Bill M. Beverly Essays - Dating, Interpersonal Relationships

Bill M. Beverly English 099-LS1 Essay #1 March 3, 2017 What a date When it comes to dating, some people have forgotten what the actual definition means. The idea of d ating has not been around as long as people might think and it can be misunderstood . There are three types of dating that one can be involved with : intimate encounters , online dating , and courting . D ating can be a very complex activity, considering different personalities and goals . When speaking of i ntimate encounters , there generally is not a lot of commitment. S ome people treat this type of dating like escorting but without being paid for services rendered. This type of rendezvous has no strings attached , which usually include just one - time encounters , but could lead to more depending on the connection made . Prostitution could even be defined as this type of encounter when the services rendered are paid. People dat e just for fun without committing in any way with the other p arty . People also date on their mobile phones by s exting , which is texting each other explicit pictures and intimate messages. Another type of mobile phone dating uses the applications of Facetime or Skype. These options use video calls where the other party is visibly live in real-time on the other end of the line. Flings also use these means of communication by people to have relationships whether sexual interac tion is to be included or not. Sometimes, it is not always about the sex but more about just having a fun night out , which people need every once in a great while. Online dating has been a successful means of connecting with others. Websites like E - H armony , which is the so-called #1 trusted online dating site , is used by all ages of men and women. This website has been the most successful per reviews from the website and users alike for connecting people with like personalities and traits . A person undergoes a very detailed application process to have a profile activated on the website. This allows the user to search and find their match , which c ould lead to either marriage or soul mate. T inder , is another online website that can be used as an online rendezvous /no strings attached method of connection . There are some precautions to take heed with when dating online. For example, the transfer of sextually transmitted diseases, where contraceptive measures are not utilized or p regnancy even if a contraceptive is to be us ed , being that it is only 99% effective. Lastly, the website Match.com , which is the leading online dating site for relationships , is typically used by older people. With the same features as E-Harmony, Match.com claims that is has the same features. People can have a lot of success while dating online but sometimes relationships do not work out. Courting is the oldest , most traditional form of dating. Dating in this way is the more proper and practical approach. There is one on one with no family interaction at the start. Flowers being brought to the first date is usually a sign of respect towards the other party. People can use this version of dating if they will be seeking out a long-term relationship with someone. This also brings into question the idea of consummation. Consummation is defined as having sexual intercourse to make marriage or a romantic relationship complete. When courting is involved, the parties will respectfully spend time with the potential spouse's family . T his is depending on how far into a relationship the parties are planning to go. After courting, an engagement is usually the next step , preceded by the purchas e of a ring for proposal. Another factor brought into the relationship is the determination of God's will for them to be married. If this is the case, the eng aged couple will possibly wait until the wedding night to consummate the relationship making it complete and faithful. D ating can be a very complex life choice , w ith regards to different people and their personalities

