Importance of Community Health Workers

Importance of Community Health Workers DEFINING THE PROBLEM Community Health Workers have been used in several countries dating back about 60 years ago, to address the gap experienced by the underserved members of these communities, with issues of access to health care. More importantly in Low and middle-income countries, Community Health Workers have particularly been helpful in reducing the impact of the shortage of skilled health workers. Community Health Workers can make valuable contributions to healthcare especially in the delivery of basic health care; however, across countries and individual programs there are varying and inconsistently established approaches on how they are recruited, trained, monitored, incentivized, as well as the roles and activities they perform. The lack of a standard structure globally and in CMMB countries creates several divisions of Community Health Workers, which may lead to poor monitoring, increased attrition, poor planning, budgeting and sustainable financing. The Effect on Women and Children Several programs have reported a high attrition rate which has led to the breakdown of the programs and is mostly due to problems with how these Programmes are structured or maintained. The initial purpose for which the CHW was set up was to link the communities with the formal health system, if the system fails, the underserved especially the vulnerable populations (women and children), in absence of quality health care are at risk of poorer health outcomes. BACKGROUND. Community health workers are adjunct health workers with a myriad of appellations across countries. According to WHO, they should be members of the community, selected by the community, trained and work within the community, answerable to the community, they should be supported by the health system but not necessary being a part of it, and have a shorter course of training than other professional workers. Although they function more at the peripheral of the health system, and their duties widely vary across countries and programs, their roles in the delivery of basic health care can not be overemphasized. In some countries, they also perform the role of record keeping. Over the years, the use of CHWs has gained prominence, with several countries adopting the trend to mitigate the growing proportion of infectious diseases and a shortage of health workers, migrating for green pasture, however, not all CHW programs follow the WHOs definition of CHW. In CMMB countries, the approach is also different across the in the individual countries. RECRUITMENT, TRAINING, AND INCENTIVES In Peru, the Ministry of health has specific regulations on how the CHWs program should be structured. CHWs in Peru are usually volunteers, they could receive incentives but they do not have contracts or salaries. They are appointed by the community organization at the general assembly or the social grassroots organization to which the community health agent belongs. There is variation in the duration of training the CHWs to receive in Peru. In South Sudan, there are no specific regulations in terms of services, CHW could receive incentives and could also be employed. They are trained in Basic health care service for 6 months whereas, in Zambia, the Implementing partners have different policies for training, recruitment, remuneration, and incentives for CHWs. Programs funded and managed by implementing partners are typically on contracts of two-to-five year but their remuneration and incentives vary across programs. The training also varies between 2-11 weeks depending on if it is af filiated with government health facility or an NGO and the Ministry of healths CHW handbook, 2005 is used as a guideline. ROLES AND ACTIVITIES Several kinds of literature have grouped the CHWs as being either generalist or specialist in the way they are trained or work. Generalist perform a wide range of functions while the specialist has a program specific focus. In the CMMB countries, the CHWs are more generalist than they are a specialist or obscured in between. They are generally involved in implementing promotive and preventive health activities especially in providing family planning and immunization. In south Sudan, CHWs perform addition roles of supporting primary health care units as health staff to clerk patients and also work in the pharmacy. They follow up pregnant women receiving ART while in Zambia, CHWS, also provide basic curative services and refer cases if complicated, they performfollow-up care including home visits for patients with TB, AIDS, pregnant and postnatal mothers, tracing for malnourished children. Most literature about CHWs and what they do, agree that they are important in improving access to care especially in areas where they are most needed. However, it is important to consider the local context where the CHW program will operate(culture, language, social norms, and values etc.) for the program to excel. The mode of selection of the CHWs, duration of training as well as the roles the CHWs would be performing should also be considered and possibly be unified across programs. In order to extrinsically motivate CHWs, it is important to also Incentivize them and a mechanism for monitoring and evaluating their activities would help assess problems in the program and health care delivery. APPROACHES AND METHODOLOGIES In order to encourage behavioral change and improve the quality of health care using CHWs, CMMB will be focusing on theses 3 approaches which have been applied in public health and have improved health outcomes: Positive deviance approach, Integrated community case management approach and make me a change agent approach. Positive Deviance: This is an approach based on the belief that unusual behavioral practices in communities among few members of the community who are called the positive deviants, help them find a better solution to problems and improve their outcomes compared other members of the same community that share similar exposures and resources, but poorer outcomes. The positive deviance is based on the principles that: (Pascale, Sternin, Sternin ,2010) Communities possess the solutions and expertise to solve their own problems. Communities are self-organizing and possess the human resources with necessary assets to solve community problems. communities have a Collective intelligence which is evenly distributed and is not dependent on the leadership of a community alone or in external experts.This collective intelligence is what the approach aim to draw out and capitalize on to solve community problems. The bedrock of the approach is sustainability. The community is encouraged to observe and develop sustainable solutions based on observed positive deviants within the community. Practicing encourages behavior change. This approach has been used successfully in communities in the management of malnutrition and has contributed immensely to reducing the burden of malnutrition in communities where it is being practiced. The community health and families after an observation made by a positive deviant inquiry, practice better ways to cook their food with a particular interest in quality, feeding, and hygiene when managing malnourished children using local resources and technologies. It is a proactive measure; harnessing the strength, knowledge, human resources locally available within the community to solve their community health problems. This approach ensures fast, sustainable, affordable, culturally acceptable solutions to solve community health problems and it also encourages local participation. Integrated