Financial Research Report for Ford Motor Company Paper

Financial Report for Ford Motor Company - Research Paper Example The company, at present, is one of the biggest producers of cars and trucks at a global level. The different brands of Ford Company vehicles include Ford, Lincoln, Mercury and its redesigned Ford Mustang and the F-Series pickup which have been very successful. The company also possesses interest in Mazda and commands the Volvo nameplate. Ford Motor Company has 95 plants spread throughout the world with 41 distribution centers and warehouses. It also has 50 engineering, research and development centers. The company carries its operations under the two sections namely, Automotive and Financial Services. For the year ended on December 31, 2008, Ford traded the ACH glass business to Zeledyne, LLC. The Nashville, Tulsa, and VidrioCar plants were also included in this sale. In the year 2008, Ford and its subsidiary, the Volvo Car Corporation sold the Thai-Swedish Assembly Group to Volvo Holding Sverige, AB. The company was able to acquire 72.4% of the shares of S.C. Automobile Craiova SA in March 2008. The sale of the company's Jaguar and Land Rover operations to Tata Motors Limited took place in June 2008. The share value of Ford has reached $1.56. Steny Hoyer, the House Majority Leader told the Fox News Sunday that he expects that the plans of the companies will win governmental aid. However, its accountability and feasibility are yet to be seen in the long run. But the Republican leader Mr. John Boehner was sceptical about these plans. He remarked that it was a matter of convincing the American tax payers that the government was financing a viable corporation. The following is the stock activity of the company: Stock Activity Last Price 6.11 52 Week High 6.75 52 Week Low 1.01 Volume 54.58 Mil Average Daily Volume (13wk) 102.05 Mil 50 Day Moving Average 5.19 200 Day Moving Average 3.31 Volatility (beta) 2.55 F Intraday Chart 5d 1m 3m 1y 3y 5y 10y Beta 2.55 Dividend & Yield NA Earnings/Share -7.03 Forward P/E -15.28 Market Cap. 19.39 Bil P/E -0.86 Return on Equity NA Total Shares Out. 3.17 Bil Financial data in U.S. dollars (Source: http://moneycentral.msn.com /detail/stock_ quote'Symbol=F, retrieved on 14th June, 2009) Ford Motor must strive hard to find out new strategies to make the company progressive. That is what the Democrats told the executives of the major three companies last week, when they sought an emergency financial aid of $25 billion. They were told by the Democratic leaders to submit new proposals with bailout plans to Congress on 2nd December. On getting the proposals they would hold hearings for voting on it the next week. Stock Charts (2009-06-14) Ford Motor The companies have to prepare a plan as to how the governmental loans will be utilised and period for which the financial loans are required. In order to get these loans the companies must forego the payment of dividends and the huge amount of executive compensation. (http://articles.moneycentral.msn.com/Investing/Dispatch/market- dispatches-112408.aspx, retrieved on 14th June, 2009) Ratio analysis Gross Profit Margin 19.4% EBIT Margin -5.1% EBITDA Margin 4.4% Pre-Tax Profit Margin -12.8% Current Ratio 2.4 Quick Ratio 1.9 Receivables Turnover 1.2 Inventory Turnover 11.2 Asset Turnover 0.5 Revenue to Assets

Case study Gary hart Assignment Example | Topics and Well Written Essays - 2250 words