The Program on Smoking Cessation for Employees

The Program on Smoking Cessation for Employees Introduction There are a number of programs on smoking cessation design for employees that are premised on various data analysis techniques. Despite the diversity of data collection methods, all the programs are aimed at improving employees’ lifestyles and creating new incentives for increasing employees’ productivity and performance.Advertising We will write a custom essay sample on The Program on Smoking Cessation for Employees specifically for you for only $16.05 $11/page Learn More Moreover, there is a growing trend in evaluating the practices and improving the strategies on creating a program. The systematic evaluation can allow managers to solve problems and help community-based organizations to improve the quality of services and working conditions. Despite the veritable understanding of evaluation of program evaluation, there is a need for creating a comprehensive framework. Therefore, analysis of other frameworks for programs on smokin g cessation will help to integrate successful data collection and analysis methods that can contribute to the quality of program outcomes. The evaluation process implies investigating worth, significance, and merits of efforts made during the program implementation. Invention of new methods and approaches has been developed to embrace the multiple aspects of the program, define its strengths and weaknesses, and outline significance and main elements of the data collection process. All these procedures will provide a better understanding of how the program can be improved and modified to reach greater objectives and goals. Finally, the evaluation process has great importance for governmental organizations that assess the usefulness and validity of the programs for future implementation in other settings. The program under analysis focuses on a smoking cessation opportunity for employees. It involved 70 participants who plan to quit smoking; 11 participants managed to quit smoking, wh ich pointed to the success of the program and its future potential.Advertising Looking for essay on health medicine? Let's see if we can help you! Get your first paper with 15% OFF Learn More Certainly, though the ratio of the participants who had quit smoking was not significant, there were still methods and alternative researches that could help understand how to improve this program and increase the number of employees who were ready to give up smoking. Main Discussion Integrating Data Collection Methods into the Program Evaluation Plan With regard to the above-presented background, the program involved only 70 participants and it was based on a local hospital in Ohio. The success of the program is evident because it was primarily based on observation process, as well as on the results of employees’ interviewing in a natural setting. Nevertheless, the framework within which the program was implemented did not allow the researchers to create great e ffect on the participants. In this respect, it is purposeful to assess related programs on smoking cessation to define which methods could be integrated into data collection methods. The studies by Shershneva et al. (2011) have introduced a spectrum of approaches and methods that allowed the researchers to reach over 43,000 clinicians (p. 29). What is more important is that the program involved collation of comparison data among different program components to define the degree of its effectiveness. Such an approach could be applied to define how employees of Ohio hospital can enhance their incentives to take part in programs and increase number of those who are ready to quit smoking. In addition, the assessment of employees performance through implementation of 4 levels of evaluation, including participation, satisfaction, learning, and performance also contributes to better outcomes through engagement of the 5 A’s algorithm. Specifically, the algorithm involves, â€Å"Ask about tobacco use, advise to quit, Assess readiness to quit, Assist with cognitive/behavioral strategies, assist with medication, Assist with relapse prevention, and Arrange for follow up† (Shershneva et al., 2011, p. 29).Advertising We will write a custom essay sample on The Program on Smoking Cessation for Employees specifically for you for only $16.05 $11/page Learn More Such an extensive overview of aspects and factors influencing employees’ behavior and perception would allow Ohio hospital program to expand its techniques and improve the quality of goals achievement. In order to accomplish the program purpose and establish a multi-strategic approach to change, implementing knowledge management and skills enhancement is crucial. Skills and experiences are vital to reach the objectives in the most effective way, as well as increase the usefulness of the training program. In this respect, Labib et al. (2012) have conducted an evaluation of th e training program to define how background knowledge and skills influence the outcomes (p. 52). Similar to Shershneva et al. (2011), the scholars have employed the 5 A’s algorithm for implementing the program objectives (p. 30). These studies have significant implications for integrating medical education in smoking cessation programs. Training healthcare personnel, therefore, is an essential condition for increasing employees’ awareness of the negative effects of smoking. The data collection methods implemented by Volpp et al. (2009) are premised on randomized sampling of employees working for a multinational company to gain data about programs on smoking cessation, as well as on the effectiveness of these programs in terms of financial incentives (p. 699). Analyzing and selecting the participants gathered across the United States was carried out through surveys that encouraged the employees to give information about their smoking habits and their willingness to part icipate in the program. In contrast to these approaches, the Ohio program on smoking cessation did not involve financial incentives for employees; rather it aimed to check for employees’ awareness of the necessity to quit smoking that is not linked to financial rewards. Nevertheless, implementing surveys could also be beneficial for the program accomplishment.Advertising Looking for essay on health medicine? Let's see if we can help you! Get your first paper with 15% OFF Learn More Strengths and Weaknesses of Data Collection Sources Assessment the strengths and weaknesses of the data collection sources creates a new insight into possible methods and approaches to conducting programs and developing efficient plans for health promotion. Due to the fact that the main purpose of the program on smoking cessation consisted in improving healthy lifestyles of their employees, the focus on cost reduction and insurance seems to be irrelevant. In order to define the potential strengths and weakness of the program, specific emphasis should be placed on the target participants involved into data analysis, the framework for interpreting data, which method is the safest for collecting data and information processing, and understanding the appropriate value of those who provide information. In addition, the methods for data collection should also be discussed in terms of their influence on the target populations. Finally, the availability of resources for collecting informati on should also be considered, including financial perspective, personnel, and level of skills and experiences. The research studies presented by Volpp et al. (2009) also reveal beneficial approaches to data collection methods that could be employed into the program at issue (p. 700). In particular, the scholars apply to the stratification process of employees in accordance with place of work, level of smoking dependence, and income. Such an approach has not been implemented into the program at Ohio hospital, although it could have provided a better picture of results and findings and that of the level of employees’ readiness to quit smoking. However, the program has the stratification of employees in accordance with age, which provides the strong side of the programs in terms of its applicability to the employees regardless of age. The main strength of the program lies in the availability of the cost-benefit analysis of its outcomes. In particular, the Ohio program on smoking cessation ensures that the more employees are invited into the program, the more moneys will be saved through the insurance cost reduction. What is more important is that the program seeks to increase employees’ productivity through considering financial incentives. Contrary to the benefits of the studies conducted by Volpp et al. (2009), there is strong necessity to introduce alternative programs that do not imply money as the main incentive for successful outcomes (p. 701). Hence, presence of financial incentive is the tangible weakness of the program because there should be other effective ways for raising employees’ awareness and reducing their dependence on smoking. In particular, Labib et al. (2012) argue that focus on training of health care professionals has a positive impact on improved smoking cessation outcomes because it encourages employees’ readiness to participate in the programs and improve the overall quality of services (p. 53). Knowledge dist ribution, therefore, is considered to be vital for triggering cessation interventions. According to Labib et al. (2012), â€Å"one of the major barriers in starting a smoking cession campaign or practice is that many health professionals do not have the skills and knowledge of how to intervene† (p. 56). In this respect, the program could have been premised on other incentives than monetary support. Another weakness of the program lies in insufficient number of employees taking part in the program. The sample does not provide perspectives for utilizing this program in future development of health care environment. Limited number of participants contributes to the selection biases. Similar problems are provided in the studies by Labib et al. (2012) that have confirmed the restriction imposed on the program implementation (p. 57). The value of appropriate sample, however, is presented in the program evaluations provided by Shershneva et al. (2012, p. 31) and Volpp et al. (2009, p. 700) who offered a much greater sample. Threats to the Data Collection Process While implementing a qualitative approach to the data collection process, there might be data biases related to the nature of observation of participants in natural environments, as well as to the depth and objectivity of conducted interviews. For example, such aspects as gender, language patterns, age, and ethnicity can affect the data analysis due to the focus of the study. Data collector bias is connected with the unconscious information distortion while collecting data. For instance, the interviewers can resort to different styles in posing questions to the respondents and such a bias is a decisive factor in case interviewing is the primary source for analysis. With regard to the program, the researchers have introduced age characteristics only and failed to consider other aspects of data collection process. Despite the fact that it does not influence greatly the program outcomes, it can negatively contribute to the accuracy and internal validity of the research. Apart from threats to internal validity, there are also hazards to the external validity as well. This is of particular concern to the selection effects that can either be delineated or replicated. Setting effects are also taken into consideration while estimating the employees’ influence on the surrounding setting and vice versa. Due to the cultural and social diversity, the outcomes of the program can also be different. Finally, the employees might perceive the scope of the program differently due to a multi-strategic approach chosen to conduct a program. As a result, some terms and definitions can be understood in a different way. Similar concerns are connected to the employees’ perception of the explanation provided by the researchers. For instance, some of participants might think that the main incentive of smoking cessation is insurance reduction rather than improvement of the health care environm ent. In fact, the reduced costs constitute only the cause of the program purposes. Data Analysis Procedures Due to the fact that the program is primarily based on the statistical evaluation of the results, the data analysis procedures should involve review of related programs on smoking cessation – a qualitative approach to estimating the practical significance of the data. This type of inductive qualitative analysis will provide a wider explanation for the program value in terms of employees’ behavior and other qualitative characteristics. In particular, the literature surveys will guide the researchers through different data analysis approaches that have been used in related programs on smoking cessation. Depending on methodology and research design, the literature review can also assist researchers in developing an efficient framework for data processing. Quantitative analysis is also essential for estimating the cost-benefit analysis of the program, as it is presen ted in the case. In this respect, the program focuses on the statistic evaluation of the age of participants who plan to quit smoking. With regard to the presented case, the chosen data analysis procedures should involve a mixed method of evaluation to insurance that both observations and statistical data, including age, gender, and other attributes, have been carefully considered. Such a decision is enhanced by the evidence received from related studies on smoking cessation programs. In particular, although not all research studies resort to the analysis of literature reviews, all of them apply to statistical analysis of the received data (Volpp et al., 2009, p. 700; Labib et al., 2012, p. 56; Shershneva et al., 2011, p. 32). Specific attention requires the studies by Chan and Heaney (1997), in which the focus is on quantitative research (p. 352). In fact, statistics allows the scholars to define which of the mentioned characteristics are the most important for the program outcome (Boulmetis Dutwin, 2005, p. 123). Qualitative aspects are revealed through presenting the conceptual framework under which various notions and definitions are presented. The conceptual framework is of high important for the program under evaluation as well, because it will allow the research to provide a detailed objective explanation of the research goals, procedures, and definitions to the participants. Practical and Statistical Significance of Data The importance of incentives included into the program implementation process is important both for the researchers and for the focus group (Posavac, 2010, p. 15). In this respect, the studies by Volpp et al. (2009) proves that the presence of financial incentives can significantly foster the employees’ engagement into the program accomplishment as compared to those participants who are triggered only by the awareness of the potential benefits of smoking cessation (p. 705). Within the context of this research, it can be stated that the program under analysis could have integrated this aspect to promote greater results. Statistical significance of the data involved into the process demonstrates how numerical data allows the program managers to conclude how the project influences employees’ awareness of smoking cessation initiative. Essential Elements of Program Evaluation Report A Program Evaluation Report should be based on the analysis of five important components that include philosophy and goals, needs assessment (analysis of the participants), program planning procedures, implementation, and the evaluation itself (Boulmetis Dutwin, 2005, p. 156). To begin with, the program has clearly stated its goals and objectives that are confined to creating incentives for employees to quit smoking, promoting healthy lifestyles, and developing a multi-strategic approach to change. Reduction of insurance costs is another important outcome of the program on smoking cessation. Needs assessment focuses on the target audience involved into the program. In this respect, the case shows that the participants are not limited to age, gender, and ethnicity, which imposes certain biases on the results. As per program planning procedures, the case study does not provide sufficient explanation for the stages of employees’ participation. Instead, it refers to the outcomes and benefits of the program accomplishment. The program implementation focus has sufficient presentation. In addition, the program outcomes have proved that its goals and objectives directly relate to the expected results. Finally, the evaluation process itself has managed to address such important issues, as data collection methods and all possible biases related to them. Such an assessment allows the program managers to predict possible threats and risks in future. Research Utilization Processes The results of the program demonstrate that employees’ engagement into the evaluation process creates cost benefits for t he hospital, irrespective of the number of employees who quit smoking. Irrespective of age of individuals who quit, the program is worth utilizing for future practices. Despite the win-win situation, the program could be advanced to provide potential benefits for employees’ welfare and future promotion of healthy lifestyles. Hence, the program both benefits the hospital and the employees. Despite the fact that the hospital employing the participants was the focus of the program, it still has a positive effect on the employees’ physical and mental health. In this respect, the utilization processes could be used for two major purposes – to develop alternative incentives for employees to quit smoking and introduce cost benefits for the hospital. Such perspectives of the utilization processes can convince stakeholders to employ the program in their settings. Conclusion The analysis of the program on smoking cessation held at Ohio hospital has outlined to major advan tages – development of incentives for employees to promote healthy lifestyles and improve their performance, as well as reduction of insurance costs that the hospital should cover for sustaining employees’ health. The program has also been evaluated concerning the data collection methods, strengths and weakness of data analysis, potential threats to implementing data collection resources, and possible utilization processes that can be used to guide practices in health care. All these aspects have revealed advantages and disadvantages of the program. In particular, the analysis of literature related to the program has provided the necessity to select a mixed method for estimating the participants and the outcomes. Involvement of qualitative and quantitative data is indispensible for enhancing practical and statistical significance of the data. The main weakness of the program lies in irrelevant approach chosen for selecting the population sample. References Boulmetis, J ., Dutwin, P. (2005). The ABCs of Evaluation: Timeless Techniques for Program and Project Managers. US: John Wiley and Sons. Chan, W., Heaney, C. A. (1997). Employee Stress Levels and the Intention to Participate in a Worksite Smoking Cessation Program. Journal of Behavioral Medicine, 20(4), 351-364. Labib, N., Radwan, G., Salama, R., Horeesh, N. (2012). Evaluation of Knowledge Change of Internal Medicine Residents Following a Training Program in Smoking Cessation. Pakistan Journal of Medical Research, 51(2), 52-58. Posavac, E. J. (2010). Program Evaluation: Methods and Case Studies. US: Pearson. Shershneva, M., Larrison, C., Robertson, S., and Speight, M. (2011). Evaluation of a collaborative program on smoking cessation: Translating outcomes framework into practice. Journal of Continuing Education in the Health Professions, 31, 28-36. Volpp, K. G., Troxel, A. B., Pauly, M. V., Glick, H. A., Puig, A., Asch, D. A., Audrain-McGovern, J. (2009). A Randomized, Controlled Trial of F inancial Incentives for Smoking Cessation. New England Journal of Medicine, 360(7), 699-709.

