyst Robert Rubin said that average population density in UK is high compared to ones US. The US( 31 per sq.km) population density is one-eighth of the UK ( 248 per sq.km) in 2004 ( world population prospectus). Tesco and Sainsbury have become successful e-grocers in the UK. These grocers target highly populated urban areas for more potential consumers. Urban areas are densely populated, people reside very close. In large cities there are less people who own cars. There are other factors which influence online grocery shopping in urban areas such as busy lifestyle, highly crowded shopping malls, public transport dependence for transportation and higher income. According to Mclaughlin(2005) cities are highly populated with internet users and considerable residents with disposable income. It is difficult expand online shopping to system to all geographic areas instead it could be done from one urban area to another, expanding business like this will make company delivery truck to achieve high number of deliveries at every trip. Psychographic Characteristics:- Fox and kempiak (2006) mentioned five major decision elements for online grocery shopping( price, convenience, product variety, ambiance and service). He also stated several reasons to increase online shopping chances such as changing family structure, busy work schedule with increased working hours, less free time and time consuming traditional shopping methods. This social system transformation result in search of alternative independent grocery shopping methods. Customer with different disability made their interest towards e-shopping rather than traditional one. Woodside, Arch G. and Randolph J. Trappey (1992) mentioned that time and conveniences are the two major factors for people to switch from traditional shopping methods to electronic shopping methods. Technology should provide complete product description to satisfy different types of customer base it may be depends on several criteria such as different food preferences such as organic, religious , ethnic origin etc Technological Characteristics:- Fox and Kempiak(2006)states that, the food marketing institute indicates US consumers are highest internet users with eighty-six percent in that seventy percent will shop online daily. Whereas in the UK, broadband user are in fifth position in world and second position in Europe. E-commerce research 2007 shows 15.9 percent respondents brought groceries once in a week, 2.7 percent shops twice or thrice a month, largest group shops once or twice in a year. Increased internet users likely contribute the growth of online shopping. Online shoppers will make more shopping than in-store shoppers. â€Å"As the economy and society have changed, so retailers have responded and shopping as an activity has altered enormously.† (Dawson and Broadbridge,1988). Online shopping is comparatively recent phenomenon, which provides an opportunity to consumers to carry out at least one part of buying process online. â€Å"Electronic grocery shopping has been defined as shopping when at least part of transaction is started electronically via third party services or the Internet, but paying and logistics are not necessarily performed digitally†. ( Carl Lewis, 2003-pp.207) E-shop business model represents one class of e-commerce where buyers and sellers interact electronically with each other, except for deliveries. Burke suggests many reasons web marketing of food. As an example, everybody has to eat, and in store shopping consumes considerable time to purchase and majority people do not like grocery shopping. Daily household goods are difficult to move physically from one place to another. Continuous growth of e-commerce enlightens many traditional grocery retailers to use internet channel to sell their goods. The development leads to many more conventional retails to enter into e-grocery field (Boedeker.M, 1997 ). E-Crm:- Smith believed that, customers thinking about the shopping are predetermined whether in means of preference to products, price and accessibility. Satisfying such conditions and preferences thorough online process is carried out through designing e-commerce website and online shopping store should focus on creating e-loyalty. Customer relationship management (CRM) programmes are the most effective way to incorporate loyalty. Customer service is one of the major aspects of business which includes customer assistant in sales, maintenance customer policies, providing customised services, after-sales maintenance etc. Due to the different type and nature of products which are purchased at e-grocery shops there should be complete product description. Some websites provide procedures for return of product or reporting problems as a part of after-sales service. Some stores allow unsatisfied customer to return their product, some websites provide vast description about their products such as r ipeness of their tomatoes (smith, 2000). All online shopping websites provide some customer rules and policies. According to Australian legislation, all online websites should maintain privacy policy (Australian Federal Government, 2000). Success And Failure Factors From Previous Studies:- Friends of Earth(2005) believed that e-grocery method is the best way to promote industrys brand image. However , Fox and Kempiak(2006) and Kotler (1996) stated conversely; brand image of company will help to promote online grocery business. They also believed that industrys business experience and its infrastructure will be added advantage for promotion. One more factor is people ability to spend money for long duration household goods. Pachauri, Moneesha 2002 stated that competition in e-grocery retail sector remains the same until company stay in game. If any child companys online business started down falling then parental company may not let it to happen for longer duration because they are inter-related in means of profit sharing. Without the demand, services of online business company will lead to business failure. Retention of existing customer is one of the main aspects of business. To gain customer loyalty, companies should provide reward to regular shopper. Customers can also gain loyalty points for their spending and it will convert into reward coupons or vouchers. Brick and mortar stores utilises their existing business infrastructure to click and mortar stores to save on costs. Delaney-Klinger, Boyer, and Frohlich (2003) mentioned Tescos success and Webvan failure because of its marketing strategy for online business. Webvan marketed its online sales with value-added service and extra delivery charges to cope up with online ordering cost. Tescos pricing strategy is little higher than the Webvan and its most suitable one for lower volume sales. Smith, Howard (2004) stated that online-only business spent heavy money for their highly automated warehouses. The operating costs for these warehouses are high and order volumes for those companies are not more than half of their capacity. High initial start up cost for online division, although pricing strategy can able to reduce cost for internal order picking and delivery methods. However, Delaney-Klinger et al (2003) believed that the expenditure for short run will increase business cost for warehouse methods and decrease for existing store picking methods comparably. High initial start-up cost will results at higher risk for any organisation. Another aspect for failure will be lack of online business management knowledge and experience. Blythman, Joanna (2005) stated that, companies are not concentrating much on customer relation management for stabilising business consistently. Traditional grocers have more advantage over online grocers in this area. Conclusion:- Online shopping and home delivery service is one of the critical aspects of e-grocery business. E-grocery business should have to understand the variable cost affecting structures and service concepts in order to turn online grocery business into profitable one. The different strategies were discussed. Analysing and adopting best strategy for e-grocery business is mast important. This literature provided insight of