community case management: This approach was adopted by WHO and UNICEF. The ICCM has been piloted in many underserved countries, where there is a major gap in access to care. The aim is to bring health care closer to the doorstep of these population and strategically increasing coverage of treatment using Community health workers who are appropriately trained, supervised and monitored. The CHWs are adequately supported with medical supplies. They are trained to identify, promptly and correctly manage or refer cases of common community diseases like malaria, pneumonia, diarrhea and malnutrition in children under 5 years. ICCM uses interventions that are evidence based and it focuses on diagnosis, the community health workers are trained to make a quick diagnosis using portable diagnostic tools and appropriate treatment. common interventions used are antibiotics for dysentery and pneumonia, ORT for diarrheal diseases, antimalaria for malaria, nutritional rehabilitation for malnutrition. The approach employs the use of CHWs who are members of the community and perform their duties either from their homes or selected community building, which is easily accessible to members of the community. Using CHWs from the community encourages trust and sustainability. Make me a change agent: To effectively improve the quality of health by encouraging behavior change, this approach which is used multi-sectorally will help the CHWs to become an effective change agent by developing their skills of effective communication, showing empathy, individual counseling. It also teaches the approach of using their individual testimonies and storytelling ability to encourage health behavioral change. CHWs after acquiring skills from health training, have to effectively communicate their training to the community which is critically important in encouraging the patient to adhere to treatment and adopt preventive health behaviors. The CHWs are engaged in several activities that include role playing to help them understand the importance of respecting patient, good communication, active listening during conversations. There are several barriers that mitigate against behavioral change, the ability to circumvent these barriers would help the CHWs reach their target population and help them make them make the right behavior change. In order to effectively do this, the CHWs needs to be able to put themselves in the perspective of their audience, sharing their experiences which help foster a personal relationship and makes the change easier to communicate. The approach also emphasizes the importance of storytelling and the use of individual testimonies to promote a particular health behavior by changing preformed misperceptions about the particular health behavior. The testimonials offer the audience the chance to appreciate changes made by someone else who is not different from them, who has had a positive result. These approach as a skill for encouraging behavioral change is easily remembered, the audience can relate to the story and have a pictural understanding of what the change is about. Moreso, it can be a source of external motivation to encourage change. INTERVENTIONS: The growing adoption of community health workers as part of the health system as a means to reach the underserved communities is met with the need to understand how to implement a sustainable CHW program in different countries across different programs. As field workers in underserved communities, we would also be employing the services of the CHWs in executing our goals. An effective process for managing (recruitment, training, supervision and support, Incentives) community health workers will help sustain the program. RECRUITMENT: Recruiting community health workers is dependent on the proposed health need they are supposed to meet. Some ministries of health have an established protocol for recruiting health workers. It is important to note that to sustain the program, several papers as well as WHO has suggested that community health workers should be selected by and from the community they are to work in. However, the primary criteria in selecting CHWs is that they should be members of the community they serve. This to harness the establish connections within the individual members of the community and the individual interest of the health worker towards the community. The recruitment process may require the use of different social structures or organization within the communities like the clinics, community-based organizations e.g market women association, religious organizations, the ruling council, other CHWs etc. as sources of referral for the appointment of community members into several CHWs position. Recruitment should be formal, individuals should follow a process of recommendation, interview, and screening. General characteristics of CHWs vary across countries and programs. Literacy is an important criterion for recruiting a CHW. Although not all programs require their CHWs to have any form of education, most programs require a primary level of education while some require a higher level of education. The least literacy level should be required; however, the higher the level of education the more preferable the CHW. The gender of the CHW should meet the cultural norm especially in places where there are limited interactions between males and females. The age of CHWs differ across programs but ranges from 20 45years. Finally, marriage status is an encouraging criterion for selection. CHWs with a married status are more likely to remain in the society for a longer period of time than those that are single. TRAINING The Success and quality of a CHWs program also depend on the process of training and continuous assessment of training. Training program varies across programs which depend on the length, depth, element, approach and authority. In some countries, a manual for training of CHWs have been developed; where necessary, it should be employed. The length of training varies across programs and it is based on the services the community health worker would be rendering. It could be from days to weeks to years; however, it is important to space the training so that the CHW can have time in between training to have an in-depth review of the material. A process of a continuous training after the initial training can help improve the performance of CHWs through supervision and adding additional knowledge to the CHW. The use of an interactive, skilled based setting that encourages participation should be employed as a style for training considering the varying educational background among the CHWs. The training material could be categorized into three major topics: skilled- based knowledge, relevant health knowledge, and research implementation knowledge. Training authority may vary, although WHO prefers the government of the countries to be involved in the training but more experienced CHWs, nurses and doctors can be part of the training team. SUPERVISION AND SUPPORT Long term sustainability of health programs involves active supervision and mentorship of the CHWs.The supervisors also provide support to CHWs. In most cases, the supervisor will be provided by the programs main authority. They are usually of different professional backgrounds but have an understanding of the program, the roles of the CHWs and the aim of the program. They evaluate the performance of the CHWs, define their roles and expectations and also answer questions raised by the CHWs. The frequency of supervision which is variable across programs depends on the target goal of the program, the available funds e.tc. Supervision as a