Comparison between Manual Gear and Automatic Gear Research Paper

Comparison between Manual Gear and Automatic Gear - Research Paper Example Such a transmission is made up of a series of gears that are used to produce the rotational force needed to turn the wheels of the vehicle. The transmission unit of a car which is commonly called a gear box has gears which transfer power form the engine of the car to its wheels. The transmission has to be equipped with multiple gears in that the car operates on the proper gear in different situations. The gearboxes are of multiple types with the difference being the determinant factor of how a car will operate. There are two main types of gears; manual gear and automatic gears. Modern cars have been equipped with two major transmission options, namely; manual or automatic transmission. There exist a number of differences between these transmission types with regards to their components, how they operate, the advantages and disadvantages associated with them and their applications. This paper is going to look at the differences evident between automatic transmission and manual transmission. A manual gearbox type is a car transmission which permits the driver to choose gears as he or she wishes with the use of a stick shift. For the driver to select the desired gear, the clutch pedal has to be depressed making it unique to cars with manual transmission (Zheng W. Chung et al 2007). This move disengages the gearbox disconnecting it from the engine. Once the desired gear has been chosen through having the shifter moved to the correct position, the clutch is now free and can be released. This action reconnects the gearbox and the engine. Manual transmission can be classified into two types; the constant-mesh type and the sliding-gear design. In the sliding gear design, its main parts are the cluster and drive gear. On each gear is a dog clutch fitted with a hub, a shaft and an outer ring (Zheng W. Chung et al 2007). Synchronizers are also fitted to prevent clashing of the gears. The hub mainly splines the drive gears while

Experience of an International Student Essay Example | Topics and Well Written Essays - 750 words

Experience of an International Student - Essay Example Older people are notably more well respected that the younger ones. Contradicting the opinions of older people is considered as a taboo in my native country. In other words, if your ideas tend to undermine the ideas of the person who is older than you are, you better keep your ideas to yourself if you don't want to offend the sensibilities of the older person. While growing up in Asian household, I deal with adult members of the family most of the time. My close associate with adults led me to become more humble and modest as our culture demands for it. Because of the strong influence of my elders in shaping my character, I tend to behave just as modestly as I would around older people when I am with my peers. Unfortunately, my modesty often leads my peers to underestimate me. This situation is really frustrating for me. While in America, I try to see things more differently. I want to broaden my horizon and embrace the freedom of expression. I am confident that having a broader pers pective of things will open up wider latitude for me to realize my dreams. Yes, I lot of people from my native land may not really understand my need to be free from the bounds of culture and practices but I feel that being able to express my true self is very important. I believe that creativity is one of the best ways to express ones uniqueness. Creativity has always fascinated me as one of the most important human characteristics. Unfortunately, I think creativity is at odds with modesty.

Unfair Treatment of Minorities in the Criminal Justice System Essay

Unfair Treatment of Minorities in the Criminal Justice System - Essay Example Unfair Treatment of Minorities in the Criminal Justice System The U.S. criminal justice system has come under critical public scrutiny in the recent years for one of the age-old problems afflicting the nation - racial discrimination. The present research attempts a review of criminal justice administration in the U.S. with a view to establishing the thesis that minorities, Blacks and Latinos, are discriminated against at every stage within the criminal justice system - the racial minorities are charged with more serious crimes, have less opportunity to plea-bargain, are convicted more frequently, and receive harsher sentences when compared with Caucasians in similar situations. The scope of the research is limited to the extent of establishing the thesis and shall not attempt to analyze the underlying causes and/or examine the possible strategies for ensuring equal justice to all. It is significant to note that the issue of unfair treatment of minorities has been a subject of research and academic interest by mainly social science researchers and lawyers. While researchers tend to disagree on the sources of disparity or overrepresentation of minorities, as to whether it is due to disproportionate involvement in criminal offenses or to criminal justice system biases, there is a general consensus that minorities are disproportionately represented and are treated unfairly at almost every stage of the justice system. [Kramer and Steffensmeir, 1993; Blumstein, 1993; Cole, 1999] A review of the available research is attempted to understand how researchers have approached and addressed the issue. According to Coramae Mann, racial discrimination is endemic to the United States; it permeates the criminal justice system and all other American institutions, resulting in the unjust treatment of racial minorities. She claims that when the "more flagrant, systemic means of economic and political control of minorities used in the past were no longer feasible or morally acceptable ... criminal law began to be used to warehouse American minorities and maintain their unequal status." [Mann, 1993; p. 127] David Cole, a professor at Georgetown University Law Center and an attorney with Center for Constitutional Rights, who studied unequal racial justice in the U.S. claims that "our [the U.S.] criminal justice system affirmatively depends on inequality" [Cole, 1999; p.5] He claims that in the absence of race and class disparities the criminal justice system could not have afforded the policy of mass incarceration pursued since the 1980s. Cole claims that African Americans, who constitute 12 percent of the general population, comprise more than half of the prison population and have higher arrest and conviction rates, serve longer sentences, face higher bail amounts and are often victims of police use of deadly force than white citizens. [Cole, 1999; p.4] According to Cassia Spohn, blacks and Hispanics who are young, male, and unemployed are particularly more likely than their white counterparts to be sentenced to prison and receive longer sentences in some jurisdictions. Spohn's study also claim that minorities convicted of drug offences, those with longer prior criminal