Case study Gary hart - Assignment Example 12,000 incurred the first week Analysis of revenues Revenue per day: 75%*60*24=?1,080 Payment in cash per day: 50%*1,080=?540 Revenue per month: 1,080*24=?25,920 Revenue per quarter: 25,920*3=?77,760 50% of daily sales are credit sales payable four weeks later Assumptions 1. Gary purchases ingredients once every month. 2. Waiting staff salaries and social security costs are payable every month. a. Gary’s Restaurant Trading cash budget For the year ended December 31, XXXX Quarter total 1 2 3 4 ? ? ? ? ? Cash b/f 48,484 126,364 213,248 Add receipts Cash sales 38,880 38,880 38,880 38,880 155,520 Collection from credit sales 77,760 77,760 77,760 77,760 311,040 Total cash available (A) 116,640 165,124 243,004 329,888 854,656 Less disbursement Kitchen staff 14,300 14,300 14,300 14,300 57,200 Waiting staff 3,432 3,432 3,432 3,432 13,728 Social security costs 5,200 5,200 5,200 5,200 20,800 Utilities 0 2,600 2,600 2,600 7,800 Rent 30,000 10,000 0 0 40,000 Council tax 2,000 2,000 2,000 2,000 8,000 Advertizing 12,000 0 1,000 1,000 14,000 Cost of ingredients 1,224 1,224 1,224 1,224 4,896 Total (B) 68,156 38,756 29,756 29,756 166,424 Cash balance (A-B) 48,484 126,364 213,248 300,132 688,228 b. ... ? Assets Current assets Debtors 9,720 Prepaid council tax 2,000 Fixed assets 50,000 61,720 Liabilities Creditors 0 Utilities due 650 Capital 61,070 61,720 Assumptions 1. The restaurant will pay all bills as they fall due, therefore there will be no creditors. 2. Utilities will be due since they are paid for the at the beginning of the following quarter; therefore those falling due December will be paid for beginning of January the following financial year. 3. I approximated the value of the restaurant’s fixed assets to be ?50,000 by the end of the first year. d. Gary’s Restaurant Weekly cash budget For the first month of operation Week 1 2 3 4 ? ? ? ? Cash b/f (27,240) (24,000) (21,168) Add receipts Cash sales 3,240 3,240 3,240 3,240 Credit sales 3,240 Total cash available (A) 3,240 (24,000) (20,760) (14,688) Less disbursement Kitchen staff 4,766.67 Waiting staff 1,144 Social security costs 1,733.33 Rent 10,000 Council tax 2,000 Advertizing 12,000 Cost of ingredients 40 8 Total (B) 30,480 408 7,644 Cash balance (A-B) (27,240) (24,000) (21,168) (22,332) Assumptions 1. Ingredients are ordered for and delivered within the first week, whereas their payment is made in the third week. 2. Staff salaries and security costs are paid for in the fourth week, assumed to be the end of month. 3. Gary’s restaurant will begin its operations in January, hence being the first moth of the restaurant’s operations. Working cash is the amount of money required for day to day operations within a business. This is a business’ capital in liquid currency that is necessary for purchasing assets to be used by the business and meeting various obligations of the business. Working cash of a business can also refer to the ability of a business to meet its liabilities and expenses that