e-groceries. In a service context, as with product marketing, getting and keeping customers is of utmost importance. With service, in particular, someone within the organization will interact with customers; hence they should be viewed as customer relationships not just customers. Customer relationships have to be built and a useful way of viewing these developments as a life cycle. The marketing objective will change as the customer proceeds through the cycle. Understanding service marketing is becoming increasingly important for all organizations as more firms seek to di fferentiate their product or services through their service offering. Interaction and customer relationship concepts, two key areas of service marketing are set to be of even greater importance to all firms in the future. Research Methodology Research topic: Strategic and Economic analysis of E-grocery system in Tesco and Sainsbury (Online shopping and home delivery methods). Background Of Home Delivery System And Its Characteristics- Home delivery is generally defined as delivering of all types of goods to customers homes (or any different location opted by customer – example workplace) regardless online or any other order forms such as traditional mailing, telephone-based ordering (phone order), internet, fax or order made in person by consumer in store premises. The study is carried out in business to customer order delivery system rather than business to business. Home delivery system refers to all household goods delivered to consumers house (the destination may change such as work place on customers selection). Hence in online shopping and home delivery method the purchased physical household goods is carried out to customers destination by specialised home delivery unit or companies instead of customers themselves. There are some reasons for home deliveries like (i) may be the retail outlet itself provide an additional service to their customers or ( ii) may be customer do not like to carry the shopped goods at that instance or the required product may be out-of-stock at that moment or (iii) due to goods weight or size ( if it became difficulty to customer to transport by themselves) or (iv) because the seller itself does not have any physical store and may be its complete operation depends on the virtual online store. Thus customer may face impossible situation to collect the goods in store by themselves. (Farahmand and Young, 1998; Nielse n, 2000) Problem Statement:- On one hand, many customers are interested to do online shopping for their household goods, but yet they are not interest to abandon shopping in-store in traditional way. Most of the people still believed that, online shopping is too expensive. On the other hand, many more industries also made their effort to build online stores by providing this extra service to the customers. Organisations are continuously striving hard to build different strategic approaches for fulfilment of orders in profitable way. However, online unit business will add extra expenditure to grocers with or without some nominal charges. The profit margin is comparably very low in e-grocery to traditional one. Many grocers have undertaken to provide online shopping experience for their customers with different strategies. Profit margin is very low and sustainability in this industry is difficult. In the history of grocery sector many more companies introduced online shopping and home delivery units and failed. Purpose Of The Study:- The online shopping and home delivery is still in emergent phase. E-grocery business is very challenging field and it provides an extraordinary opportunities for business. E-groceries made many more efforts to implement various strategies and service concepts, there is no much research carried out in this area. This research study is provides insight of e-grocery methods in retail sector, identifies operating strategies and strategic and economic analysis of home delivery methods in Sainsbury and Tesco. Main Research Questions:- This research study is carried out to understand the factors of e-grocery success by trying to find answer to following research questions. How Tescos and Sainsburys online units are functioning strategies to its success? What are the business models they are following? How are they processing their order? Should they use warehouse system or in-store picking system? Whether home delivery system is profitable or not? How should online unit function to achieve operational efficiency and how they are managing customer relationship? Hypothesis: Home delivery is neither a profitable nor a strategic contributor to Tesco and Sainsbury. Research Objectives:- The objective of this study is to find out the above was mentioned research explained empirically by using various research methods. Our approach is comparative in nature. The steps adopted in our study are as follows: (1) Identification of the industries under study; (2) Study of background of the industries; (3) Interpretation of appropriateness of strategies and methods of individual firm; (4) Analysis of home delivery methods impact on organisational performance from individual firm. Research Approach And Methodology:- Research data collection is carried out both quantitatively and qualitatively. It will become difficult to distinguish between these two methods. Generally quantitative research method means collecting numerical data or coded information for objective analysis, data will be later interpreted. Qualitative research method is data collection by observations by peoples activity generally and they are noted in coded description. However, this codified information can be used for later analysis. The important form of this method is often reporting and interpretations by researcher by timely observation. A semi structured interview will be carried out during research which consists of analysis of six Sainsbury and six Tesco stores for data collection about home delivery. Interviews will be carried out with key persons like grocery manager, online delivery driver, and duty manager etc in each store to collect the quantitative and qualitative data. The quantitative data will be calculated and qualitative data will be gathered for analysis. And results will be drawn from the following methods. This study uses semi-structured quantitative primary analysis (interview for data collection) and majorly uses qualitative method (secondary source) to identify UK grocery sector and to focus to answer research questions stated. Interviews will provide large amount of information which is main source of information and key pathway for time-constrained studies such as this (Esterberg, 2002). Case Study And Historical Analysis Method:- According to Yin (1989), there are mainly five major investigating methods in social science research namely surveys, archival analysis, case studies, experiments and historical analysis. He also distinguish them on the basis of three criteria; those are i) what kind of research question will be asked, ii) what will the degree of control over present behavioural consequences and iii) present emphasis compared to past events. Case studies and historical analysis are desirable approaches to evaluate strategies of organisations. These methods are useful to describe and answer the â€Å"how† and/or â€Å"why† scenario when events happen beyond researcher control and also while researching present phenomenon in real-life time. Inductive and deductive approaches will be used for analysis of research data. Inductive way means drawing the general conclusions from researcher based on empirical grounds. Deductive approach means drawing the conclusions from researchers logical reasoning (Ghauri,et.Al,. 