Effectiveness of Support for Children in Homeless Families

Effectiveness of Support for Children in Homeless Families The whole issue of parents and children in need is a vast, complex and ethically challenging one. This review is specifically charged with an examination of those issues which impinge upon the stresses and strains that are experienced by parents of children in need. A superficial examination of these issues that are involved in this particular area would suggest that there are a number of â€Å"sub-texts â€Å"which can all give rise to this particular situation. Firstly, to have child in need is clearly a stressful situation for any parent.(Meltzer H et al. 1999) This can clearly be purely a financial concern and a reflection of the fact that the whole family is in financial hardship, perhaps due to the economic situation or perhaps due to the actions of the parents themselves. Equally the need of the child can be a result of anon-financial need, so we should also consider the child who is in some way handicapped, ill, emotionally disturbed or perhaps in need in some other way. This produces another type of stress on the parent, and these stresses are typically longer lasting and, in general, less easily rectified than a purely financial consideration of need. (Hall D1996). It is part of the basic ethos of the welfare state that it should look after its less able and disadvantaged members. (Welsh Office 1997).Parents of children in need will often qualify in this definition. We shall therefore examine the various aspects of this problem. Literature Review Effectiveness of family support for children in homeless families We will make a start by considering one type of child in need. The first paper that we will consider is that of Prof. Vostanis (Vostanis2002), which looks at the mental health problems that are faced by deprived children and their families together with the effectiveness of the resources that are available to them. It is a well written and well researched paper, if rather complex and confusing in places. We will consider this paper in some detail as it provides an excellent overview of the whole area. The paper starts with a rather useful definition for our purposes. It qualifies the deprived child, initially in terms of a homeless family, that being : A family of any number of adults with dependent children who are statutorily accepted by local authorities (housing departments) in teak, and are usually accommodated for a brief period in voluntary agency, local authority or housing association hostels. This period of temporary accommodation can vary enormously depending on the time of year and the area considered, and can range from a few days to perhaps several months. The target in Greater London is currently storehouse homeless families within 4-6 weeks. In London particularly, the homeless families can be placed in Bed Breakfast accommodation.(D of H 1998) In this respect, the immediate family support mechanisms do appear tube in place. Vostranis however, goes on to make the observation that despite the fact that the definition of the homeless family is rather broad, it does not cover all of the potential children in need, as those children and their carers who have lost their homes but have managed to live with relatives, on the streets or perhaps live as travellers, are not covered by the statutory obligation to provide housing. The official figures therefore, he observes, are generally an underestimate of the true situation. The official figures for the homeless families are put (in this paper) at 140,000. (Vostanis Cumella, 1999) The authors give us further information in that many families will become homeless again within one year of rehousing and the typical family seen is the single mother and at least two children who are generally under the age of 11 yrs. They also observe that the typical father and adolescent child tend to be placed in homeless centres. (Doff H 1995) In exploration of the particular topic that we are considering, the authors give us the situations that typically have given rise to the degree of parental stress that may have led to the homelessness. They point to the fact that a homeless family is usually homeless for different reasons to the single homeless adult. Vostanis (et al 1997)is quoted as showing that 50% of the cases studied were homeless as direct result of domestic violence and 25% as a result of harassment from neighbours. The authors observe that the numbers in this category(and therefore the problems), are rising. (Welsh Office 1999). There are a number of section to this paper which are not directly referable to our considerations. We shall therefore direct our attention purely to those parts that have a direct bearing on the subject. One particularly useful and analytical part of the paper is the section that details the characteristics and needs of the target group. This is a very detailed section, but it makes the point that the children in need in this group are particularly heterogeneous, generally all with multiple and inter-related needs. Homelessness is seldom a one off event. This particular observation, (say the authors),is crucially important for the development and provision of services. Most families have histories of previous chronic adversities that constitute risk factors for both children and parents (Bassuk et al,1997). Such events include family conflict, violence and breakdown; limited or absent networks for family and social support; recurring moves; poverty; and unemployment. Mothers are more likely to have suffered abuse in their own childhood and adult life and children have increased rates of placement on the at-risk child protection register, because of neglect, physical and/or sexual abuse. If we specifically consider the health needs of this population, the authors categorise them thus: The children are more likely to have a history of low birthweight, anaemia, dental decay and delayed immunisations, to be of lower stature and have a greater degree of nutritional stress. They are also more likely to suffer accidents, injuries and burns. (BPA 1999) Some studies have found that child health problems increase with the duration of homelessness, although this finding is not consistent. Substantial proportion of homeless children have delayed development compared with the general population of children of a similar chronological age. This includes both specific developmental delays, such as in receptive and expressive language and visual, motor and reading skills, as well as general skills and educational status (Webbet al. 2001). It is for this reason specifically, that it has proved extremely difficult to assess the effectiveness of the family support services because of the multivariate nature of the problems that are presented. The authors point to the fact that one of the prime determinants of the degree of support available, is the actual access that the families have to these services. Many sources (viz. Wilkinson R 1996), equate the poor health of the disadvantaged primarily with the lack of access to services. One immediate difficulty is the current registration system in the UK. In order to be seen in the primary healthcare team setting, one must be registered with a named doctor. In the majority of cases that we are dealing with here, they have moved area and registration is probably not high on their list of priorities. One can argue that there is the access to the A E departments of the local hospitals but there is virtually no continuity here and they arena geared up to provide anything other than immediate treatment. (HallD 1996). This fact restricts their access to primary healthcare team procedures such as immunisations and other preventative medicine health clinics.(Lissauer et al, 1993) . By the same token these groups also have restricted access to the social services, whether they be the access teams, the family teams or the family support units and other agencies. The authors also point to other more disruptive trends in this group such as an inability to attend a particular school for fear of being tracked by an abusive partner. It follows that these children do not have a stable social support of a school. They are denied such factors as peer groups, routines and challenges which are both important protective and developmental factors. (Shankleman J et al2000). The summation of all of these factors, and others, is that the effectiveness of the family support services is greatly reduced by the mobility and the transient nature of the family unit. Quite apart from the difficulties outlined above relating to the problems of access to avenues of help open to the child in need and their families there are the problems engendered by the fact that social service departments indifferent areas of the country may not have immediate access to the previous records giving rise to many potential, and real, problems with continuity of care. This problem is brought into more immediate focus when one considers the increased frequency of child protection registrations in this particular group. (Hall D et al 1998). One specific analysis of the family support services of this particular group comes in the form of the psychiatric services. In the context of the title of this piece, it demonstrates how these particular services,(but not these alone), are failing to deal with the totality of the problem. All of the aspects that we have outlined so far are conspiring to dilute the effectiveness of the services provided. The fact that they are a mobile population with no fixed address means that some of the services may choose to invoke this as a reason for not making provision for them, particularly if resources are stretched. If more resources are given, then they are typically preferentially targeted at the single adult homeless population where the need is arguably greater. The authors of this paper point to the fact that this may not actually be true as some studies have shown that homeless single mothers and their children have a 49% psychopathy rate and only an 11% contact with the support services. (Cumella et al, 1998). The impact of this fact on the children can only be imagined. To an extent however, it can be quantified as the authors cite other studies which show a 30% need rating for children, (they do not actually define exactly what their perceived level of need was), contrasted with a 3% contact rate for children and adolescents in this area. (viz. Power S et al. 1995). Suggestions for improvement Putting these considerations together, the authors outline a set of proposals which are designed to help improve the access to some of the essential services. The model that they propose could, if successful and with a degree of modification, prove suitable for adaptation to other areas of the family support services. It is not appropriate to discuss this model in detail, but suffice it to say that it has tiered structure so that the degree of distress and need is titrated against the degree of input generated. One of the reasons that we have selected this particular paper to present in this context is for its last section. It proposes a â€Å"family support services model† which has been developed and pioneered in the Leicester area. In the context of our review, it is worth considering in some detail. A service provided through a family support team (four family support assistants).This is designed to detect a range of problems at the time of crisis; manage a degree of mental health problems (behavioural and emotional); provide parenting-training; support and train housing(hostel) staff; co-ordinate the work of different agencies; and provide some continuity after rehousing by ensuring intake by appropriate local services. The family workers are based at the main hostel for homeless children and families. Other, predominantly voluntary, services have established alternative posts, such as advocates and key workers. Whatever the title of the post, it is essential that the post-holder has some experience and on-going training in mental health and child protection, so that he or she can hold a substantial case-load, rather than merely mediate between already limited services. The family support workers have direct access to the local child and adult mental health services, whose staff provide weekly outreach clinics. Their role is to work with the family support workers another agencies, assess selected children and families, and provide treatment for more severe problems or disorders such as depression, self-harm and PTSD. A weekly inter-agency liaison meeting at the main hostel is attended by a health visitor, representatives of the local domestic violence service and Sure Start, There are also close, regular links with education welfare and social services. The aim is to effectively utilise specialist skills by discussing family situations from all perspectives at the liaison meeting. A bimonthly steering group, led by the housing department, involves senior managers representing these agencies, as well as the education and social services departments and the voluntary sector, and they oversee and co-ordinate the service. This appears to be something of an exemplar in relation to services provided elsewhere. The paper does not provide any element of costing sin this area neither does it provide any figures in relation to its success rates, contact rates or overall effectiveness. In conclusion this paper is an extremely well written and authoritative overview of the situation relating to the stresses of the homeless parent with children and the effectiveness (or lack of it) in its ability to reduce the stresses experienced by the homeless children in need and their parents. It proposes remedies but sadly it does not evaluate the effectiveness of those remedies. The effectiveness of the support services on families of children with psychiatric morbidity In order to address these shortcomings we can consider another paper by Tickler (et al 2000). This looks at a similar outreach set up which has been designed to capture the families of children in need who might otherwise slip through the net. This paper is written from different perspective and specifically analyses the effectiveness of these services as they pertain to an entry cohort of 40 families. This particular study was set up after preliminary work was done in the Birmingham area with 114 homeless families and this study defined the needs of the families but did not quantify their support systems.(Vostanis et al 1998). This paper set out to identify and measure the support systems available and their effectiveness as far as the families were concerned. The stresses encountered were partly reflected by the incidence of psychiatric morbidity. The mothers in the group were found to have over 50% more morbidity than a matched control group. The children in the group were found to have â€Å"histories of abuse, living in care, being on the at-risk protection register, delayed communication and higher reported mental health problems.