Infosys Case Analysis Essay Example for Free

Infosys Case Analysis Essay ? Case analysis infosys document structure We have approached the case by first analyzing the identified issues, and then associate root causes to those issues. Further to it we have used two frameworks, â€Å"Web of Change† and â€Å"Hewitt Best Employer Characteristics†, to theoretically assess the weaknesses in Infosys Human Resource and Change Management policies. These frameworks can be used by organizations to better plan their change management and human resource management initiatives. We have used â€Å"Hewitt’s Best Employer Survey†, to identify the key initiatives which Infosys should undertake to enable it to reach its target of â€Å"Best Employer† by 2011. Further to it we believe that â€Å"Best Employer† and â€Å"Best Performer† are complementary goals, and it’s difficult to achieve one without the other, and hence we have identified the key initiatives which can help Infosys to achieve â€Å"Best Performer† target without compromising on its â€Å"Best Employer† objective. about infosys Infosys is the second largest Indian IT software services company. Infosys has reached pinnacles of success in short span of 20 years, through innovative business strategies and human resource practices. Currently it is facing challenges around balancing between business growth and employee satisfaction. About its business Model Infosys delivers IT services to its clients globally in a model called GDM (Global Delivery Model). The main characteristic of this model is that it decouples client location and project execution. Project is executed in locations which provide best combination of cost and talent. Project teams are spread across client site and offshore development centers in countries like India, China, and Mexico etc which provide rich availability of talent at competitive cost. Usually teams at client site document requirements and manage client relationship and offshore team manages delivery. This is a human resource intensive industry and the challenge is exacerbated by the fact that most of the resources are highly skilled professionals (engineers, MBAs, computer scientists etc). Being an industry where human resource is your only asset and your only competitive advantage, managing, ssues and Root Cause analysis In this section we’ll analyze the issues identified in the case and will attempt to identify root causes which led to employee dissatisfaction. After our analysis we believe that issues mentioned in the case is symptomatic of gaps in general principles of leadership, change management and HRM. Policies are not written in blood and stone, and they change ov er the lifetime of organizations. What should not change are basic organizations principles around human resource management. Our assessment is that policy changes in Infosys were reflective of external environment and business imperatives. However, diverging from the basic principles of Change management, leadership, communication and employee development in implementing new policies is what led to its fall in Best Employer ratings. â€Å"Stock Options started lacking luster to the new employees and created equity imbalance among employees† Stakeholders involved New Employees Discontentment Impact Inequity of income/wealth effect in the company which created tension between employees. New employees who had seen Infosys from outside as an organization committed to fairness, equity, and employee wealth creation got disenchanted. Root Cause Failure to Manage Expectations This issue primarily arose because of incorrect expectation setting of new employees. Infosys kept on using stock options and the millionaires’ stories as branding activity, even when stock options were no more an incentive to new recruits. Company should have made it very clear about its new compensation philosophy when it discontinued ESOPS. 1. Managing scale and attrition risk Stakeholders involved Employees Managers Discontentment Impact Infosys was growing at a speed where it was doubling its organizational strength every 1-2 years. However organization was plagued by high attrition rate. Employees felt lack of motivation, due to repetitive process tasks, which the business model demanded. Due to high growth, a lot of employees moved up the managerial ladder, but lacked proper training and orientation and hence couldn’t connect to employees Root Cause Lack of Employee fulfillment ( from the job ) Detached Lleaderships To stress on the need for the above two, we’ll give two examples from Indian public sector. Indian Railways Indian railways has recently transformed itself into a highly profitable organization, and according to the officer on special with Railways, single most critical factor which contributed to this success is involvement and commitment of employees of railways despite having a poor compensation structure. Employees of Indian railways take great pride in their work, since they believe they are contributing to the running of the country’s biggest infrastructure and are responsible for transporting of 2 crore customers every days. This association with organizational goal and pride in your organization is what makes an organization for perpetuity. Due to changing business needs, Iinfosys couldn’t connect to its employees in motivating them. Indian Army A unit commander in the army is able to inspire its soldiers to give up their life, compensation etc notwithstanding. The only reasons soldiers are so committed, is their immediate leader. It depends on the unit commander’s ability to connect to his soldiers, motivate them and show a genuine concern for their wellbeing, is what motivates the soldiers to do the unthinkable for their leader. According to research in human resources field, people leave managers and not companies. The leadership skills of managers are the greatest source of employee fulfillment at work. Lack of engagement and commitment of managers towards their subordinates, was probably the single biggest reason for high attrition rate at Infosys. 