1995). This study focus on collecting information regarding operational strategies of Tesco and Sainsbury and to understand, why they are providing online shopping facility to customers while many of the supermarket failed to stay in game. During the process of study, the companies actions or strategic implementations from them are beyond the control of researcher, case study and historical analysis methods will be best, for a part of research. Meta-Analysis:- On this part, research study is carried out through qualitative meta-analysis for selected e-grocery organisations. Answers to main research questions will be collected qualitatively for each individual case (Lyons, 2003). The collected data will be analysed and possible relationships between business models and various out comes will be fetched out. This method is used to compare operations characteristics and strategies of Tesco and Sainsbury from the gathered data. This is the systematic approach for cross comparison of business models. There are few draw backs in meta-analysis such as, since data collected from various sources hence results quality is directly depends on the quality of source. Another, may companies may use similar strategic approach to achieve their goals which may be rarely identical. There is no unique approach to analyse data for meta-analysis. This effort is made to reveal answers from confirmed information from various sources (Graney and Engle, 1990). Significance And Limitations:- The study is carried out on case studies and available literature for the analysis of success in online grocery business, hope this study helps to find the major research questions. Study carried out to compare business models of only two named companies. This study is limited to only e-grocery business of Tesco and Sainsburys home delivery methods. Dissertation will be carried out only in the grocery section and applicability of results to other departments is not recommended. Dissertation will be carried out for sample quantity which will restrict the chances of generalisation. References:- AC Nielsen (2000) the Retail Pocket Book, 2000. Burke, R. R. 1997. Real Shopping in a Virtual Store. Peterson R. A. (editor). Electronic Marketing and the Consumer. Thousand Oaks: Sage Publications, 81-88. Boedeker, M. 1997. Recreational Shopping, The role of the basic emotional dimensions of personality. Turku: Publications of the Turk u School of Economics and Business Administration. Series A-9:1997 Blythman, Joanna (2005) Shopped: The Shocking Power of British Supermarkets, Second Edition, 2005, Harper Perennial, Hammersmith. Ramus, K. and Nielsen, N.A. (2005). Online Grocery Retailing: What Do Consumers Think? Internet Research, 15 (3), 335-352. Porter, M.E. (2001). Strategy and the Internet. Harvard Business Review, 79 (3), 62-78. Hong, S. and Kim J. (2004). Architectural Criteria for Website Evaluation Conceptual Framework And Empirical Validation. Behaviour and Information Technology, 23 (5), 337-357. Teo, T.S.H., (2002). Attitudes toward Online Shopping and the Internet. Behaviour and Information Technology, 21 (4), 259-271. Hong, S. and Kim J. (2004). Architectural Criteria for Website Evaluation Conceptual Framework And Empirical Validation. Behaviour and Information Technology, 23 (5), 337-357. Anderson Consulting (2000), E-Europe: connecting the dots, Anderson consulting. Australian Federal Government 2000, Privacy Act, Privacy Amendment (Private Sector) Act 2000( Cth), Canberra, Australia. Smith, E. 2000, E-Loyalty: How to Keep Customers Coming Back To Your Website, Harper Business, New York. Ghauri, P.N., Gronhaug, K., Kristianslund, I. (1995), †Research Methods in Business Studies – A Practical Guide†, Prentice Hall 1995 Esterberg, K G (2002) Qualitative Methods in Social Research, 2002, McGraw-Hill, Boston. Delaney-Klinger, K., Boyer, K. K., Frohlich, M. (2003). The return of online grocery shopping: a comparative analysis of Webvan and Tescos operational methods. The TQM Magazine, 15(3), 187-196. Graney, M. J. Engle, V. F. (1990, September). Meta-analysis techniques. Journal of Gerontological Nursing, Fox, M. A., Kempiak, M. (2006). Online grocery shopping: Consumer motives, concerns, and business models. Friends of the Earth (2005), Briefing: The Tesco Takeover, June 2005, Friends of the Earth, London. Kotler, Philip (1996) Marketing Management – Analysis, Planning, Implementation and Control, Eighth Edition, 1996, Prentice Hall. Europe. Pachauri, Moneesha (2002) Consumer Behaviour; a Literature Review, The Marketing Review, 2002, 2, pp. 319–355. Smith, Howard (2004) Supermarket Choice and Supermarket Competition in Market Equilibrium, The Review of Economic Studies, Volume 71, 2004, pp235-263. McLaughlin, K. (2005). Pricelines ex-CEO puts eggs in basket of an online grocer. Wall Street Journal, p. B7 Russell Aylott and Vincent- Wayne Mitchell, 1998- â€Å"An exploratory study of grocery shopping stressors†- International Journal of retailing and distribution management, volume 26, number 9, 1998, Pp.363 Spufford, M (1994) the pedlar, The Historian and the Folklorist: Seventeenth Century Communications, Folklore, Vol. 105, pp. 13-24. Farahmand, R and Young, M. (1998) Home shopping and its future. Paper presented at the 10th annual TRICS conference, 22-23rd September. Webb, G. (2000) â€Å"The multi-channel route – and need to keep a cool head†, in E-logistics Magazine, September. Tesco (2000), Tesco press release –i-village and Tesco.com, 19th July. Verdict (2006a), How Britain Shops 2006: Food and Grocery, Verdict Research Limited, May 2006, London. Woodside, Arch G. and Randolph J. Trappey (1992) Finding out why customers shop your store and buy your brand: Automatic cognitive processing models of primary choice, Journal of Advertising Research, November/December 1992, pp.52-78. Yin, R.K. (1989), â€Å"Case Study Research: Design and Methods†, Sage Publications 1989 http://www.statistics.gov.uk/hub/ ,accessed on 22/09/09

History and Vectors of Rabies Essay -- Medical Disease

History and Vectors of Rabies Literally meaning â€Å"madness and fury†, rabies is commonly recognized by the characteristic foaming of the mouth and wild behavior. However, this is only the tip of the iceberg. This disease is spread through the saliva of infected carriers. Rabies is a viral disease that targets the nervous system which is always fatal with the exception of a single case. Natural remedies and spiritual therapies were used in hopes of warding away this fatal disease until the discovery of vaccination revolutionized medicine. This mysterious virus has a very unique history dating back to the first civilizations. The earliest mentioning of rabies in the past is a set of documents existing back as early as 2300 B.C. These legal documents explained the penalty when an owner’s pet caused any deaths resulting from the animal’s bite (Alan 1). This is the first written document acknowledging the existence of rabies. Pre-Socratic philosophers had discussed the â€Å"seed of disease† which gave the people a greater understanding on diseases in general. Well known philosophers and doctors, such as Hippocrates, Aristotle, Democritus, Celsus, Galen, and Pliny, discussed the nature of rabies during their eras but were commonly dismissed due to the insignificance of science at the time, people would often would overlook the complexity of this virus. The Roman doctor Celsus focused on the effect of rabies on humans during the first century A.D., especially prophylaxis and hydrophobia (Alan 2). He focused on treating this disease, although he admitted that there was â€Å"very little hope for the sufferer† once the extreme symptoms had revealed themselves (Alan 3). His treatment included cauterizing and bleeding the wound in order to allow t... ...and of the future discover an effective cure. As for now, there are still numerous breakthroughs to be discovered. Works Cited Jackson, Alan C., and William H. Wunner. Rabies. London: Elsevier Science, 2002. Kaplan, Colin, et al. Rabies the Facts. Ed. Colin Kaplan. Oxford: Oxford UP, 1977. MMWR Dispatch. â€Å"Investigation of Rabies Infections in Organ Donor and Transplant Recipients.† Morbidity and Mortality Weekly 53.26 (July 2004): 586-589. 24 July 2007 . West, Geoffrey P. Rabies in Animals and Man. Ed. Newton Abbot. Great Britain: David & Charles Limited, 1972. Willoughby, Rodney E, Jr, et al. â€Å"Survival after Treatment of Rabies with Induction of Coma.† Survival after Treatment of Rabies with Induction of Coma 24 ser. 352.2508-2514 (June 2005). The New England Journal of Medicine. 22 July 2007 .