† Allot which adds to the general background stress levels. (Kerouac S etal. 1996). This particular study found that despite the psychiatric morbidity in the children, (estimated to be about 30%), and the psychiatric morbidity in the parents, (estimated at about 50%), only 3%of the children and 10% of the parents had had any significant contactor support from the social services. In this respect, this paper is very useful to our purpose as it quantifies the levels of intervention and access to healthcare resources that this particular group has. By any appreciation, it would be considered woefully inadequate in any society that calls itself civilised. In the terms of the title of this piece, the effectiveness of the family support services is minimal. Suggestions for improvement Like the last paper discussed, this one also considered how best to tackle the problem, and this one is of much greater value to us, as it specifies a response, or intervention, to the problem in much the same way as the Vostranis 2002 paper did, but it makes the same measurements as it did prior to the intervention, and therefore allows us an insight into the actual effectiveness of the intervention. The way this particular study worked was to assess the problem (as it has been presented above), devise an intervention strategy and then to measure its effect. This particular study goes to great lengths to actively involve all the appropriate agencies that could help the situation by having a central assessment station that acted as liaison between all of the other resources. In brief, it actively involved liaison with the following: Education, social services, child protection, local mental health services, voluntary and community organisations to facilitate there-integration of the family into the community, and particularly their engagement with local services following rehousing; and training of staff of homeless centres in the understanding, recognition and management of mental illness in children and parents. This is essential, as hostel staff often work in isolation and have little knowledge of the potential severity and consequences of mental health problems in children. It was hoped that, by doing this, it would maximise the impact that the limited resources had on reducing the levels of morbidity and stress in the families of the children in need. Results The post intervention results were, by any estimate, impressive considering the historical difficulty of working with this particular group (OHara M 1995). 40 families (including 122 children) were studied in detail. The paper gives a detailed breakdown of the ethnic and demographic breakdown of the group. By far the biggest group were single mothers and children (72%) The results showed that the majority of referrals were seen between1-3 times (55%), with a further 22% being seen 4-6 times. It is reflection of the difficulty in engaging this type of family in need that over 25% did not actually keep their appointments despite the obvious potential benefits that could have been utilised. The authors investigated this group further and ascertained that a common reason for nonattendance was the perception that the psychological welfare of the children was not actually the main concern. The families perceived that their primary needs were rehousing and financial stability. Other priorities identified were that physical health was a greater priority than mental health. The authors also identify another common failing in the social services provision, and that is the general lack of regular contact. They cite the situation where some families cope well initially, apparently glad to have escaped an abusive or violent home situation, but a prolonged stay in a hostel or temporary accommodation may soon precipitate a bout of depression in the parents and behavioural problems in the children of such parents. (Brooks RM et al 1998). They suggest that regular re-visiting of families who have been in temporary accommodation for any significant length of time should be mandatory. This paper takes a very practical overview by pointing out that workability of the system is, to a large extent, dependent on the goodwill of a number of committed professionals. The authors state that this has to be nurtured and they call for sufficient funding must be given to enable this particular model to be extended to a National level. Thus far in the review we have considered the effectiveness of the service provision in the support of the families of the children in need in one specific target grouping, those who are stressed by virtue of the fact that they are homeless. We will now consider the literature on a different kind of family stress, and that is when a parent dies. This leaves the children with a considerable amount of potential emotional â€Å"baggage† and the surviving parent with an enormous amount of stress. (Webb E 1998). Effectiveness of support services in the case of parental bereavement An excellent paper by Downey (et al 1999) tackles this particular problem with both sensitivity and also considerable rigour. It is a long and complex paper, but the overall aims and objectives are clear from the outset. The structure of the paper is a prospective case study which aims to assess whether the degree of distress suffered by a family during a time of bereavement is in any way linked to the degree of service provision that is utilised. The base line for this study is set out in its first two paragraphs. Parentally bereaved children and surviving parents showed a greater than predicted level of psychiatric morbidity. Boys had greater levels of demonstrable morbidity than did girls, but bereaved mothers showed more morbidity than did bereaved fathers. Children were more likely to show signs of behavioural disturbance when the surviving parent manifested some kind of psychiatric disorder. (Kranzler EM et al 1990). The authors point to the fact that their study shows that the service provision is statistically related to a number of (arguably unexpected[Fristad MA et al 1993]) factors namely: The age of the children and the manner of parental death. Children under 5 years of age were less likely to be offered services than older children even though their parents desired it. Children were significantly more likely to be offered services when the parent had committed suicide or when the death was expected. Children least likely to receive service support were those who were not in touch with services before parental death. Paradoxically the level of service provision was not found to be statistically significantly related to either the parental wishes or the degree of the psychiatric disturbance in either the parent orchid. (Sanchez L et al 1994) The service provision did have some statistical relationships but that was only found to be the manner of the parental death and the actual age of the child at the time. The authors therefore are able to identify a mismatch between the perceived need for support and the actual service provision made. Part of that mismatch is found to be due to the inability of the social services and other related agencies to take a dispassionate overview. Elsewhere in the paper the authors suggest that there are other factors that add to this inequality and they include lack of resources and a lack of specificity in identifying children at greatest risk.(Harrington R 1996) The authors examine other literature to back up their initial precept that bereaved children have greater levels of morbidity. They cite many other papers who have found distress manifesting in the form of â€Å"anxiety, depression, withdrawal, sleep disturbance, and aggression.†(Worden JW et al. 1996) and also psychological problems in later life(Harris T et al. 1996). In terms of study structure, the authors point to methodological problems with other papers in the area including a common failing of either having a standardised measure or no matched control group(Mohammed D et al 2003). They also point to the fact that this is probably the first UK study to investigate the subject using a properly representative sample and certainly the first to investigate whether service provision is actually related to the degree of the problems experienced. The entry cohort involved nearly 550 families with 94 having children in the target range (2-18). With certain exclusions (such as two families where one parent had murdered the other etc.) and no respondents, the final cohort was reduced to 45 families and one target child was randomly selected from each family. It has to be noted that the comparatively large number of on-respondents may have introduced a large element of bias, insofar as it is possible that the families most in need of support were those who were most distressed by the death of a family member and these could have been the very ones who chose not to participate. (Morton V et al2003) The authors make no comment on this particular fact. The authors should be commended for a particularly ingenious control measure for the children. They were matched by asking their schoolteacher to complete an inventory of disturbed behaviour on the next child in the school register after the target child. A large part of the paper is taken up with methodological issues which ( apart from the comments above) cannot be faulted. Results In terms of being children in need, 60% of children were found to have â€Å"significant behavioural abnormalities† with 28% having scores above the 95th centile. In terms of specific service support provision, 82% of parents identified a perceived need for support by virtue of the behaviour of their children. Only 49% of these actually received it in any degree. Perhaps the most surprising statistic to come out of this study waste fact that of the parents who were offered support 44% were in the group who asked for it and 56% were in the group who didn’t want it. The levels of support offered were independent of the degree of behavioural disturbance in the child. Suggestions for improvement As with the majority of papers that we have either presented here or read in preparation for this review, the authors call for a more rationally targeted approach to the utilisation of limited resources. The study also provides us with a very pertinent comment which many experienced healthcare professionals will empathise with, (Black D1996), and that is: Practitioners should also be aware that child disturbance may reflect undetected psychological distress in the surviving parent. While not suggesting that this is a reflection of Munchausen’s syndrome by proxy, the comment is a valid reflection of the fact that parental distress may be well hidden from people outside of the family and may only present as a manifestation of the child’s behaviour. (Feldman Met al. 1994) The conclusions that can be drawn from this study are that there is considerable gap in the support offered ( quite apart form the effectiveness of that support) in this area of obvious stress for both parents and children. (Black D 1998). This study goes some way to quantifying the level of support actually given in these circumstances. Effectiveness of support in families where there is domestic violence We have considered the role of the effectiveness and indeed, even the existence, of adequate support services for the children in need and their parents in a number of different social circumstances. The next paper that we wish to present is an excellent review of the support that is given to another specific sub-group and that is women and children who suffer from domestic violence. Webb and her group (etal 2001) considered the problem in considerable (and commendable) depth The study itself had an entry cohort of nearly 150 children and their mothers who were resident in a number of hostels and women’s refuges that had been the victims of family violence at some stage in the recent past. The study subjected the cohort to a battery of tests designed to assess their physical, emotional and psychological health, and then quantified their access to, and support gained from, the primary healthcare teams and other social service-based support agencies. This study is presented in a long and sometimes difficult tread format. Much of the presentation is (understandably) taken up with statistical, ethical and methodological matters – all of which appear to be largely of excellent quality and the result of careful consideration. Results The results make for interesting and, (in the context of this review), very relevant reading. Perhaps one of the more original findings was that nearly 60% of the child health data held by the various refuges was factually incorrect. This clearly has grave implications for studies that base their evidence base on that data set(Berwick D 2005). Of great implication for the social services support mechanisms was the finding that 76% of the mothers in the study expressed concerns about the health of their children. Once they had left the refuge there was significant loss to the follow up systems as 15% were untraceable and25% returned to the home of the original perpetrator. The study documents the fact that this particular group had both high level of need for support and also a poor level of access to appropriate services. In the study conclusions, the authors make the pertinent comment that the time spent in the refuge offers a â€Å"window of opportunity† for the family support services to make contact and to review health and child developmental status. This is not a demographically small group. In the UK, over 35,000children and a parent, are recorded as passing through the refuges each year, with at least a similar number also being referred to other types of safe accommodation. Such measures are clearly not undertaken lightly with the average woman only entering a refuge after an average of 28separate assaults. One can only speculate at the long term effects that this can have on both the mother and the children. Suggestions for improvement In common with the other papers reviewed, this paper also calls for greater levels of support for the families concerned as, by inference, the current levels of effectiveness of the family support services is clearly inadequate. Conclusions This review has specifically presented a number of papers which have been chosen from a much larger number that have been accessed and assessed, because of the fact that each has a particularly important issue or factor in its construction or results. The issue that we have set out to evaluate is the effectiveness of the family support services which are specifically aimed at reducing the stress levels for the parents of children in need. Almost without exception, all of the papers that have been accessed (quite apart from those presented) have demonstrated the fact that the levels of support from the statutory bodies is â€Å"less than optimum† and in some cases it can only be described as â€Å"dire†. Another factor that is a common finding, is that, given the fact that any welfare system is, by its very nature, a rationed system, the provision of the services that are provided is seldom targeted at the groups that need it the most. One can cite the Tickler (et al 2000)and Downey (et al 1999) papers in particular as demonstrating that substantial proportion of the resources mobilised are actually being directed to groups that are either not requesting support or who demonstrably need it less than other sectors of the community. Some of the papers (actually a small proportion) make positive suggestions about the models for redirecting and targeting support. Sadly, the majority do little more than call for â€Å"more research to be done on the issue†. In overview, we would have to conclude that the evidence suggests that the effectiveness of the family support services in reducing stress and poverty for the parents of children in need is poor at best and certainly capable of considerable improvement. References Bassuk, E., Buckner, J., Weiner, L., et al (1997) Homelessness in female-headed families: childhood and adult risk and protective factors. American Journal of Public Health, 87, 241–248 1997 Berwick D 2005 Broadening the view of evidence-based medicine Qual. Saf. Health Care, Oct 2005; 14: 315 316. Black D. 1996 Childhood bereavement: distress and long term sequelae can be lessened by early intervention. BMJ 1996; 312: 1496 Black D. 1998 Coping with loss: bereavement in childhood. BMJ 1998; 316: 931-933 BPA 1999 British Paediatric Association. Outcome measures for child health. London: Royal College of Paediatric Effectiveness of Support for Children in Homeless Families Effectiveness of Support for Children in Homeless Families The whole issue of parents and children in need is a vast, complex and ethically challenging one. This review is specifically charged with an examination of those issues which impinge upon the stresses and strains that are experienced by parents of children in need. A superficial examination of these issues that are involved in this particular area would suggest that there are a number of â€Å"sub-texts â€Å"which can all give rise to this particular situation. Firstly, to have child in need is clearly a stressful situation for any parent.