general term could be practice in different styles and approaches. Group supervision involves a group of CHWs with a supervisor and has been implemented in many programs. Community supervision is another approach for CHWs. The innovative approach involves communitys participation by providing feedback and guidance to CHWs and their supervisors. Other methods that can be used are the peer supervision, clinical mentoring and mobile electronic devices. It is also important to note that the supervisors also needs to be actively supported by the programs main authority by providing material support e.g medical supplies, transportation etc. supporting the supervisors will help them perform their functions regularly. INCENTIVES The incentives for CHWs is one of the most controversial topics but it plays a significant role as it has been shown to be associated with CHWs performance, motivation and retention. many studies have debated on how compensations should be structured for the most effective way to incentivize CHWs. There are two categories of CHWs: the Volunteers and Full-time employees. Some countries have a process for how the community health workers should be paid based on the type of appointment and who employs them. CHWs employed by the government on a full-time basis are on paid salaries while most, especially the volunteers are given either monetary or non-monetary incentive; however, it is important to recognize that an opportunity for career advancement in this field can be an incentive. Full-time CHWS are comparatively rare to the part-time CHWs because of the financial implication on programs. A small amount of incentive is more commonly implemented in community-based programs. common monetary incentives are small monetary compensation for their time and transportation subsidies. How much monetary incentive is enough is unknown but it is important to give the CHWs some monetary incentives. The non-monetary incentive is also common. CHWs could get meals during training, bicycles for transportation, umbrellas etc. like the monetary incentive, there are no rules on how the authorities should incentivize their CHWs, or what item will effectively attract CHWs and motivate them. ROLES AND ACTIVITIES IN MATERNAL AND CHILD HEALTH The CHWs globally have been very effective in improving maternal and child health as well as reducing mortality especially in low-income countries. Their function varies across countries and programs; while in some countries, it is just preventive, in others it also involves diagnosis and treatment. The table below highlights how and areas where CHWs can work effectively to promote maternal and child health. PREVENTION DIAGNOSIS TREATMENT OBSTETRIC CARE Anemia *Nutrition Supplement, *Routine Haematinics Nutrition Supplement HIV *HIV Counseling *Distribution of condom Routine Followup on PMTCT Malaria *Distribution of Insecticide-treated net *Prevent therapy with sulfadoxine-pyrimethamine Rapid Diagnostic kit Antimalaria Obstetric Care Routine Tetanus toxiod Routine ANC Visit Post partum care PPH *Breast feeding counselling *Distribution of misoprostol at home births. GYNAECOLOGICAL CARE Family planning *Use of contraceptive PEDIATRIC CARE Diarrhea *Health education on handwashing, food preparation and packaging ORS Zinc supplement Malaria *Distribution of Insecticide-treated net Rapid Diagnostic kit Anitmalaria Antipyretics Pneumonia Antibiotics Malnutrition *Breast feeding Education *Growth monitoring Nutrition supplement Routine Immunization of Children INFECTIOUS DISEASES Tuberculosis Direct observation of tuberculosis treatment CHWs roles and activites are not limited to the above, there are also actively involved in diseases surveillance, home visits, record keeping, community health education, monitoring people with chronic diseases e.g hypertension , diabeties. INTEGRATION INTO CMMB PROJECTS AND PROGRAMS References: Pascale, Sternin, Sternin. (2010) The Power of Positive Deviance: How Unlikely Innovators Solve the Worlds Toughest Problems. Harvard Business Press. Print.

Human societ

The human society is a very complicated structure. It consists of a huge quantity of members, each of them with their own thoughts, emotions and experiences. The notion of â€Å"society† unifies all those members and therefore, they must correspond to the standards of that society. They have to elaborate some special mode of living, thinking, behaviour in order to be like other. â€Å"Being like all† – that’s the main motto of human society of all times. Within the complex structure of society one can be happy and rich, other unhappy and poor but everyone tries to be like the rest.But it is well known that each rule can have its exceptions. So, the human society has. There are people who are not able to find their place in the society. Each of them has his own reasons. One just doesn’t want to be like all, the other just can’t behaviour like people around him and so on. In the world literature the notion of the â€Å"outsider† has been rather often discussed. Among these discussions the view of â€Å"outsider† by Thomas Mann and Albert Camus are one of the most interesting. Tonio Kroeger in the novel of the same name by T. Mann is rather a typical outsider. So, what made him to be so?Surely, he is an artist and the real artist is always a little bit different from the crowd. But there are many talented artists which are not outsiders at all in their real life. Tonio is a lonely artist. These two words- â€Å"lonely artist† are able to explain the Kroeger’s problem. The first word is â€Å"lonely† and the second is â€Å"artist†. The â€Å"lonely† is the reason and the â€Å"artist† is the consequence. Kroeger has become an artist because he was lonely and couldn’t find himself in this life. All he can do is creating art describing the reality around him but he is not able to live in this reality.He realizes that his inability and suffers a lot because of tha t. Some of the events of this story must be perceived in symbolic manner because of Kroeger’s difficulties in being like other. His homosexual sympathy to Hans Hansen hasn’t to be understood as just a physical sexual expression. This sympathy symbolizes the Kroeger’s aspiration for prestige bourgeois life as Hans was the bright representative of same. Kroeger couldn’t find himself in this bourgeois life but was eager of living like his â€Å"ordinary† contemporaries. That’s why Hans attracted him. Kroeger lived in constant paradox within him.His heart was the heart of an artist but in his veins the bourgeois blood was flowing. He wanted to be as easygoing and careless as his friends but he couldn’t be so because his mind was depressed all the time by the events of the life around him and he could only describe them in his art. That was the main reason of Kroegen’s being the outsider. The main thing Kroeger had to learn during h is life was that probably his outstanding skills as an artist were conditioned by his withdrawing from the ordinary life. In other words, if he had been an ordinary bourgeois personality he wouldn’t have been a gifted artist.The main reason of his unhappiness was that he didn’t want to understand that simple thing: it is not possible to connect things which can not be connected – the commonplace satisfied life and the delicate, sensitive vision of the artist. Should Kroegen understand that in time, the life would be much easier for him. But he understood that later. Perhaps, that’s the fate of each real talent – to pass through many difficulties in order to find oneself in the art. The ordinary always remains to be ordinary. It is not worth to follow it.We must follow things