2. Strong formalization and process orientation, which came as part of growth, took away bandwidth to innovate from employees. Stakeholders involved Employees Discontentment Impact Employees who were used to getting the thrill and satisfaction from using their skill on technical challenges were feeling cocooned because of new process driven and re-use methodology. Similar impact was observed in people policy issues. All personal policies were getting more and more formalized. Root Cause Lack of employee Motivation Resistance to change One of the basic principles of organization design is that you don’t use strong formalization from highly skilled agents (employees). Formalization is for low skilled repeatable tasks. Infosys should have come up with business models aimed at high end, value added services much earlier. This would have kept its inherent talent not only motivated but better utilized for higher margins. In 1990s moving away from body shopping to GDM provide this opportunity, but in early to middle 2000s, Iinfosys couldn’t reinvent itself. Formalization in organizational policies when it grows out from entrepreneurial stage is inevitable. It’s actually needed to ensure consistent implementation of policies and create a sense of equity and fairness among employee. Dissatisfaction on this front could be attributed to resistance to change, and hence effective change management principles should be employed for disruptive changes. 3. Introduction of variable pay Stakeholders involved Employees Senior Management HR Department Discontentment Impact Variable pay was received with a lot of skepticism by the employees, fearing that it was introduced to reduce their compensation Root Cause/s Change Management Failure Lack of Leadership engagement Communication Failure This was probably one of the most disruptive changes introduced by Infosys. The amount of skepticism and distrust displayed by employees was a first in Infosys. Immediate reaction of employees was that this policy has been introduced to cut employee costs to satisfy shareholders demand for higher and higher profitability. The fact that a vast majority of senior management were shareholders in the company added to employee distrust. There was no clarity among employees how this policy will pan out. A lot of employees were not comfortable in linking their performance to factors outside their control (market conditions, decision taken by management etc). Also since the amount of variable component was high (more than 50% for project managers and above), employees could not understand how much their monthly take home were. This is a classic case of failure in change management and involvement of leadership at every level. Infosys data on variable payout shows that most of the time company has delivered 100% payout and even higher percentage to high performers. So employee skepticism bore from lack of clarity and communication on this policy. Lack of clarity, communication and involvement of employees was to such an extent that even middle management was taken by surprise by this policy. Many managers, who couldn’t appreciate the policy implementation, were reluctant in communicating the changes to the employees. For an employee first point of contact for clarification is his/her immediate line manager, hence it’s important to fully equip leadership at every level with information. To understand the role what leadership plays in motivating, retaining employees, we should look at armed forces. Unit commanders are able to motivate their employees to give their life, despite the fact that compensation package of soldiers is one of the lowest. This commitment in subordinates comes because of total commitment of their leader in engaging with them and motivating with them. Immediate line managers are the biggest reason employees leave an organization and are also the main reason employees go beyond their capabilities to outperform. 4. Retaining Organizational Culture with fast track growth Stakeholders involved HR Department Employees Discontentment Impact Due to business growth imperatives, and its business model, Infosys was doubling its employee strength every 1-2 years. To accommodate this type of growth, it had to lower its hiring standards and quality and culture was a victim of this. Root Cause/s Lack of Employee on boarding ( orientation) planning This issue had an impact on multiple facets. It led to a feeling disenchantment in existing employees, as they felt their brand equity in the market was getting diluted. New employees, who were not able to appreciate infosys inherent culture, didn’t felt comfortable and had a feeling that the organization is biased toward old employees. Root cause of this issue was that although organization had changed its selection criteria, it didn’t change its employee orientation strategy, or training methodology. Infosys should have changed its orientation program to be more customized offering for similar group of employees and using existing employees as mentor to help develop organizational culture and values in new employees. Similarly if you are hiring for quantity and not quality, it should have modified its training plan to be more exhaustive. 5. Broad Banding and promotions Stakeholders involved Employees Discontentment Impact Lack of faith in the organization Chaos and confusion in employees minds Root Cause/s Change Management Communication Leadership This policy again created a lot of employee discomfort since they didn’t knew the details of change. It’s again a classic change management failure. Although the policy was designed to bring more clarity in role structure and bring equity amongst similar roles, across the organization, poor communications created fear and scientism in minds of people. We can observe from the reinvention of Indian Railways, one of the reasons organization could progress on the growth trajectory, was employee commitment to the cause of Indian Railways, despite of low compensation. Employees felt proud to be part of the world’s biggest railways and were motivated to excel. Some of the senior managers lacked clarity about policies, hence they were apprehensive of clarifying the policy. This shows a major organizational failure in terms of change management and engagement of leadership with people. Similarly as discussed above, since employee appraisal parameters were not clearly defined, an employee could not appreciate how his/her appraisal going to impact promotions? Web Of Change – Change Management Framework To do substantiate our above understanding of issues at Iinfosys, we used â€Å"Web of Change†, a change management framework to understand the change management issues at Infosys. â€Å"Web of change: is the framework proposed by Stephen Thomas. This model defines 8 change elements as shown below and the web of change helps us to see how the values of each element changed during the Organization Change process in Infosys. The baseline score is the value of the Change elements in Infosys during the glory years of 1990’s and the re-assessment scores the value of the same change elements in the 2000’s when Infosys was going through the â€Å"Growth pangs†.