(Meltzer H et al. 1999) This can clearly be purely a financial concern and a reflection of the fact that the whole family is in financial hardship, perhaps due to the economic situation or perhaps due to the actions of the parents themselves. Equally the need of the child can be a result of anon-financial need, so we should also consider the child who is in some way handicapped, ill, emotionally disturbed or perhaps in need in some other way. This produces another type of stress on the parent, and these stresses are typically longer lasting and, in general, less easily rectified than a purely financial consideration of need. (Hall D1996). It is part of the basic ethos of the welfare state that it should look after its less able and disadvantaged members. (Welsh Office 1997).Parents of children in need will often qualify in this definition. We shall therefore examine the various aspects of this problem. Literature Review Effectiveness of family support for children in homeless families We will make a start by considering one type of child in need. The first paper that we will consider is that of Prof. Vostanis (Vostanis2002), which looks at the mental health problems that are faced by deprived children and their families together with the effectiveness of the resources that are available to them. It is a well written and well researched paper, if rather complex and confusing in places. We will consider this paper in some detail as it provides an excellent overview of the whole area. The paper starts with a rather useful definition for our purposes. It qualifies the deprived child, initially in terms of a homeless family, that being : A family of any number of adults with dependent children who are statutorily accepted by local authorities (housing departments) in teak, and are usually accommodated for a brief period in voluntary agency, local authority or housing association hostels. This period of temporary accommodation can vary enormously depending on the time of year and the area considered, and can range from a few days to perhaps several months. The target in Greater London is currently storehouse homeless families within 4-6 weeks. In London particularly, the homeless families can be placed in Bed Breakfast accommodation.(D of H 1998) In this respect, the immediate family support mechanisms do appear tube in place. Vostranis however, goes on to make the observation that despite the fact that the definition of the homeless family is rather broad, it does not cover all of the potential children in need, as those children and their carers who have lost their homes but have managed to live with relatives, on the streets or perhaps live as travellers, are not covered by the statutory obligation to provide housing. The official figures therefore, he observes, are generally an underestimate of the true situation. The official figures for the homeless families are put (in this paper) at 140,000. (Vostanis Cumella, 1999) The authors give us further information in that many families will become homeless again within one year of rehousing and the typical family seen is the single mother and at least two children who are generally under the age of 11 yrs. They also observe that the typical father and adolescent child tend to be placed in homeless centres. (Doff H 1995) In exploration of the particular topic that we are considering, the authors give us the situations that typically have given rise to the degree of parental stress that may have led to the homelessness. They point to the fact that a homeless family is usually homeless for different reasons to the single homeless adult. Vostanis (et al 1997)is quoted as showing that 50% of the cases studied were homeless as direct result of domestic violence and 25% as a result of harassment from neighbours. The authors observe that the numbers in this category(and therefore the problems), are rising. (Welsh Office 1999). There are a number of section to this paper which are not directly referable to our considerations. We shall therefore direct our attention purely to those parts that have a direct bearing on the subject. One particularly useful and analytical part of the paper is the section that details the characteristics and needs of the target group. This is a very detailed section, but it makes the point that the children in need in this group are particularly heterogeneous, generally all with multiple and inter-related needs. Homelessness is seldom a one off event. This particular observation, (say the authors),is crucially important for the development and provision of services. Most families have histories of previous chronic adversities that constitute risk factors for both children and parents (Bassuk et al,1997). Such events include family conflict, violence and breakdown; limited or absent networks for family and social support; recurring moves; poverty; and unemployment. Mothers are more likely to have suffered abuse in their own childhood and adult life and children have increased rates of placement on the at-risk child protection register, because of neglect, physical and/or sexual abuse. If we specifically consider the health needs of this population, the authors categorise them thus: The children are more likely to have a history of low birthweight, anaemia, dental decay and delayed immunisations, to be of lower stature and have a greater degree of nutritional stress. They are also more likely to suffer accidents, injuries and burns. (BPA 1999) Some studies have found that child health problems increase with the duration of homelessness, although this finding is not consistent. Substantial proportion of homeless children have delayed development compared with the general population of children of a similar chronological age. This includes both specific developmental delays, such as in receptive and expressive language and visual, motor and reading skills, as well as general skills and educational status (Webbet al. 2001). It is for this reason specifically, that it has proved extremely difficult to assess the effectiveness of the family support services because of the multivariate nature of the problems that are presented. The authors point to the fact that one of the prime determinants of the degree of support available, is the actual access that the families have to these services. Many sources (viz. Wilkinson R 1996), equate the poor health of the disadvantaged primarily with the lack of access to services. One immediate difficulty is the current registration system in the UK. In order to be seen in the primary healthcare team setting, one must be registered with a named doctor. In the majority of cases that we are dealing with here, they have moved area and registration is probably not high on their list of priorities. One can argue that there is the access to the A E departments of the local hospitals but there is virtually no continuity here and they arena geared up to provide anything other than immediate treatment. (HallD 1996). This fact restricts their access to primary healthcare team procedures such as immunisations and other preventative medicine health clinics.(Lissauer et al, 1993) . By the same token these groups also have restricted access to the social services, whether they be the access teams, the family teams or the family support units and other agencies. The authors also point to other more disruptive trends in this group such as an inability to attend a particular school for fear of being tracked by an abusive partner. It follows that these children do not have a stable social support of a school. They are denied such factors as peer groups, routines and challenges which are both important protective and developmental factors. (Shankleman J et al2000). The summation of all of these factors, and others, is that the effectiveness of the family support services is greatly reduced by the mobility and the transient nature of the family unit. Quite apart from the difficulties outlined above relating to the problems of access to avenues of help open to the child in need and their families there are the problems engendered by the fact that social service departments indifferent areas of the country may not have immediate access to the previous records giving rise to many potential, and real, problems with continuity of care. This problem is brought into more immediate focus when one considers the increased frequency of child protection registrations in this particular group. (Hall D et al 1998). One specific analysis of the family support services of this particular group comes in the form of the psychiatric services. In the context of the title of this piece, it demonstrates how these particular services,(but not these alone), are failing to deal with the totality of the problem. All of the aspects that we have outlined so far are conspiring to dilute the effectiveness of the services provided. The fact that they are a mobile population with no fixed address means that some of the services may choose to invoke this as a reason for not making provision for them, particularly if resources are stretched. If more resources are given, then they are typically preferentially targeted at the single adult homeless population where the need is arguably greater. The authors of this paper point to the fact that this may not actually be true as some studies have shown that homeless single mothers and their children have a 49% psychopathy rate and only an 11% contact with the support services. (Cumella et al, 1998). The impact of this fact on the children can only be imagined. To an extent however, it can be quantified as the authors cite other studies which show a 30% need rating for children, (they do not actually define exactly what their perceived level of need was), contrasted with a 3% contact rate for children and adolescents in this area. (viz. Power S et al. 1995). Suggestions for improvement Putting these considerations together, the authors outline a set of proposals which are designed to help improve the access to some of the essential services. The model that they propose could, if successful and with a degree of modification, prove suitable for adaptation to other areas of the family support services. It is not appropriate to discuss this model in detail, but suffice it to say that it has tiered structure so that the degree of distress and need is titrated against the degree of input generated. One of the reasons that we have selected this particular paper to present in this context is for its last section. It proposes a â€Å"family support services model† which has been developed and pioneered in the Leicester area. In the context of our review, it is worth considering in some detail. A service provided through a family support team (four family support assistants).This is designed to detect a range of problems at the time of crisis; manage a degree of mental health problems (behavioural and emotional); provide parenting-training; support and train housing(hostel) staff; co-ordinate the work of different agencies; and provide some continuity after rehousing by ensuring intake by appropriate local services. The family workers are based at the main hostel for homeless children and families. Other, predominantly voluntary, services have established alternative posts, such as advocates and key workers. Whatever the title of the post, it is essential that the post-holder has some experience and on-going training in mental health and child protection, so that he or she can hold a substantial case-load, rather than merely mediate between already limited services. The family support workers have direct access to the local child and adult mental health services, whose staff provide weekly outreach clinics. Their role is to work with the family support workers another agencies, assess selected children and families, and provide treatment for more severe problems or disorders such as depression, self-harm and PTSD. A weekly inter-agency liaison meeting at the main hostel is attended by a health visitor, representatives of the local domestic violence service and Sure Start, There are also close, regular links with education welfare and social services. The aim is to effectively utilise specialist skills by discussing family situations from all perspectives at the liaison meeting. A bimonthly steering group, led by the housing department, involves senior managers representing these agencies, as well as the education and social services departments and the voluntary sector, and they oversee and co-ordinate the service. This appears to be something of an exemplar in relation to services provided elsewhere. The paper does not provide any element of costing sin this area neither does it provide any figures in relation to its success rates, contact rates or overall effectiveness. In conclusion this paper is an extremely well written and authoritative overview of the situation relating to the stresses of the homeless parent with children and the effectiveness (or lack of it) in its ability to reduce the stresses experienced by the homeless children in need and their parents. It proposes remedies but sadly it does not evaluate the effectiveness of those remedies. The effectiveness of the support services on families of children with psychiatric morbidity In order to address these shortcomings we can consider another paper by Tickler (et al 2000). This looks at a similar outreach set up which has been designed to capture the families of children in need who might otherwise slip through the net. This paper is written from different perspective and specifically analyses the effectiveness of these services as they pertain to an entry cohort of 40 families. This particular study was set up after preliminary work was done in the Birmingham area with 114 homeless families and this study defined the needs of the families but did not quantify their support systems.(Vostanis et al 1998). This paper set out to identify and measure the support systems available and their effectiveness as far as the families were concerned. The stresses encountered were partly reflected by the incidence of psychiatric morbidity. The mothers in the group were found to have over 50% more morbidity than a matched control group. The children in the group were found to have â€Å"histories of abuse, living in care, being on the at-risk protection register, delayed communication and higher reported mental health problems.