that we have skills for and there always will be place for the ordinary in our life – it will come into our lives by itself. But if talented person tries to overtake the ordinary or to live between the ordinary and the exalted he or she is doomed to unhappiness and misfortune. Precisely that started to happen with Tonio Kroeger. When he understood that it is not possible to find compromise between â€Å"the Dionysian† (all the passionate and emotional) and â€Å"the Apollonian† (rational and reasonable) he decided to combine them in his art and that was the unique correct decision for him.Albert Camus in his â€Å"Stranger† gives us the other notion of outsider. Meursault – a man of absurd in the world of absurd, – that’s the Camus’ vision of the problem in case. When after the first sentence of the novel -â€Å"Maman died today† follow the indifferent meditations of the protagonist regarding when died his mother – today or yesterday, we understand the Meursault is completely indifferent to the notions of time, place and many other phenomena of our real world. All along the novel new ar guments prove that. Meursault lives being ruled by purely physical instincts.His life consists of a number of patterns (ways of behaviour) which he uses every day. For example, he becomes sad because Sunday came and broke the customary way of his everyday life. The heat produced by the sun when he goes back from the funeral of his mother worries him more than the very death of his mother. In other words the Meursault activities look completely paradoxical for other people, but not paradoxically for him. Camus presents in his hero his understanding of life in general and of truth in particular. To say more, Meursault believes sincerely in justice and truth.But he has his own notion of that â€Å"truth†. Yes, he doesn’t cry at his mother’s funeral. But on the other hand he never says lies. He doesn’t see any sense in acting like the rest of people. He just shows his own true emotions or indifference in each particular moment of his life. He is independent i n the full meaning of this word. He doesn’t believe in God, he lives by his own motives. Society tries to find some meaning in his behaviour but all in vain. It is not possible to find sense in absurd. Otherwise, it will not be absurd any more. Thus, Meursault embodies the Camus’ notion of so-called â€Å"relative truth†.That is not all society’s truth but the truth of one person. Yes, he guns down the Arab but he believes in justice and doesn’t try to avoid it. Certainly, it sounds terribly but that is Camus’ absurd vision of the truth. On the one hand Meursault’s activities are horrible as that his â€Å"relative truth† makes a lot of harm to other people but on the other hand he is not eager of making harm to anyone, he never lies, he is just living his own life which is right to his opinion. This difference between Meursault’s truth and society’s truth makes Meursault to be the outsider.He can’t underst and the sense of the society’s existence (to say it more exactly – he doesn’t even want to understand it as it is not important for him) and the society, in its turn, can’t find out any meanings in the mode of Meursault’s life. Nevertheless, Meursault has learnt his lesson towards the end of the story. When we see him sentenced to death it is already possible to speak about â€Å"new† Meursault. It doesn’t mean that he has completely changed his moral perception. He still doesn’t believe in God and is sure that after death there is nothing but non-existence.But he started using his memory what he has never done before. He remembers his father and understands all the â€Å"advantages† of human memory. He had never resorted to his memories and lived only following his physical impulses. When being in prison he understood how good it can be – to remember something that has happened once. Meursault starts to distingui sh the past and the future. His imagination and feelings work like they never did before. He realizes that both imagination and feelings (spiritual, not physical feelings) are rather useful in regular life.Only in prison he begins to perceive each new day like a gift (as there were few left before his death penalty) without classifying them in days which are good and in days which break his customary way of life. In other words he began to understand that his life was not as correct as it seemed to him before. But he started to understand that too late when his life was going to be cut by those who haven’t managed to find some meaning in his life. Both Tonio Kroeger and Meursault realized the mistakes of their existence.Kroeger understood that he was unable to learn living like other people because the problem which was, by the way, created by himself was already too significant and complex for him and he had to find some area in which he could get rid of that immense moral t ension. That area became his art for him. Meursault couldn’t change his life because he was already sentenced to death for the actions of his previous egoistic â€Å"self-life†. These two protagonists are similar in this respect as they both realized the necessity to change their lives. Nevertheless, there is a clear difference in â€Å"being outsider† between Kroeger and Meursault.Kroeger was a brightly expressed outsider as he couldn’t find himself in his society and that was hurting him a lot. He really was out of society’s side. He crossed successfully with the society within his professional skills only when he was describing that society in his works. As to the commonplace reality- he was an unhappy man. Meursault, contrary to Kroegen, represents another type of outsider: â€Å"outsider within society†. Meursault was the member of society and that’s why society was astonished by his behaviour. He was a stranger within society an d that made his activities paradoxical.Kroeger experienced pain because he was outsider and the society didn’t care a lot about it. Meursault didn’t suffer a lot because of being outsider – but society suffered because of his activities. Speaking about the outcomes made by each of these two protagonists it is necessary to say that Kroeger’s conclusion was more successful than Meursault’s. Kreoger found the decision of his problem in his art and Meursault had not already time for the correction of his mistakes as he realized them under the threat of guillotine. Being outsider means to not coincide with the public’s opinions and norms of life.T. Mann and Albert Camus showed us that the notion of the outsider is poly-semantic. Tonio Kreoger and the stranger Meursault are both outsiders but each in his proper manner. Kroeger is an â€Å"outer outsider† (he wants to be within the society being like all) and Meursault is an â€Å"inner out sider† (he doesn’t feel himself to be outsider but the society consider him to be so). Regarding Mann’s story it would be helpful to conclude that it is not worth to follow the common opinion and try to be like all. The most important thing is to preserve the skills and the lofty given to you by the nature.As to the Camus’ novel, it is possible to learn from it that being honest only for oneself is not enough, it is also necessary to thing about the society you live in and that one’s notions of truth are not always common for all. The society was created by people precisely in order to find the compromise between different people’s opinions. Both Kroeger and Meursault have become outsiders by themselves. The conclusions they have made from their mistakes are rather consoling. So, hope that Mann and Camus’ novels will serve as good examples for many for not being an outsider in the future.