Eastern Stars Shining In The West Essay

To most people out there who do not speak Korean, † Gangnam Style†¦Yay,sexy lady†¦oh.oh.oh.† is basically the only words out of all lines that they can understand in the song Gangnam Style by Psy. However, this Korean song somehow has turned out to be a viral popular pop song even to non-Korean speakers with little understanding of what the lyrics mean. Apparently, Asian singers are gaining popularity around the globe and their appeal is no longer limited to Asian audiences only. Singers apart, movie stars are also gaining a place in the Western countries–Jackie Chan, Bruce Lee, Li Gong and Jet Li to name but a few. Generally speaking, technological advancement, trend of Asian cultures and change in music type are the major reasons why the stars from the East can survive and thrive in the West, where there is a cut-throat showbiz market. Technologically speaking, advancement in this aspect extenuates the significance of geographic restrictions. In the pas t, with fewer choices yet higher cost of transportations, it was nearly impossible to travel a long distance to different lands. In this regard, convenient transportation at present allows Asian artists to fly to Western countries for promotion with ease. What is also noteworthy is that the emergence of the Internet forms a platform where films and music videos can be shared from one place to the other side of the world in just a blink of an eye. Given the ever-evolving technology, it comes as no surprise that people in the West are exposed to and provided with countless Asian movies and songs through promotion in both the actual world and the digital one. Truth be told, who does not like refreshingly new things? That Asian songs and movies are right up their alley in terms of refreshingness is very likely. Culturally speaking, the rise in popularity of Asian culture in various aspects leads to more attention paid to Asian actors. Under the influence of globalization, cultures are passed from countries to countries. The most noticeable change or what I would call the trend is that people from the West have a great inclination for the cultures in Asia. For example, Kung Fu was introduced to the US and is now the type of exercise many A mericans try to and like to learn; cheongsam has become a type of formal clothing for Westerners and has stirred up a new retrograde fashion. With more people showing interest in Asian cultures, more focus is put onto the people who exhibit them, the Asian actors. Moreover, many Hollywood film  producers are riding on this Asian culture craze and make a lucrative business by incorporating Asian features into their new movies. For a case in point, the Karate Kid, although namely Karate, is Kung-Fu-themed and it makes a great box office. In other words, more chances are given to Asian actors to appear on world-class movies. Without a doubt, there is a subtle but solid correlation between the trend of Asian cultures and the rising popularity of Asian movie stars. Probably out of the need to adapt to a new place and a new kind of customers? Asian singers from time to time have made songs in English that are comprehendible to most people who speak this international language. In this way, with more understanding about the meaning of the lyrics, Western people can more easily recognize the talent of Asian singers and in turn more easily idolize them, or at least this could be the case for those who define good songs as the ones with a deep meaning . For others that do not seek a lesson from listening to songs, the fast rhythms and beats of some Asian songs can be a reason good enough for them to admire Asian singers. As aforementioned, Psy is now a sensation worldwide even though he sings in Korean. Music is a universal â€Å"language† everyone understands. While some people nowadays still insist on the importance of having an introspective message in a song for it to be good, some define good songs as those with catchy beats. Given the fact that some Asian singers are making songs in English or with exciting rhythm and beats, it is not hard to explain why they can get so popular in the West. In conclusion, the phenomenon of stars from the East gaining popuplarity in the West can be explained by technology advancement, trending Asian cultures and change in music type. By far, it is still a healthy phenomenon, but everything is a double-edged sword. Will this bring about any problems in the future? Only time could tell.

global warming1 essays

global warming1 essays Greenhouse gases (chlorofluorocarbons, carbon dioxide, methane, nitrous oxide, etc.)let heat in but stop it from going back out - like a windshield in a parked car. At our current rate of creating these gases by industry, cars and burning fossil fuels, scientists predict a temperature increase of 4 to 9 degrees F by 2050. (9 degrees F separates today's average temperatures from the last ice age.) The United Nations Panel on Climate Change recommends that we immediately cut our use of fossil fuels by at least half. To prevent the current rate from increasing, we would have to cut by 60%. This same panel projects that by 2050 over a million more people dying each year from malaria because of higher mosquito populations due to global warming. Already yellow and dengue fever bearing mosquitoes are found over 3000' higher than their normal range in South America. Other predicted results of global warming include expanding deserts, forest fires, heat waves, crop failure, erosion, mud slides, mass extinction of plants and animals, sea level increases causing flooding and damage to coastal aquifers. The US with c. 5% of the world's population creates 25% of the 7 billion tons of carbon dioxide that causes 50% of the global warming trend. Five tons per capita per year! US oil consumption is now the highest since 1979. Since 1988, insurance companies paid 17 multi billion dollar weather-related claims. There had never been one even as high as $1 billion before 1988. Before 1900, carbon dioxide in the atmosphere was stable at 280 parts per million. The concentration now is over 360 and the increase rate has doubled since 1958. 1995 was globally the hottest year in over 100 years and the driest in the UK for over 300 years. The green house effect gas and the global warming It is said, "if the carbon dioxide increases, the Earth becomes hot." By what mechanism does this happen? The gas which absorbs the infra-red lay...