† Allot which adds to the general background stress levels. (Kerouac S etal. 1996). This particular study found that despite the psychiatric morbidity in the children, (estimated to be about 30%), and the psychiatric morbidity in the parents, (estimated at about 50%), only 3%of the children and 10% of the parents had had any significant contactor support from the social services. In this respect, this paper is very useful to our purpose as it quantifies the levels of intervention and access to healthcare resources that this particular group has. By any appreciation, it would be considered woefully inadequate in any society that calls itself civilised. In the terms of the title of this piece, the effectiveness of the family support services is minimal. Suggestions for improvement Like the last paper discussed, this one also considered how best to tackle the problem, and this one is of much greater value to us, as it specifies a response, or intervention, to the problem in much the same way as the Vostranis 2002 paper did, but it makes the same measurements as it did prior to the intervention, and therefore allows us an insight into the actual effectiveness of the intervention. The way this particular study worked was to assess the problem (as it has been presented above), devise an intervention strategy and then to measure its effect. This particular study goes to great lengths to actively involve all the appropriate agencies that could help the situation by having a central assessment station that acted as liaison between all of the other resources. In brief, it actively involved liaison with the following: Education, social services, child protection, local mental health services, voluntary and community organisations to facilitate there-integration of the family into the community, and particularly their engagement with local services following rehousing; and training of staff of homeless centres in the understanding, recognition and management of mental illness in children and parents. This is essential, as hostel staff often work in isolation and have little knowledge of the potential severity and consequences of mental health problems in children. It was hoped that, by doing this, it would maximise the impact that the limited resources had on reducing the levels of morbidity and stress in the families of the children in need. Results The post intervention results were, by any estimate, impressive considering the historical difficulty of working with this particular group (OHara M 1995). 40 families (including 122 children) were studied in detail. The paper gives a detailed breakdown of the ethnic and demographic breakdown of the group. By far the biggest group were single mothers and children (72%) The results showed that the majority of referrals were seen between1-3 times (55%), with a further 22% being seen 4-6 times. It is reflection of the difficulty in engaging this type of family in need that over 25% did not actually keep their appointments despite the obvious potential benefits that could have been utilised. The authors investigated this group further and ascertained that a common reason for nonattendance was the perception that the psychological welfare of the children was not actually the main concern. The families perceived that their primary needs were rehousing and financial stability. Other priorities identified were that physical health was a greater priority than mental health. The authors also identify another common failing in the social services provision, and that is the general lack of regular contact. They cite the situation where some families cope well initially, apparently glad to have escaped an abusive or violent home situation, but a prolonged stay in a hostel or temporary accommodation may soon precipitate a bout of depression in the parents and behavioural problems in the children of such parents. (Brooks RM et al 1998). They suggest that regular re-visiting of families who have been in temporary accommodation for any significant length of time should be mandatory. This paper takes a very practical overview by pointing out that workability of the system is, to a large extent, dependent on the goodwill of a number of committed professionals. The authors state that this has to be nurtured and they call for sufficient funding must be given to enable this particular model to be extended to a National level. Thus far in the review we have considered the effectiveness of the service provision in the support of the families of the children in need in one specific target grouping, those who are stressed by virtue of the fact that they are homeless. We will now consider the literature on a different kind of family stress, and that is when a parent dies. This leaves the children with a considerable amount of potential emotional â€Å"baggage† and the surviving parent with an enormous amount of stress. (Webb E 1998). Effectiveness of support services in the case of parental bereavement An excellent paper by Downey (et al 1999) tackles this particular problem with both sensitivity and also considerable rigour. It is a long and complex paper, but the overall aims and objectives are clear from the outset. The structure of the paper is a prospective case study which aims to assess whether the degree of distress suffered by a family during a time of bereavement is in any way linked to the degree of service provision that is utilised. The base line for this study is set out in its first two paragraphs. Parentally bereaved children and surviving parents showed a greater than predicted level of psychiatric morbidity. Boys had greater levels of demonstrable morbidity than did girls, but bereaved mothers showed more morbidity than did bereaved fathers. Children were more likely to show signs of behavioural disturbance when the surviving parent manifested some kind of psychiatric disorder. (Kranzler EM et al 1990). The authors point to the fact that their study shows that the service provision is statistically related to a number of (arguably unexpected[Fristad MA et al 1993]) factors namely: The age of the children and the manner of parental death. Children under 5 years of age were less likely to be offered services than older children even though their parents desired it. Children were significantly more likely to be offered services when the parent had committed suicide or when the death was expected. Children least likely to receive service support were those who were not in touch with services before parental death. Paradoxically the level of service provision was not found to be statistically significantly related to either the parental wishes or the degree of the psychiatric disturbance in either the parent orchid. (Sanchez L et al 1994) The service provision did have some statistical relationships but that was only found to be the manner of the parental death and the actual age of the child at the time. The authors therefore are able to identify a mismatch between the perceived need for support and the actual service provision made. Part of that mismatch is found to be due to the inability of the social services and other related agencies to take a dispassionate overview. Elsewhere in the paper the authors suggest that there are other factors that add to this inequality and they include lack of resources and a lack of specificity in identifying children at greatest risk.(Harrington R 1996) The authors examine other literature to back up their initial precept that bereaved children have greater levels of morbidity. They cite many other papers who have found distress manifesting in the form of â€Å"anxiety, depression, withdrawal, sleep disturbance, and aggression.†(Worden JW et al. 1996) and also psychological problems in later life(Harris T et al. 1996). In terms of study structure, the authors point to methodological problems with other papers in the area including a common failing of either having a standardised measure or no matched control group(Mohammed D et al 2003). They also point to the fact that this is probably the first UK study to investigate the subject using a properly representative sample and certainly the first to investigate whether service provision is actually related to the degree of the problems experienced. The entry cohort involved nearly 550 families with 94 having children in the target range (2-18). With certain exclusions (such as two families where one parent had murdered the other etc.) and no respondents, the final cohort was reduced to 45 families and one target child was randomly selected from each family. It has to be noted that the comparatively large number of on-respondents may have introduced a large element of bias, insofar as it is possible that the families most in need of support were those who were most distressed by the death of a family member and these could have been the very ones who chose not to participate. (Morton V et al2003) The authors make no comment on this particular fact. The authors should be commended for a particularly ingenious control measure for the children. They were matched by asking their schoolteacher to complete an inventory of disturbed behaviour on the next child in the school register after the target child. A large part of the paper is taken up with methodological issues which ( apart from the comments above) cannot be faulted. Results In terms of being children in need, 60% of children were found to have â€Å"significant behavioural abnormalities† with 28% having scores above the 95th centile. In terms of specific service support provision, 82% of parents identified a perceived need for support by virtue of the behaviour of their children. Only 49% of these actually received it in any degree. Perhaps the most surprising statistic to come out of this study waste fact that of the parents who were offered support 44% were in the group who asked for it and 56% were in the group who didn’t want it. The levels of support offered were independent of the degree of behavioural disturbance in the child. Suggestions for improvement As with the majority of papers that we have either presented here or read in preparation for this review, the authors call for a more rationally targeted approach to the utilisation of limited resources. The study also provides us with a very pertinent comment which many experienced healthcare professionals will empathise with, (Black D1996), and that is: Practitioners should also be aware that child disturbance may reflect undetected psychological distress in the surviving parent. While not suggesting that this is a reflection of Munchausen’s syndrome by proxy, the comment is a valid reflection of the fact that parental distress may be well hidden from people outside of the family and may only present as a manifestation of the child’s behaviour. (Feldman Met al. 1994) The conclusions that can be drawn from this study are that there is considerable gap in the support offered ( quite apart form the effectiveness of that support) in this area of obvious stress for both parents and children. (Black D 1998). This study goes some way to quantifying the level of support actually given in these circumstances. Effectiveness of support in families where there is domestic violence We have considered the role of the effectiveness and indeed, even the existence, of adequate support services for the children in need and their parents in a number of different social circumstances. The next paper that we wish to present is an excellent review of the support that is given to another specific sub-group and that is women and children who suffer from domestic violence. Webb and her group (etal 2001) considered the problem in considerable (and commendable) depth The study itself had an entry cohort of nearly 150 children and their mothers who were resident in a number of hostels and women’s refuges that had been the victims of family violence at some stage in the recent past. The study subjected the cohort to a battery of tests designed to assess their physical, emotional and psychological health, and then quantified their access to, and support gained from, the primary healthcare teams and other social service-based support agencies. This study is presented in a long and sometimes difficult tread format. Much of the presentation is (understandably) taken up with statistical, ethical and methodological matters – all of which appear to be largely of excellent quality and the result of careful consideration. Results The results make for interesting and, (in the context of this review), very relevant reading. Perhaps one of the more original findings was that nearly 60% of the child health data held by the various refuges was factually incorrect. This clearly has grave implications for studies that base their evidence base on that data set(Berwick D 2005). Of great implication for the social services support mechanisms was the finding that 76% of the mothers in the study expressed concerns about the health of their children. Once they had left the refuge there was significant loss to the follow up systems as 15% were untraceable and25% returned to the home of the original perpetrator. The study documents the fact that this particular group had both high level of need for support and also a poor level of access to appropriate services. In the study conclusions, the authors make the pertinent comment that the time spent in the refuge offers a â€Å"window of opportunity† for the family support services to make contact and to review health and child developmental status. This is not a demographically small group. In the UK, over 35,000children and a parent, are recorded as passing through the refuges each year, with at least a similar number also being referred to other types of safe accommodation. Such measures are clearly not undertaken lightly with the average woman only entering a refuge after an average of 28separate assaults. One can only speculate at the long term effects that this can have on both the mother and the children. Suggestions for improvement In common with the other papers reviewed, this paper also calls for greater levels of support for the families concerned as, by inference, the current levels of effectiveness of the family support services is clearly inadequate. Conclusions This review has specifically presented a number of papers which have been chosen from a much larger number that have been accessed and assessed, because of the fact that each has a particularly important issue or factor in its construction or results. The issue that we have set out to evaluate is the effectiveness of the family support services which are specifically aimed at reducing the stress levels for the parents of children in need. Almost without exception, all of the papers that have been accessed (quite apart from those presented) have demonstrated the fact that the levels of support from the statutory bodies is â€Å"less than optimum† and in some cases it can only be described as â€Å"dire†. Another factor that is a common finding, is that, given the fact that any welfare system is, by its very nature, a rationed system, the provision of the services that are provided is seldom targeted at the groups that need it the most. One can cite the Tickler (et al 2000)and Downey (et al 1999) papers in particular as demonstrating that substantial proportion of the resources mobilised are actually being directed to groups that are either not requesting support or who demonstrably need it less than other sectors of the community. Some of the papers (actually a small proportion) make positive suggestions about the models for redirecting and targeting support. Sadly, the majority do little more than call for â€Å"more research to be done on the issue†. In overview, we would have to conclude that the evidence suggests that the effectiveness of the family support services in reducing stress and poverty for the parents of children in need is poor at best and certainly capable of considerable improvement. References Bassuk, E., Buckner, J., Weiner, L., et al (1997) Homelessness in female-headed families: childhood and adult risk and protective factors. American Journal of Public Health, 87, 241–248 1997 Berwick D 2005 Broadening the view of evidence-based medicine Qual. Saf. Health Care, Oct 2005; 14: 315 316. Black D. 1996 Childhood bereavement: distress and long term sequelae can be lessened by early intervention. BMJ 1996; 312: 1496 Black D. 1998 Coping with loss: bereavement in childhood. BMJ 1998; 316: 931-933 BPA 1999 British Paediatric Association. Outcome measures for child health. London: Royal College of Paediatric