Characters are similar throughout books Essay

Henrik Ibsen’s characters are similar throughout his books. There are pairs of characters with similarities in A Doll’s House and Ghosts. One such pair is Nora and Mrs. Alving.  Both characters were unhappily married, but had other significant men in their lives. Manders and Dr. Rank both appeared as good friends to the women. This is a similarity, but with the difference that Nora rejected one and Mrs. Alving was rejected by the other. These men helped the women through their problems however and they would do anything for them. â€Å"To have loved you as much as any one else does? Was that horrid?† (A Doll’s House, Act II, p. 40) Dr. Rank tells Nora. He is expressing that he has loved her the whole time that she thought they were just best friends.  Mrs. Alving ran away from her husband in their first year of marriage and went to Manders. She had been in love with him, but he respected the sanctity of marriage so had to turn her away. â€Å"That I was able to turn you from your outrageous intention, and that it was vouchsafed to me to succeed in leading you back into the path of duty and back to your lawful husband.† (Ghosts, Act I, p. 89)  Nora and Mrs. Alving both have children that they love very much. Nora is talking to Mrs. Linde, an old friend, when she brings up the topic of her children, â€Å"So you are quite alone. How dreadfully sad that must be. I have three lovely children.† (A Doll’s House, Act I, p. 8) Nora often brings up the topic of her children when talking, because she loves them so much and wants to tell the whole world about them. Mrs. Alving loved her son Oswald so much that she sent him away, even though it would be very painful for her, so that he wouldn’t become like his father. â€Å"It was then that Oswald was sent away. He was about seven then, and was beginning to notice things and ask questions as children will†¦ It seemed to me that the child would be poisoned if he breathed the air of this polluted house. That was why I sent him away.† (Ghosts, Act I, p. 93) She rationalizes her decision. Mrs. Alving and Nora prove that they love their children through their actions in the plays, which are often similar.  As much as Ibsen deliberately made his characters similar, he also made what happens to them different. At the end of A Doll’s House, Nora ends being the victor. She leaves her husband because it is what she wants and she knows how to get it. â€Å"Oh, Torvald, I don’t believe any longer in wonderful things happening†¦ That our life together would be a real wedlock. Good-bye.† (A Doll’s House, Act III, p. 68) With this, she leaves her house and the man she was in a loveless marriage with. Mrs. Alving does not have the same fortune as Nora. At the end of Ghosts, her beloved son is left in a vegetative state and she is left to despair over it.  Ã¢â‚¬Å"Oswald! What is the matter with you! Oswald! Oswald! Look at me! Don’t you know me!†¦ I can’t bear it! Never!† (Ghosts, Act III, p. 128) A main difference in Mrs. Alving and Nora’s attitudes is that Nora left her husband when she couldn’t take it any more and Mrs. Alving waited for hers to die.  Ã¢â‚¬Å"Listen, Torvald. I have heard that when a wife deserts her husband’s house, as I am doing now, he is legally freed from all obligations towards her.† (A Doll’s House, Act III, p. 67) Nora tells him. This shows that she is a stronger character than Mrs. Alving, because she actually stood up to her husband and told him that his behavior was unacceptable. â€Å"I had my little boy, and endured it for his sake†¦ I took the upper hand in the house absolutely – both with him and all the others. I had a weapon to use against him†¦Ã¢â‚¬  (Ghosts, Act I, p. 92-93) Mrs. Alving shows that she took the easy way out. She could have stood up to Mr. Alving and taken her son and left, but instead she chose to go along with it, just standing in his shadow and quietly telling him that she was unhappy. The similarities that come out in the characters of Mrs. Alving and Nora are always mixed in with other situations that make them different. Ibsen wanted to prove to his audience that it wasn’t always healthy to be in a marriage and by doing this he went against the norms of society. Neither play has a so-called ‘happy ending’, because not all the characters have had their issues resolved by the end. The two plays show the different angles that he wanted the audience to be aware of, but their endings repeat a point for clarity.

Inventions During The Period Of War - Free Essay Example

Sample details Pages: 3 Words: 789 Downloads: 1 Date added: 2019/05/13 Category History Essay Level High school Tags: War Essay World War 1 Essay Did you like this example? In my paper I will be discussing the many inventions, weaponry, tools that were being released during that period of war. Many new weapons were being pushed out and provided for us to use against our enemies. One of the biggest inventions of the early 1900s was the tank, during this time it was a war of trenches filled with machine guns spraying down men before they could even make it past the no mans land the solution to that problem was a heavily armored vehicle with heavy weapons attached and wheels fitted for the rough terrain. The first tank manufactured was the British mark 1 , the French followed with their own version of the tank Renault ft. which had the class look with the turret on top as the weapon. Don’t waste time! Our writers will create an original "Inventions During The Period Of War" essay for you Create order The Germans established the first flamethrower in 1901 produced by Richard Fiedler. It was a weapon of mass destruction at the time as it could do very lethal damage from close to mid-range distance of contact. Very useful to flush out a trench of enemies as it could burn them alive. Although during medieval times there was weapons that hurled flames to inflict damage none compared to the modern produced flamethrower. Machine guns were produced during this time, its predecessor before was the famous and most used Gatling gun at the time, looking like a cannon and weighed about as much as it. The portability and power made it a heavily used weapon in our arsenals as it packed a very big punch. During the war fighting at night was very complicated because there was no way to see which way you were shooting so how would you know you hit or made the kill if you cant even see what youre shooting at? The invention of the tracer bullet came into play, it emitted a phosphorescent trail with every round shot hence the name tracer the first attempt was somewhat successful only limiting it to 100 meters. The second was a hit, leaving a bright green-white trail with every round shot. German U-boats killed many civilians and sailors and sank millions of tons of cargo. We needed a way to fight off the submerged weapons and our solution was the depth charge, an underwater bomb thats charges were set to go off at a certain depth. The first idea was brought in 1913. The first charge made named Type D produced by Royal Navy and mine school in 1916. The first German boat was sunken by depth charge U-68 on March 22,1916. Although poison gas only contributed to a small portion of deaths during the war it did much more then thought, just the phycological damage it did made it a devastating weapon to an extent. The first gas tear inducing irritants rather than fatal effects. The first use of a fatal gas was made possible by German military using chlorine to cause a death by asphyxiation suffocation. A very useful weapon against enemy trenches as it could inflict harm throughout the trench flushing out whoever is in there. Early 1900s, men all around are suffering gruesome, fatal life threating injuries and we needed a way to see what was going on with our soldiers, Marie Curie was working to mobilize the x-ray machine, so it would be easier to look at the medical diagnostics and by 1914 she had installed many in trucks and cars making it very simple to see what injuries our men were dealing with. During a time of advancements in many forms, technology wasnt far behind from where we are now. Pilotless drones were developed for the us navy in 1916 by two men, Elmer Sperry and Peter Hewett originally meant to be an unmanned bomb. Too far ahead for its time as it was called imprecise, the navy lost interest in the project in the mid 1920s. Many advancements were made, and some were too slow to adapt to this new age of technology sweeping across the world before our eyes. At this time weapons of fatal destruction were being produced like never before, deadlier then we have ever seen them, and it was a scary sight to see as it made it close to impossible to win a battle on the western front. Tanks were a very huge part and maybe the greatest and most useful during that time as it solved the problem of men dying in numbers just trying to get across no mans land as they worked effectively through the rough terrain, it was armor for you and a mobile arsenal at your disposal making it a hell of a rough thing to overcome. We made great advances in weaponry and other technological things and it proved how great we were as a nation.