Factors Affecting Antipsychotic Medication Compliance

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

Discuss the Role of the Inspector in An Inspector Calls Essay -- An In

Birlings, he controls the development of events: who will speak and when; who may or may not leave; who will or will not see the photograph. He even Priestley describes the Inspector, when he first appears on stage, in terms of 'massiveness, solidity and purposefulness' (p.11), symbolizing the fact that he is an unstoppable force within the play. His 'disconcerting habit of looking hard at the person he addresses before speaking' (p.11) gives the impression that he sees through surface appearances to the real person beneath. It also gives him a thoughtfulness that contrasts with the thoughtlessness of each character's treatment of the girl. His role in the play is not simply to confront each character with the truth, but to force each character to admit the truth they already know. He works methodically through the characters present one at a time, partly because he recognizes that 'otherwise, there's a muddle' (p.12), and partly because, given the chance, the characters are all quick to defend each other, or to call upon outside help (such as Colonel Roberts) in order to avoid accepting the truth of what he suggests. He arrives just after Birling has been setting out his views of life: that every man must only look out for himself. The Inspector's rule is to show that this is not the case. Throughout the play he demonstrates how people are responsible for how they affect the lives of others; his views are summed up in his visionary and dramatic final speech: that 'we are members of one body. We are responsible for each other' (p.56). Responsibility is one of the play's two key themes, and the Inspector is Priestley's vehicle for putting across his own views of this as a socialist. In this final speec... ...led as both an alcoholic and a thief. After the Inspector has gone, Birling simply wants things to return to the way they were. He cannot understand Sheila's and Eric's insistence that there is something to be learnt, and he is relieved and triumphant when he feels that scandal has been avoided and everything is all right. Right up until the end, he claims that 'there's every excuse for what both your mother and I did - it turned out unfortunately, that's all' (p.57). Birling is not the cold and narrow-minded person that his wife is; he simply believes in what he says. He is a limited man, who is shown to be wrong about many things in the play; it is the Birlings of the world whom Priestley feared - in 1945 - would not be willing or able to learn the lessons of the past, and so it is to the younger generation that Priestley hopefully looked instead...

There Are No Children Here Essay example -- Essays Papers

There Are No Children Here Alex Kotlowitz was a freelance journalist. In 1985 a friend came to him and asked him to write a text for a photo essay he was doing on (children living in poverty) for a Chicago magazine. That is when he met the Rivers brothers, Lafeyette, age ten, and Pharoah age seven. He spent only a few hours with them interviewing for the photo essay. Lafeyette had an impact on Kotlowitz. When asked what he wanted to be, Lafeyette responded with "If I grow up, I'd like to be a bus driver." Meaning, at ten years old, he wasn't sure if he'd make it to adulthood. In 1988 Kotlowitz suggested to the boys' mother, LaJoe, the idea of writing a book about Pharoah, Lafeyette and the other children in the neighborhood. LaJoe liked the idea. However, she then said, "But you know, there are no children here. They've seen too much to be children." Alex Kotlowitz entitled his book, There Are No Children Here. It is a story of two brothers growing up in a housing project of Chicago. By the author following the boys throughout their day to day lives, we, the readers, are also enveloped in the boys' surroundings. We learn about their everyday lives, from how they pick out their clothes, to how they wash them. We go to school with them and we play with them. Throughout the book, we are much like flies on the wall. We see and feel everything the boys' go through at Henry Horner Homes, the project where they live. LaJoe moved into the Henry Horner...