Bowel cancer is the third most common cancer in the United Kingdom The WritePass Journal

Bowel cancer is the third most common cancer in the United Kingdom Introduction Bowel cancer is the third most common cancer in the United Kingdom IntroductionReferences Related Introduction Bowel cancer is the third most common cancer in the United Kingdom with approximately 35,000 new cases diagnosed each year.   1 in 16 men and 1 in 20 women will develop colorectal cancer at some point in their lives. It is also the second most common cause of cancer death, with just over 16,000 (approximately 9,000 men and 7,000 women) deaths per year (ONS, 2010) Incidence rates for colorectal cancer increased by 28 per cent for men and 11 per cent for women between 1971 and 2007.   Rates peaked at 57 per 100,000 in men in 1999 and 38 per 100,000 women in 1992. In the ten year period from 1998 to 2007, incidence rates for men and women have remained relatively stable (ONS 2010). Being overweight, having an inactive lifestyle and a low fibre diet can increase the risk of colorectal cancer. Eating red and processed meat, and insufficient amounts of fruit and vegetables, smoking and drinking excess alcohol are contributing factors. People with Crohn’s disease in the colon, ulcerative colitis, polyps in the colon or a family history of colorectal cancer may also be at an increased risk (Department of Health, 2000). More than four out of every five new cases of colorectal cancer are diagnosed in people aged 60 and over, with most cases presenting in the 70-79 age group in men and in the 75 and over age group in women (ONS, 2010). Survival from cancers of the colon and rectum has doubled in 30 years.   For colon cancer, five-year survival was 50% for men and 51% for women diagnosed in 2001-2006 and followed up to 2007.   Five-year survival for those diagnosed in 1971-1975 and followed up to 1995 was 22 per cent for men and 23 per cent for women (Rachet et al 2009). Differences in survival rates are based on how early, or at what ‘stage’, a patient presents for treatment.   This ‘staging’ is a method (first developed in 1932) of evaluating the progress of the cancer in a patient. The classification considers the extent to which the cancer has spread to other parts of the body. Once established, the best course of treatment is then decided.   There are currently for categories: Dukes Stage A: The tumour penetrates into the mucosa of the bowel wall but no further Dukes Stage B: The tumour penetrates into, but not through the muscularis propria (the muscular layer) of the bowel wall. Dukes Stage C: The tumour penetrates into, but not through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the lymph nodes. C2: tumour penetrates into and through the muscularis propria of the bowel wall; there is pathologic evidence of colon cancer in the lymph nodes. Dukes Stage D: The tumour, which has spread beyond the confines of the lymph nodes (to organs such as the liver, lung or bone). Five year survival rates according to the Dukes’ stage of classification are:   Dukes’ Stage A 85–95%, B 60–80%, C 30–60%, D less than 10%.   These significant differences in survival rates were the basis for the introduction of a national screening programme for bowel cancer (Rachet et al 2009). The NHS Bowel Cancer Screening Programme in England began in July 2006, as part of the NHS National Cancer Plan (2000).   Patients aged between 60-69 were initially offered screening every two years and people 70 and over could request it via their GP. The criteria has since changed (from January 2010) with screening now offered to those aged 70-75 years. The objective of bowel screening is to detect bowel cancer at an early stage and get these identified patients into an appropriate treatment pathway.   The screening programme can also detect polyps, which, although are not cancers they may develop into cancers over time. They can easily be removed which reduces the risk of bowel cancer developing. This essay outlines the process of the UK bowel screening programme and from this provides a critical analysis of the test, performance and cost-effectiveness leading to a broader discussion considering   whether to implement the screening programme in relation to UK NSC criteria. Description and critical analysis of the evidence about the test performance (15 marks) Screening is defined by Raffle Gray (2007) as; ‘The systematic application of a test, or inquiry, to identify individuals at sufficient risk of a specific disorder to warrant further investigation or direct preventive action, amongst persons who have not sought medical attention on account of symptoms of that disorder.’ There is a distinct difference between screening and case finding (e.g. NHS Health Check) In clinical practice, patients approach healthcare professionals to ask for medical advice and help, in contrast with screening programmes, where professionals actively encourage people to undergo an investigation on the basis that it may benefit them. The performance of a screening programme is based on its ‘sensitivity’ and ‘specificity’.   The sensitivity of a screening test is the percentage of the screened population that has the disease and tests positive.   For instance, a sensitivity of 70% means that for every ten participants with the disease, seven will test positive and the other three will be false negatives.   A test with poor sensitivity results in a high percentage of the population with the disease escaping detection. These people will be falsely reassured and could delay presenting important symptoms. The specificity of a test is the percentage of the screened population that is disease free and also tests negative. For instance, a specificity of 80% means that eight out of ten people who do not have the disease will have a negative result. Two out of ten will have a false positive result and require further assessment before the possibility of disease can be eliminated.   A test with poor specificity will have an important effect for the individual, including increased anxiety and unnecessary clinical follow up. The ideal screening test would have a high sensitivity (to reduce the number of false negatives) and a high specificity (to reduce the number of false positives). It is usually difficult to achieve this as there is a trade off between the two measures; limiting the criteria for one results in a decrease in the other. Another key feature of a screening test is the predictive value for which there are two key aspects. The positive predictive value (PPV) of a test is the percentage of people who test positive who have the disease. The negative predictive value is the percentage of those who test negative who are disease free. The predictive value is influenced by both the sensitivity and specificity of the test, as well as the prevalence of the condition being screened for. In the UK the screening test used for the bowel screening programme is the ’faecal occult blood test’ (FOBT).   In terms of operational delivery there are approximately 20 Hubs across the country responsible for coordinating the screening programme, each Hub sends out letters of invitation to the eligible population, explaining about bowel cancer screening.  Ã‚   Standard practice ensures that within a week of receiving a letter a FOBT kit will be sent to patients.   The kits are used by the patient, samples taken and returned to the Hub, who then send normal results to individuals, and inform GPs via a standards letter.   For positive tests, the Hub contacts the individual directly, and an appointment is them made for the patient to have further investigations (colonoscopy) with the commissioned provider of colonoscopy services. The test and the framework for its operational delivery are based on a number of large scale trials which were undertaken to assess whether FOB testing of asymptomatic people could be useful in detecting individuals with early bowel cancer the largest trial conducted in Nottingham. The trials and the subsequent UK pilots (2008) found: uptake of approximately 60%, subsequent pilots returned a lower uptake which decreased with deprivation sensitivity was approximately 60% for cancer and 80% for adenomas biannual testing was as effective as annual testing screening of asymptomatic 55-75-year-olds reduced mortality from bowel cancer by 16%   overall, or by 25% in those 60% of individuals who return an FOBT there was no reduction in all-cause mortality from FOB screening. These results meant that FOBT can detect 60% of all colon cancers.   Alternatively, this also means that 40% are not routinely detected.   