Online Shopping Is Very Popular All Over The World Essay

Internet has brought huge transformations in the lives of people all around the World. Ecommerce is one of the best applications of the Internet society. E Commerce reduces the time and distance between the manufacturer and the consumer. Gone are those days when people used to spend endless time waiting in long queues to buy and pay for their goods and services. Online shopping is very popular all over the world. Even third world countries like India, Pakistan and Bangladesh are doing a variety of online businesses. USA has one of the biggest online markets. All retail businesses like Walmart, Target, Sears, Macy’s etc. are giving their customers the flexibility of online shopping. This gives the customers the ease of buying products online and delivered to their door step. The websites are made very interactive for the users. This is leading to increasing sales and profits for businesses. Customers can now access huge databases of products and services and can view any products detailed description and usage. The better information provided on the website the easier it is for the customer to make an informed decision. The required elements are: Images, technical specifications, features and benefits, categorization, cross references and year make model (Rick Weber, How to make eCommerce work, 2015). Users can very easily compare prices from different vendors to get the best deal. They can easily add items to their online shopping cart. Consumers can use coupons to getShow MoreRelatedOnline Shopping versus Traditional Retail Store639 Words   |  3 PagesOnline Shopping vs. Traditional Retail Store One of the most debatable decisions for most Americans during the sale event or holiday is whether to shop or not to shop. Especially, when considering that some of the online shopping websites such as Amazon and eBay are established. To shop online or to shop in the store has become a more practical question. I used to be a traditional shopper, but I changed my mind sometime over years since I found that shopping online is much cheaper and more convenientRead MoreThe Expansion and Uses of Internet Browers822 Words   |  4 Pagesexamples of some of the web browsers that are used throughout the world. These web browsers have become even more common as the years have gone by. People use them in their everyday life to accomplish tasks that they need to get done. The beginning of this profitable and popular invention all started back in 1990. Internet browsers have been around for the last 23 years. The first browser to be invented in 1990 was called the World Wide Web and then later was renamed to Nexus. The inventor that createdRead MoreOnline Shopping Habits1389 Words   |  6 Pages REVIEW OF LITERATURE ONLINE SHOPPING Online shopping or online retailing is a form of electronic commerce which allows consumers to directly buy goods or services from a seller over the Internet using a web browser. Alternative names are: e-shop, e-store, Internet shop, web-shop, web-store, online store, and virtual store. An online shop evokes the physical analogy of buying products or services at a bricks-and-mortar retailer or shopping center; the process is calledRead MoreOnline Shopping And Traditional Shopping756 Words   |  4 PagesShopping can be enjoyable for some people; however, it can also be a burden for others. The preference of the shopper really determines whether or not they have a pleasant experience and the time to look for their items. There are many similarities as well as differences with online shopping and traditional shopping. The main factors that I will be discussing are convenience, discounts and item availability. Convenience is really a significant factor with both types of shopping. As of the 2011 TimeRead MoreOnline vs Brick and Mortar844 Words   |  4 PagesJacobie COM170 10/27/2014 Laura L. Dorsey Online vs. Brick-and-Mortar Shopping One of the opportunities we have in today’s world is whether to buy online or go to a brick and mortar store to do our purchasing. The two offer great sales and promotions along with selections from which we can choose. As online shopping and brick and mortar may seem similar; however, both differ in pricing, convenience and selection. Discounts are offered both online and in store which makes it easy for theRead MoreEssay on E-Shopping837 Words   |  4 Pages E-Shopping Online shopping has impacted the economic, political and cultural development of the financial markets and the economy. Many consumers have been using the World Wide Web in order to purchase items. The computer technology has allowed consumers to use the internet to their convenience to shop. Online shopping has impacted the United States economy greatly. The impacts of online shopping have been advantageous as well as disadvantageous. The beneficial impacts of online shopping areRead MorePlaying Fields Between Offline And Online Stores1271 Words   |  6 Pagesoffline and online stores uneven? For example: Are you the type to window shop in real stores but buy in virtual stores? Online shopping has largely influenced consumers for over 30 years. However during its inception, many consumers still preferred to travel to a physical store location to purchase products as they were unsure about this new method of shopping but as time passed, more people jumped on the bandwagon and soon it became mainstream. The question now though, is that are the shopping fieldsRead MoreEssay Electronic Commerce (E-Commerce) and the Global Economy1178 Words   |  5 PagesIntroduction The world we live in today, revolves around technology, new innovations and constant change. The global economy incorporates these changes into its daily applications forming a technological driven world where businesses thrive on information and competitive markets. Computers and communication networks have planted a seed in this information age where enterprises flourish forming revolutionized market economies. One of the most profound changes emerging in the world of business todayRead MoreElectronic Commerce and Page Load Speed1631 Words   |  7 Pagesfor 15 years, the appropriate ecosystem has now started to fall in place. The considerable rise in the number of internet users, growing acceptability of online payments, the more number of internet-enabled devices and favorable circumstances are the key factors driving the growth story of e-Commerce in the country. The number of users making online transactions has been on a rapid growth trajectory, and it is expected to grow from 11 million in 2011 to 38 million in 2015. Flipkart is a leading e-CommerceRead MoreThe Spread Of Internet Usage1725 Words   |  7 Pagesthe retail sector. As can be seen, many retailers began to use online channels, as they take advantage of one of the most successful platforms of trade (Limayem et al., 2000; Levy and Weitz, 2001; Shim et al., 2001). The growth of new online shopping channels catches the attention of consumers who have become excited to try this new platform. Although Internet shopping channels seem to be growing, the growth of grocery shopping via online has been slower than other forms of retail (Yan and Opperwal