Duties of Fidelity Essay -- Business, Duties of Reparation

Ross prima facie duties speak of fidelity, reparation, gratitude, justice, beneficence, non- maleficence and self-improvement. Even though Ross has explained each duties, it is still uncertain that how these duties can be implied in marketing activities. If we look at each duty, it is not easy to implement every duty in a situation unless it demands so. One has a prima facie duty (not) to do a certain action if and only if there is some moral demand for one (not) to do it (Baumrin, 1965). Therefore in order to execute these duties, understanding the circumstances is very important. It is understood that prima facie duties are expressions referring to a characteristic by certain individual act-tokens rather than by certain act-types (Atwell, 1978). A sense of which duties are towards the bottom of the scale and which duties are towards the top is to be made sure in order to achieve every duty (Robinson, 2010). Duties of fidelity are the duty of keeping up promises. The company should not promise anything to their customers that they cannot execute. Promise can be anything related to product quality, size, etc. Breaking a promise can bring down the value for the products as there will be no trust for the products in the market. Keeping up promises will encourage the customers to buy the product. According to prima facie duties, one cannot be blamed if he undertakes to make the right choice but it does not produce a good act (Meyers, 2009). Duties of reparation are only essential when one cannot keep up the promise or when unintentional mistakes happened. If the product is damaged then the product is to be recalled and repaired or new products have to be issued to the customers. Cash Payments can also be made fo... ...tilitarian can increase the costs for the company but they are responsible to do so because, the fault is not caused by customers. Whether a person’s action is morally justifiable, is a deontological question; whether the act is good is ultimately a consequentiality question (Meyers, 2009). According to my point of view what Maruti Suzuki did was correct but these faults are not supposed to be happened from a company like these. Instead of repairing faulty cars new cars is to be provided immediately when they recalled faulty ones. Also they should have taken additional efforts to help customers when they were waiting for their car to get repaired. They should have given bonus packages to their customers for the mistake happened. Even though it can add total cost for the company, it can support them in maintaining their customers and good will in the market.

Healthcare Finance Essay

Houston Dialysis Center is a department of Houston General Hospital, a full-service, not-for-profit acute care hospital with 325 beds. The bulk of the hospital’s facilities are devoted to inpatient care and emergency services. However, a 100,000 square-foot section of the hospital complex is devoted to outpatient services. Currently, this space has two primary uses. About 80 percent of the space is used by the Outpatient Clinic, which handles all routine outpatient services offered by the hospital. The remaining 20 percent is used by the Dialysis Center. The Dialysis Center performs hemodialysis and peritoneal dialysis, which are alternative processes for removing wastes and excess water from the blood for patients with end-stage renal (kidney) disease. In hemodialysis, blood is pumped from the patient’s arm through a shunt into a dialysis machine, which uses a cleansing solution and an artificial membrane to perform the functions of a healthy kidney. Then, the cleansed blood is pumped back into the patient through a second shunt. In peritoneal dialysis, the cleansing solution is inserted directly into the abdominal cavity through a catheter. The body naturally cleanses the blood through the peritoneum—a thin membrane that lines the abdominal cavity. In general, hemodialysis patients require three dialyses a week, with each treatment lasting about four hours. Patients who use peritoneal dialysis change their own cleansing solutions at home, typically about six times per day. This procedure can be done manually when active or automatically by machine when sleeping. However, the patient’s overall condition, as well as the positioning of the catheter, must be monitored regularly at the Dialysis Center. The hospital allocates facilities costs (which primarily consist of building depreciation and interest on long-term debt) on the basis of square footage. Currently, the facilities cost allocation rate is $15 per square foot, so the facilities cost allocation is 20,000 Ãâ€" $15 = $300,000 for the Dialysis Center and 80,000 Ãâ€" $15 = $1,200,000 for the Outpatient Clinic. All other overhead costs, such as administration, finance, maintenance, and  housekeeping, are lumped together and called â€Å"general overhead.† These costs are allocated on the basis of 10 percent of the revenues of each patient service department. The current allocation of general overhead is $270,000 for the Dialysis Center and $1,600,000 for the Outpatient Clinic, which results in total overhead allocations of $570,000 for the Dialysis Center and $2,800,000 for the Outpatient Clinic. Recent growth in volume of the Outpatient Clinic has created a need for 25 percent more space than currently assigned. Because the Outpatient Clinic is much larger than the Dialysis Center, and because its patients need frequent access to other departments within the hospital, the decision was made to keep the Outpatient Clinic in its current location and to move the Dialysis Center to another location to free up space. Such a move would give the Outpatient Clinic 100,000 square feet, a 25 percent increase. After attempting to find new space for the Dialysis Center within the hospital complex, it was soon determined that a new 20,000 square foot building must be built. This building will be situated two blocks away from the hospital complex, in a location that is much more convenient for dialysis patients (and Center employees) because of ease of parking. The new space, which can be more efficiently utilized than the old space, allows for a substantial increase in patient volume, although it is unclear whether the move will result in additional dialysis patients. The new dialysis facility is expected to cost $3 million. Additionally, furniture and other fixtures, along with relocation expenses of current equipment, would cost $1 million, for a total cost of $4 million. The funds needed for the new facility will be obtained from a 20-year loan at local bank. The loan (including interest) will be paid off over 20 years at a rate of $400,000 per year. Because the specific financing details are known, it is possible to estimate the actual annual facilities costs for the new Dialysis Center, something that is not possible for units located within the hospital complex. Table 1 (see Excel spreadsheet) contains the projected profit and loss (P&L)  statement for the Dialysis Center before adjusting for the move. The hospital’s department heads receive annual bonuses on the basis of each department’s contribution to the bottom line (profit). In the past, only direct costs were considered, but the hospital’s chief executive officer (CEO) has decided that bonuses would now be based on full (total) costs. Obviously, the new approach to awarding bonuses, coupled with the potential for increases in indirect cost allocation, is of great concern to Linda Rider, the director of the Dialysis Center. Under the current allocation of indirect costs, Linda would have a reasonable chance at an end-of-year bonus, as the forecast puts the Dialysis Center in the black. However, any increase in the indirect cost allocation would likely put her â€Å"out of the money.† At the next department heads’ meeting, Linda expressed her concern about the impact of any allocation changes on the Dialysis Center’s profitability, so the hospital’s CEO asked the chief financial officer (CFO), Roger Hedgecock, to look into the matter. In essence, the CEO said that the final allocation is up to Roger but that any allocation changes must be made within outpatient services. In other words, any change in cost allocation to the Dialysis Center must be offset by an equal, but opposite, change in the allocation to the Outpatient Clinic. To get started, Roger created Table 2 (see Excel spreadsheet). In creating the table, Roger assumed that the new Dialysis Center would have the same number of stations as the old one, would serve the same number of patients, and would have the same reimbursement rates. Also, operating expenses would differ only slightly from the current situation because the same personnel and equipment would be used. Thus, for all practical purposes, the revenues and direct costs of the Dialysis Center would be unaffected by the move. The data in Table 2 for the expanded Outpatient Clinic are based on the assumption that the expansion would allow volume to increase by 25 percent and that both revenues and direct costs would increase by a like amount. Furthermore, to keep the analysis manageable, the assumption was made that the overall hospital allocation rates for both facilities costs and general overhead would not materially change because of the expansion. Roger knew that his â€Å"trial balloon† allocation, which is shown in Table 2 in the columns labeled â€Å"Initial Allocation,† would create some controversy. In the past, facilities costs were aggregated, so all departments were charged a cost based on the average embedded (historical) cost regardless of the actual age (or value) of the space occupied. Thus, a basement room with no windows was allocated the same facilities costs (per square foot) as was the fifth floor executive suite. Because many department heads thought this approach to be unfair, Roger wanted to begin allocating facilities overhead on a true cost basis. Thus, in his initial allocation, Roger used actual facilities costs ($400,000 per year) as the basis for the allocation to the Dialysis Center. Needless to say, Linda’s response to the initial allocation was less than enthusiastic, but before Roger was able to address Linda’s concerns, he suddenly left the hospital to take a new position in another city. The task of completing the allocation study was given to you, Houston General’s current administrative resident. You believe that any cost allocation system should be perceived as being â€Å"fair,† but you also realize that in practice cost allocation is very complex and somewhat arbitrary. Some department heads argue that the best approach to overhead allocations is the â€Å"Marxist approach,† by which allocations are based on each patient service department’s ability to cover overhead costs, but this approach has its own disadvantages. Considering all the relevant issues, you must develop and justify a new facilities cost allocation scheme for outpatient services. Be prepared to justify your recommendations at the next department heads’ meeting.