This lower sensitivity rate is a trade off based on the fact that FOBT screening is non-invasive, easily performed without the need for bowel preparation, and can be performed on transported specimens and of low cost.   A higher sensitivity rate could be achieved through once-only flexible sigmoidoscopy screening in prevention of colorectal cancer but uptake, patient acceptability and cost would be a barrier to population roll-out. Description and critical analysis of the evidence about the cost-effectiveness (15 marks) There are a number of research publications that compare specific models of bowel screening through the application of different these will be described, but from a public health perspective, this essay will also consider the wider opportunity cost in relation to bowel screening. Agreement relating to how cost-effective an intervention is depends on what the intervention is being compared against. For instance, a starting point in the evaluation of the UK pilot for Bowel Screening Cost-effectiveness (2003) states ‘Analysis found that the cost-effectiveness of a national programme compared well with other forms of cancer screening such as breast and cervical cancer screening.’ This statement is all about comparison with associated interventions that are deemed reasonable and safe with a generally fair return on investment this is more about acceptable levels of investment producing acceptable levels of return compared to similar interventions of the same type rather than considering whether the programme can be delivered more efficiently or could the resource be allocated in a different way to achieve the desired results. The issue of whether the programme could be delivered more cost effectively has been reviewed in a number of publications (Allison et al. 2006.   Rozen et al. 2000.   Levin et al 1997).   These comparisons have, in particular, considered the merits of; FOBT alone, flexible sigmoidoscopy and FOBT combined, and one-off colonoscopy with cost-effectiveness more often defined as the cost per cancer death prevented.   Of all the screening tests, FOBT alone prevents fewer cancer deaths than the other interventions, but the addition of a flexible sigmoidoscopy to the FOBT increases the rate of cancer prevention. One-off colonoscopy has the greatest impact on colorectal cancer mortality.   Although purported to be the most cost effective the outcomes are all based on clinical outcome alone but when considering cost FOBT returns better broader population results (in terms of patient acceptability and absolute cost to deliver) than any other of the interventions outlined. One of the most popular measures of cost effectiveness is considered through estimating the lifetime NHS costs and potential health benefits (defined as cost per QALY quality-adjusted life-years).   For bowel screening this equates to comparing the population not offered screening but treated according to current practice compared with a sample of the population who are offered screening as per the protocol used in the pilot study.   The cost per QALY is the additional costs of screening, after allowing for treatment cost savings, and the gain in survival and quality of life. The problem with QALYs has always been the question of what is the upper limit on what society is prepared to pay for health gains.   Ã‚  The National Institute for Clinical Excellence (NICE) provides some limited information about upper limits in this context.   It has been suggested that  £30,000 per QALY might represent an acceptable threshold (NICE, 2008).   Studies (Young et al, 2005. Lieberman, 2005. Khandker RZ, 2000) have returned a cost per QALY for bowel screening of between  £2,000 to  £3,000 which is well within the acceptable cost guidance offered through NICE but this does not mean that it is the more cost effective or efficient way of delivering the service. Raffle Gray (2007) touch on the issue of broader public health view and the influence of single issue groups, they outlined that; ‘If information for policy making is to serve the health needs of the public to best effect, then it must enable policy makers to keep a sense of perspective and context.   Doing this requires policy questions that are concerned with whole programmes of care, not just the single issue being considered.’ If we consider this in the context of a UK bowel screening programme costing  £50 million per year can we justify its delivery on the associated reduction in mortality of up to 16%? On face value, it seems we can (e.g. economic analysis and QALY returns etc) but that is assuming 60% uptake.   PCTs in the West Midlands are currently delivering the programme at between 28% and 42% uptake. As public health policy makers at what point do we consider the low uptake at sustained high cost as a reasonable return on investment?   There may be a greater return on investment if the  £50 million was invested in broader public health programmes targeted at reducing the population risks by changing behaviour (e.g. smoking cessation, diet, exercise). Taking this even further, could we reinvest the total  £50 million in another, unrelated, public health issue such as falls prevention programmes and tackle the risk factors associated with bowel cancer through legislation and regulation (e.g. increased taxation of tobacco or introducing a more challenging approach to price per unit for alcohol)?   In the long term, this may have more effect on a population effect on bowel cancer mortality at a lower cost. Description and analysis of the ethical issues associated with implementing this screening programme including accessibility, equity, the balance of harm and good and informed choice (15 marks) The benefits of bowel screening include a modest reduction in colorectal cancer mortality and a possible reduction in cancer incidence through the detection and removal of colorectal adenomas.   These benefits need to balanced against the potential harm of the programme.   One of these identified harms is the psycho-social consequences of receiving a false-positive result or a false-negative result, the possibility of over diagnosis (leading to unnecessary investigations or treatment) and the complications associated with treatment. Another key possible harm relates to the possibility of bowel perforation for those patients who have with a positive FOBT and require further investigation.   The UK National Bowel Cancer Screening evaluation (2003) suggested a perforation rate of 1 in 1500 colonoscopies.   This compares well with other bowel screening programmes in Australia and France which have returned a rate of 0.96 per 1000 procedures .   Following a diagnosis of perforation, most patients (over 90%) require surgery, and a significant number (30%) require colostomy or ileostomy. From a health inequalities viewpoint there are a number of issues relating to accessibility and equity that are cause for concern.   The first of these is the issues of uptake in the context of deprivation. Data for 2004-2008 shows us that there is a 11% of higher incidence rate of colon cancer for males in the most deprived population compared with the least deprived population (ONS 2008). This can be compared with uptake of screening which has demonstrated that males and younger age groups have lower uptake rates (Weller et al, 2007).   In the long term this pattern has the potential to further increase inequalities in health. There is also strong evidence that suggests certain ethnic sub-groups have lower participation rates of bowel screening than the general population (Robb et al, 2008; Szczepura et al, 2008). The reasons for these differences are complex ranging from health beliefs, misunderstanding and cultural attitudes. This defined lack of uptake by ethnic group is not evident in all screening programmes, for example, South Asian women are significantly less likely to undertake bowel screening compared to breast screening   (29% compared to 49%)   (Price et al. 2010).   This suggests more research needs to be undertaken to try and understand the key factors involved. Literacy can also be linked to deprivation and ethnicity and is a critical factor in participation in colorectal cancer screening.   