Influence Of Shakespeare On English Language - 793 Words

Shakespeare And The English Language William Shakespeare has influenced the English Language in many ways. Much of his work goes unseen since it is at a higher reading level and is more confusing. He uses a different way of writing, but it is fascinating and challenges the reader to interpret the reading in other ways. We also get many of our modern sayings from Shakespeare that are found in his writing. Some people may not think that Shakespeare has no impact on the English Language, but in reality we can see through the depth of his writing. Shakespeare has influenced the English Language in many ways through the depth and sincerity of his writing. Shakespeares writing is very different compared to other authors. It is†¦show more content†¦Shakespeare’s writing has also influenced our daily language by using the phrases he uses in his writing. We get several modern day phrases from Shakespeare’s writing. A common phrase that is used is â€Å"in a pickleâ₠¬  which means that one stuck or cannot find a solution. The phrase is from the play, The Tempest. Another phrase is â€Å"a wild goose chase† which means that someone sends you on a mission or task that is not existent. This phrase comes from Romeo and Juliet. We also get the phrase â€Å"be-all end-all† which is from the play Macbeth, and is used when he contemplates murdering King Duncan or not. His plays are also very popular since they incorporate drama and romance, so it reaches a larger audience. Some of his more popular writings are Romeo and Juliet, Macbeth and Hamlet, all have a unique story and are very popular. All of these phrases we get from Shakespeare show how he has influenced the English Language since these phrases are commonly used. Some people just see Shakespeare as just another writer and do not have the knowledge or do not see how he has influenced the English Language. When looking at Shakespeare’s writing and by analyzing it we can see the true meaning and depth behind the text. Even though his way of writing can be confusing and complex, it’s meaning and depth has a profound message. One reason that makes Shakespeare’s writing so popular is that it incorporates many different types of interestsShow MoreRelatedWilliam Shakespeare s Influence On Modern Culture1090 Words   |  5 PagesSam Ebersole Mrs. Ruiz English 9A Period 1 19 November 2015 Shakespeare s Influence on Modern Culture William Shakespeare is one of the world s most influential people to ever live. â€Å"BBC audience survey names Shakespeare as Britain s Man of the Millennium.† (Andrews 2) Shakespeare’s works continue to be evident globally in modern society. 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Current Medical Diagnosis and Treatment †MyAssignmenthelp.com

Question: Discuss about the Current Medical Diagnosis and Treatment. Answer: Introduction The following is a case assessment for patient Kasim, aged 49 years old suffering from cholecystitis. The report will be based on clinical reasoning cycle. It is a model which nurses and clinicians use to collect cues, information processing, understanding patient problem and implementing interventions, outcome evaluations and reflection on the learning process of a case study. The outline below shows a detailed assessment report for the patient. Cholecystitis is the inflammation of the gall bladder, (ICGT, 2014) and it occur major on patience of previous history of gall stones. Blockage of cystic duct contributes to the inflammation of the gall bladder. Common symptoms of the condition are the abdominal pain and severe prolonged pain. The patient is admitted with right upper quadrant abdominal pain, fever and vomiting. The patients vitals are the blood pressure is 100/45; heart beat rate is 126 and temperature measuring 38.8oc. The patient further has pale dry mucous membrane his score on pain at the shoulder is at 7/10. For typical confirmed case, inflammation causes effects on the outside body. Pain occurs deeply with inspiration which often leads to breathe termination when the right upper quadrant causes pain. Another key observation is the yellowing of skin pr jaundice which is often a mild appearance. Patience who may have multiple conditions like diabetes and chronic illness and those with immune compromised immune ma y have vague symptoms which include fever and tenderness at a specific region, (Demehri Alam, 2014). The highest risk factor for cholecystitis is gall stones due to increased inflammation. The risk factors for gall stone s include gender, pregnancy, obesity , age, oral contraceptives and eight loss, (Greenberger Paumgartner, 2012). Typical examination for cholecystitis reveals presence of fever, tachycardia and tenderness in the right upper quadrant with rebounding, palpability of the gall bladder or fullness by 30%-40% and jaundice occurrence however it occurs on 25% of the patients. Symptoms of cholecystitis often appear suddenly or develop slowly for a period of time. These symptoms include severe abdominal pains, nausea, vomiting, loose, light coloured tools, fever, abdominal cramp, chills, jaundice and itching, typical attacks last for 2-3 days depending on the person status. Complications can occur which include, pancreatic due to the inflammation, gall bladder perforation due t the infection, enlarged gall bladder, infection build upper and tear of the gall bladder. The most prevalent observed symptoms of cholecystitis are the upper pain in the abdomen, physical examination has tachycardia and the type of tenderness on right upper quadrate is missing from the information. In the case study blood tests are missing, in a case of cholecystitis, blood tests are done for the biomarkers of inflammation. These test include complete blood count and C- reactive protein and the assessment of levels of bilirubin for bile blockage assessment, (Friedman, 2015). In cholecystitis assessment of blood there is an increase in the white blood count with level range of 12,000- 15,000/mcL. The reactive protein is usually increased, bilirubin level is mildly elevated at 1-4 mg/Dl. Blood amino transferees are elevated. The elevation levels of the laboratory values depend on the degree of gall bladder inflammation. Abdominal upper quadrate on the right