Difference Between Necessity and Private Defence Essay

The two grounds of justification known as necessity and private defence are closely related. In both cases the perpetrator protects interests which are of value to her, such as life, physical integrity and property, against threatening danger. The distinctions between these two grounds of justification are the following (Snyman C.R: 2008): (1) the origin of the situation of emergency: Private defence always stems from an unlawful (and therefore human) attack; necessity, on the other hand, may stem either from an unlawful human act, or from chance circumstances, such as natural occurrences. (2) the object at which the act of defence is directed: Private defence is always directed at an unlawful human attack; necessity is directed at either the interests of another innocent third party or merely amounts to a violation of a legal provisio: E.G: X, who has a gun, tells Y that he kidnapped Y’s daughter and orders Y, the bank manager, to use his code to open the safe of the bank and to hand him all the money inside the safe. If Y does not do what he says he, X will kill his daughter. If Y hands him the money he will be harming the bank and therefore act in necessity. If he takes his own gun and shoot X because he knows that X lied and that his daughter is safe, he will be acting in private defence to protect this own and the interest of the bank. The distinction between necessity and private defence is also illustrated by the requirements for the successful plea of the grounds of justification (necessity and private defence). These requirements are described below: NECESSITY A person acts out of necessity – and her conduct is therefore lawful – if she acts in the protection of her own or somebody else’s life, physical integrity, property or other legally recognised interest which is endangered by a threat of harm which has already begun or is immediately threatening and which cannot be averted in any other way; provided that the person who relies on the necessity is not legally compelled to endure the danger, and the interest protected by the act of defence is not out of proportion to the interest threatened by such an act (Burchell, J:2004). This defence arises when a person is confronted with a choice between suffering an injustice and breaking the law. It is regularly used to justify actions in emergencies. One would, for instance, be able to rely on necessity against a charge of speeding when driving a person requiring urgent medical care to hospital. Requirements of Necessity (1) Some legal interest of X, such as her life, physical integrity or property must be threatened. In principle, one should also be able to protect other interests such as dignity, freedom and chastity in a situation of necessity. (2) One can also act in a situation of necessity to protect another’s interest, for example where X protects Z from being attacked by an animal. (3) The emergency must already have begun or be imminent, but must not have terminated, nor be expected in the future only. (4) Whether a person can rely on the defence of necessity if she herself is responsible for the emergency, is a debatable question. In our opinion X should not be precluded from successfully raising this defence merely because she caused the emergency herself. If she were precluded, this would mean that if, because of X’s carelessness, her baby swallowed an overdose of pills, X would not be allowed to exceed the speed limit while rushing the baby to hospital, but would have to resign herself to the child’s dying (compare the facts in Pretorius supra). The two acts, namely the creation of danger and rescue from it, should be separated. If the first act amounts to a crime X can be punished for it, for example where she sets fire to a house and then has to break out of the house to save her own life (Milton, J.R.L:1997). (5) If somebody is legally compelled to endure the danger, she cannot rely on necessity. Persons such as policemen, soldiers and firemen cannot avert the dangers inherent in the exercise of their profession by infringing the rights of innocent parties. Another aspect of this rule is that a person cannot rely on necessity as a defence if what appears to her to be a threat is in fact lawful (human) conduct. Thus it was held in Kibi 1978 (4) SA 173 (EC) that if X is arrested lawfully, he may not damage the police van in which he has been locked up, in order to escape from it. (6) The act committed in necessity is lawful only if it is the only way in which X can avert the threat or danger. Where, for example, Z orders X to kill Y and threatens to kill X if she does not obey, and it appears that X can overcome her dilemma by fleeing, she must flee, and if possible, seek police protection (Bradbury 1967 (1) SA 387 (A) 390). (7) X must be conscious of the fact that an emergency exists, and that she is therefore acting out of necessity. There is no such thing as a chance or accidental act of necessity. If X throws a brick through the window of Y’s house in order to break in, and it later appears that by so doing she has saved Z, who was sleeping in a room filled with poisonous gas, from certain death, X cannot rely on necessity as a defence. (8) The harm occasioned by the defensive act must not be out of proportion to the interest threatened, and therefore X must not cause more harm than is necessary to escape the danger. It is this requirement which is the most important one in practice, and it can also be the most difficult to apply. The protected and the impaired interests are often of a different nature, for example where somebody damages another’s property in protecting her own physical integrity.