As with many screening programmes a great deal of resource has been allocated to producing information and materials for the bowel cancer screening programmes – but we know that health literacy varies a great deal in the population (Von Wagner et al, 2009), and many patients will have limited comprehension of the material provided. Equity of access to diagnostic services is also a possible issue to manage. For two of the hospitals participating in the UK bowel screening pilot, there were significant differences between waiting times for colonoscopy for screened and symptomatic patients. For example, in Scotland the average waiting times for pilot patients was between 2 and 7 weeks, whereas for symptomatic patients they rose from around 10 weeks to between 16 and 20 weeks within the first year of the Pilot (Scottish Executive Health department 2006). Description of how to implement programme quality assurance and an assessment of the practical issues with implementation (15 marks) There are a number of frameworks for assessing and assuring the quality of healthcare service.   Examples include Deming’s 14 principles of management and Donabedian’s seven components of quality.   Raffle and Gray build in these two models and advocate six key points in applying quality assurance to screening. These are; Defining the objectives of the programme in a way that encapsulates what a ‘good’ screening programme will look like. Devise ways of measuring quality that will ensure these objectives are met. Set standards for each measurement; this is a subjectively chosen level that you will want the programme to achieve. Give responsibility to the local programmes for monitoring, how well they are doing in meeting the standards, and for working to improve quality in meeting those standards. Collate information about performance against standards and publications nationally for all the local programmes Provide support mechanisms for overseeing quality and for assisting local programmes with training and quality improvement. One way of doing this is by creating regional quality assurance teams. From personal experience, working with breast screening a cervical screening programmes, the need for clear standards and an overarching review process (the support mechanism) is essential.   A ‘deep dive’ approach to some of the key performance indicators is also very useful.   For example, if the target for local uptake is 60% a PCT, with the help of public health team, should approach this in terms of ensuring this uptake is achieved within the hardest to reach populations. In terms of the practical issues of implementation issues such as ease of completing the kit can be an important factor in determining uptake (The UK CRC Screening Pilot Evaluation Team, 2003).   Uptake can also be greatly affected by simple mistakes in postal address –so intended recipients do not receive the testing kit. This is one of the biggest factors associated with the uptake of an Australian trail where 20% of respondents in an Australian study claimed that they had not completed a FOB test because it had never been received in the post (Worthley at el., 2006). The Australian study also identified a preference by patients for increased GP involvement or promotion in the bowel cancer screening procedure (Salkeld et al., 2003; Worthley et al., 2006).   Many patient may prefer to have been offered screening through their GP, while almost half of those patients suggesting an alternative method of invitation wanted greater GP involvement (Worthley et al., 2006).   Similar evidence findings have emerged in the US, where a physician’s recommendation has been cited as the ‘strongest predictor’ of compliance with screening among men and women (Rabeneck, p. 1736, 2007). Overall discussion and conclusions about whether to implement the screening programme in light of the considerations already discussed and the UK NSC criteria (20 marks) Evidence suggests there is a reduction in colorectal cancer mortality as a result of introducing the UK bowel screening programme.   Following the national evaluation, it is also indicated that there was a beneficial shift towards identifying colorectal cancer at an earlier stage (e.g. Dukes Stage A).   Other benefits of screening that were not explored in this essay include the reduction in colorectal cancer incidence through detection and removal of colorectal adenomas, and potentially, less invasive treatment of identified early-stage colorectal cancers. These outcomes alone may be justification enough to continue to implement the programme in the UK. Several important additional areas require further research when deciding whether to continue with the programme or not. First, there is limited information currently available concerning the information needs and psychosocial consequences of screening for colorectal cancer.   Secondly, there is limited research on patient acceptance of colorectal cancer screening or on how best to involve particular socio-economic or ethnic groups who, as outlined previously, are often under-represented in uptake. Thirdly, the accuracy of other methods of the faecal occult blood test (e.g. RHNA) for colorectal cancer screening also requires further investigation. Maybe conclusions could be drawn through assessing the programme against the The UK NSC criteria which are considered below. NSC criteria states that all the cost-effective primary prevention interventions should have been implemented as far as practicable before consideration is given to proceed with the screening programme. This has not been the case in the UK. As outlined in this essay, greater effort could have been made to tackle the population risk factors before decision on implementing a  £50 million programme.   The screening programme could also be seen to negate the need for individuals to take responsibility for lifestyle behaviour and the risks associated with colorectal cancer. In terms of ‘The test’, it is simple, safe, precise and validated as per NSC guidance, and is generally acceptable in the population. Although, the essay has outlined the differences in uptake by socio-economic group and ethnicity. When considering ‘The Treatment’, there are effective treatments for patients identified through early detection, and this evidence has shown to lead to better outcomes than late treatment. The Screening Programme is based on good evidence from high quality Randomised Controlled Trials that the screening programme is effective in reducing mortality or morbidity and there is evidence that it is   clinically, socially and ethically acceptable to health professionals and the public. The benefits from the screening programme also outweigh the physical and psychological harm (caused by the test, diagnostic procedures and treatment).   The opportunity cost of the screening programme resource has been touched upon in this essay. The view is that all other options for managing the condition have not been fully considered, particularly primary prevention. Overall, the national bowel screening programme does provide a population drop in mortality.   The programme follows NSC guidance which is a benchmark for acceptability and although this essay supports the programme there still needs to be some further research undertaken in relation to uptake for specific population groups and the opportunity cost of the investment. References Allison, J., M. Tekawa, et al. (1996). A comparison of faecal occult-blood test for colorectal cancer screening. NEJM 334: 155-9. Donabedian, A. (1990), The seven pillars of quality’’, Archives of Pathology and Laboratory Medicine, Vol. 114, pp. 1115-18. Hardcastle JD, Chamberlain JO, Robinson MHE, Moss SM, Amar SS, Balfour TW et al. Randomised controlled trial of faecal occult blood screening for colorectal cancer. Lancet 1996, 348; 1472-1477 Hoff G, Bretthauer M (2008) Appointments timed in proximity to annual milestones and compliance with screening: randomised controlled trial. Br Med J 337: 2794 Khandker RZ, Dulski JD, Kilpatrick JB, Ellis RP, Mitchell JB, Baine WB: A decision model and cost-effectiveness analysis of colorectal cancer screening and surveillance guildelines for average-risk adults. Int J Tech Assess in Health Care 2000, 16;3:799-810. Kronborg O, Fenger C, Olsen J, Jorgensen OD, Sondergaard O. Randomised study of screening for colorectal cancer with faecal occult blood test. Lancet 1996; 348; 1467-1471 Levin, B., K. Hess, et al. (1997). Screening for colorectal cancer: a comparison of 3 faecal occult blood tests. Archives of Internal Medicine 157(9): 970-7. Lieberman DA: Cost-effectiveness model for colon cancer screening. Gastroenterology 1995, 109:1781-90. Mandel JS, Bond JH, Church JR, Snover DC, Bradley GM, Schuman LM et al. Reducing mortality from colorectal cancer by screening for faecal occult blood. N Engl J Med 1993; 328; 1365-1371 National Institute for Health and Clinical Excellence. 2007/042a updated.   NICE responds to judicial review outcome. NCIN, Cancer Incidence by Deprivation England, 1995-2004. 2008. NHS MEL(1998)62. Screening for Colorectal Cancer Office for National Statistics. 2010. statistics.gov.uk/sdataset.asp?9091 Price et al. 2010) BMC Health Services Research 2010, 10:103 biomedcentral.com/1472-6963/10/103 Rachet, B., et al., Population-based cancer survival trends in England and Wales up to 2007:an assessment of the NHS cancer plan for England The Lancet Oncology (2009). Raffle A, Gray M. Screening; Evidence and Practice, Oxford University Press, 2007. Rozen, P., J. Knaani, et al. (2000). Comparative screening with a sensitive guaiac and specific immunochemical occult blood test in an endoscopic study. Cancer 89: 45-52. Robb KA, Power E, Atkin W, Wardle J (2008) Ethnic differences in participation in flexible sigmoidoscopy screening in the UK. J Med Screen 15: 130–136 Salkeld, G., Solomon, M., Short, L., Ward, J. (2003). Measuring the impact of attributes that influence consumer attitudes to colorectal cancer screening. ANZ Journal of Surgery, 73, 128–132. Szczepura A, Price C, Gumber A (2008) Breast and bowel cancer screening uptake patterns over 15 years for UK south Asian ethnic minority populations, corrected for differences in socio-demographic characteristics. BMC Public Health 8: 346 The NHS Cancer Plan Department of Health, 2000. Towler BP, Irwig L, Glasziou P, Weller D, Kewenter J. Screening for colorectal cancer using the faecal occult blood test, Hemoccult (Cochrane Review). The Cochrane Library, Chichester, UK: John Wiley Sons, Ltd. Issue 3, 2004. Scottish Executive Health Department (2006). Cancer Scenarios: An aid to planning cancer services in Scotland in the next decade. Edinburgh: The Scottish Executive. Steele RJC, Gnauck R, Hrcka R, Kronborg O, Kuntz C, Moayyedi P, et al (2004) Methods and economic considerations, Report from the ESGE/UEGF workshop on colorectal cancer screening. Endoscopy; 36, 349-53. Steele RJC, McClements PL, Libby G et al. (2008) Results from the first three rounds of the Scottish demonstration pilot of FOBT screening for colorectal cancer. Gut 2009 58: 530-535 originally published online November 26, 2008 doi: 10.1136/gut.2008.162883 Tengs TO, Adams ME, Pliskin JS, Safran DG, Siegel JE, Weinstein MC et al (1995) Five hundred life-saving interventions and their cost-effectiveness. Risk Analysis; 15, 369-90. UK CRC Screening Pilot Evaluation Team (2003) Evaluation of UK Colorectal Cancer Screening Pilot – Final Report UK Colorectal Cancer Screening Pilot Group (2004) Results of the first cycle of a demonstration pilot of screening for colorectal cancer in the United Kingdom. British Medical Journal, doi:10.1136/bmj.38153.491887.7C ( published 5 July 2004) Von Wagner C, Semmler C, Good A, Wardle J (2009b) Health literacy and self-efficacy for participating in colorectal cancer screening: the role of information processing. Patient Education. 75: 352–357 Weller D, Coleman D, Robertson R, Butler P, Melia J, Campbell C, Parker R, Patnick J, Moss S (2007) The UK bowel cancer screening pilot: results of the second round of screening in England. Br J Cancer 97: 1601–1605 Weller, D., Alexander, F., Orbell, S. et al. (2003) Evaluation of the UK colorectal cancer screening pilot: final report. NHS Cancer Screening Programmes Worthley, D., Cole, S., Esterman, A., Mehaffey, S., Roosa, N., Smith, A., et al. (2006). Screening for colorectal cancer by faecal occult blood test: Why people choose to refuse. Internal Medicine Journal, 36, 607–610. Young GP, St John JB, Winawer SJ, Rozen P. Choice of Faecal Occult Blood Tests for Colorectal cancer Screening: Recommendations Based on Performance Characteristics in population Studies. A WHO (World Health Organisation) and OMED (World Organisation for Digestive Endoscopy) Report. The American Journal of Gastroenterology 2002:97(10) 2499-2507.

Systems in Organizations for Safety and Improvement Essay

Systems in Organizations for Safety and Improvement - Essay Example (Don Fienley). It is a fact that there is actually a medical revolution as far as medical improvements are concerned, such as fertility treatment, cancer cures, cardiac care and AIDS management are some of them to mention, on the other hand, in the United States health care system often fails to deliver on the promise of science it employs (Spear S. 79). This paper will look at some of the possible errors in this field and their remedies to prevent harm and injuries to the public. An earlier study showed that as many as 98000 people succumb to medication errors each ear in United States hospitals (Burke J). If this is the case of the health care conditions of country which leads the world in medical science, the situations in the third world can be beyond any calculations. Firstly, the medical errors include mistakes such as administering wrong dose, wrong drug or wrong time. Then, the eventualities such as misread prescription due to poor handwriting, mismanagement due to look-alike and sound-alike medicines and adverse drug reaction. Broadly, every nation and governments have made every possible step to make sure that the health care professionals are typically intelligent lot. ... The hospitals and organizations are to integrate systems to improve primary care, nursing care, medication administration and a great lot of clinical processes. All this improvements will have a direct impact on the safety, quality, efficiency, reliability and timeliness of healthcare (Spear S. 79). Improvement and understanding will only take place when the gap between the health care system and the professionals working in it will narrow. Communication Errors It is common knowledge that poor communication will lead to adverse effect and results. Unless and until all in a team becomes completely sure of the situation that must be dwelt with and work that is to be completed and who are responsible for what aspect of work, moreover, the way it should be accomplished, the chances of error will always be there. When a problem arises in between a task the best way is for everyone to work closely around the problem. 80% of errors were initiated by miscommunication, including missed communication between physicians, missing information in medical records, mishandling of patient requests and messages, inaccessible records, mislabeled specimens, misfiled or missing charts, and inadequate reminder systems (Smith Peter). Most of the communicative error will round up to one staff member's failure to inform the other staff member of a patient's condition or verbal instructions are misunderstood. Often, a subordinate is smart enough to identify the problem but bit nervous to mention it to the senior who may not give the deserved appreciation for the hard work. Lack of proper and purposeful communication often ends up in a failure to perform medical procedure properly for example placing a feeding tube into the lungs and cutting an organ

Week 5 Research Paper Example | Topics and Well Written Essays - 750 words

Week 5 - Research Paper Example From the output shown above, we can assess the categorical variables. This indicates that how many people gave each response. No mean or standard deviation requirement is appropriate as it does not make any sense for categorical variables, such as sex, marital status etc. From the table we can note that there are total of â€Å"537† with sub groups ranging from ‘0’ to ‘6’ along with frequency, percent, valid percent and cumulative percent. Frequency table for all other variables â€Å"number of persons living in this household, gender (male, female), helper (professional, service support, blue collar, unemployed/ Retired, student, DTS), marital status (Single, married, DTS), number of years in school(1-19yrs), ethnic(Asian, Mexican, Caucasian, black, Hispanic) and income(15000- 50,000 and above)† are similar to the categorical variable of children. The first table illustrates the gender with 325 female respondents and 212 male respondents. While the types of the problem experienced by the gender includes 229 respondents for goal disruptive, 209 relational break, 86 illnesses and 13 catastrophic. Second output elaborates that mean of the helper as dependent variable. The independent variable will be gender (male and female) and the problem experienced. The typical research question of interest is: do males and females differ significantly in experiencing problems, which problem is more among male or females? And is the influence of two variables idiosyncratic i.e gender has one effect in a particular problem, but a different effect in the different problem. There is no significant main effect for the problem as the M= - 0.2738 for Goal Disruptive , M= 0.1729 for relational break, M= 0.2742 for illness and M= 0.2672 for catastrophic. F= 12.187 and p=0.0000, a lot less than