side is used as diagnosis for cholecystitis, (Strasberg, 2008). Ultra sound results suggest acute cholecystitis which illustrates gall stones, fluid with the gall bladder and the thickening of the gall bladder walls. CT scan diagnostics tests are also not utilised, however it is utilised in severe conditions such as gangrene or perforation. Boazs sign can be used for assessment as it applies on the right scapula and can be an alarm for acute cholecystitis. The patient is exhibiting various vital signs for cholecystitis however they are few for confirmation of diagnosis. Further diagnostic tests need to be done for the patient. A complete blood count should be conducted, and results obtained should be segregated into white blood cells, red blood cells, lymphocytes. The results obtained should be cross checked with reference values. the normal range of white blood cell is 4.3 10 g/l, red blood cell120-175 g/l and platelets 140-450g/l. Creatin levels should also be assessed, it is used as an indicator for renal function tests, normal values ranges at 0.60 1.7 mg/dl. Another focused assessment is BUN, which shows renal function perfusion and the dietary intake of carbohydrates and the level of protein metabolism, referenced based on the normal range values. Another important assessment to be carried is the urinalysis test. It is important for testing in acquisition of information regarding the disorders of the kidney and the lower urinar y tract, and associated disorders that affect urine composition. In the urinalysis assessment, data such as colour, gravity, the Ph and protein availability, red blood cells, white blood cells, bacteria, esterase, ketones, bilirubin and crystals casts are measured. In the preoperative assessment, the patient is experiencing pain at a scale score of 7/10, the acute pain is linked to the increased inflammation and the gall bladder dislocation. This can be largely attributed to the stone availability in the gall bladder, it causes blockage in the cystic duct thus causing acute pain in the right side. There is need for pre-operative assessment which is conducted to run from head to toe and running of objective assessments, which include test such as over the counter drugs, anti-coagulant drugs, smoking history, respiratory problems and nutritional status of the patient. Further focussed assessment of various body organs should be done, these include, the heat, abdomen and lungs. A complete ECG should be conducted so as to asses any previous myocardial infarction and chest x-rays. Full pain assessments and nausea should be done. The patient may appear to be ill with presence of fever and tachycardia, the patient pain score reveals elevated level of pain. Cholecystitis often results in the pain localized at the peritoneal area which causes inflammation and disturbance in the patient is characterized with a lot of pain. Physical examinations should be conducted efficiently and effectively. Accurate measurement soft he vital signs forms the basis of assessments. The physical exam guide should follow inspection, auscultation, percussion, palpation and relevant tests such pelvic positioning. Procedure involves assessing the general appearance of the patient, if the patient is moving around and is not able to find comfortable positions, can be an indicative of renal colic while abdominal scars may be an indicative of distension. Laboratory tests conducted can be no specific and are used to boost the evidence of clinical support, (Liau, Teh Serrablo, 2014). Initials test include complete blood count, leukocytosis is observable in cholecystitis. Urinalysis tests can be able to identify any urinary infection. Chest x rays can be done on the patent as this will assist in ruling respiratory causes of pain. Fluid balance measure can be used to assess the patient, the ratio of intake and output of the patient are used. This data on the patient reflects causes of fluid imbalance such as decrease and increase in fluid levels. Even though laboratory findings may appear to suggest presence of cholecystitis, imaging might be conducted. Procedures such as ultra sonography might be conducted, which asses the right upper quadrate, gall stones can be observed using the ultrasound. Conducting Murphy sign by sonographic method is done by applying pressure on the transducer of the ultra sound linking to the gall bladder and displayed on the screen. Computer tomography can be utilized to assess the patient. Acute condition state, with similarities as gall bladder, edema on the walls and fluid in the periphery can be displayed. Ultra sonography is the readily and more accurate tool for assessment of cholecystitis, (RUQ, 2017) In a more precise manner on tests and assessments for the patient, maintenance of accurate records of intake and output data in fluid management are essential. Skin assessments and the mucous membranes for this patient are evident; they provide clear information on the fluid state and circulating volume of fluid. Monitoring of vital signs and the presence of nausea, cramps on the abdomen, seizures and depressions on the respirations are useful for identification of deficiencies which are associated like decline in sodium, potassium, and chloride. Encourage the patient to perform regular oral hygiene proper treatment mouth wash, this assist in decreasing the dryness of the mucous membrane of the oral cavity. Conclusion Hence in the patient assessment there is need to focus planning goals on pain management with an aim of alleviating pain. Prompt diagnosis of the patient is effective in the overall care strategy, (Baron Grimm, 2015). There is need for maintaining balance of the fluid and the electrolytes in the body of the patient. Clear respiratory are essential for respiratory ability of the patient. In patient assessment, there is need for comprehensive history evaluation and effective physical and laboratory examinations, as this ensures clear and appropriate diagnosis of cholecystitis condition. Reference Baron, T. H., Grimm, I. S. (2015). Nonsurgical management of cholecystitis: a tailored approach. Gastrointestinal endoscopy, 82(6), 1037-1038. Demehri, FR; Alam, HB, (2014). "Evidence-Based Management of Common Gallstone-Related Emergencies". Journal of intensive care medicine. doi:10.1177/0885066614554192. PMID25320159. Friedman L.S. (2015). Liver, Biliary Tract, Pancreas Disorders. In Papadakis M.A., McPhee S.J., Rabow M.W. (Eds), Current Medical Diagnosis Treatment 2015. Greenberger N.J., Paumgartner G (2012). Chapter 311. Diseases of the Gallbladder and Bile Ducts. In Longo D.L., Fauci A.S., Kasper D.L., Hauser S.L., Jameson J, Loscalzo J (Eds), Harrison's Principles of Internal Medicine, 18e Internal Clinical Guidelines Team, (2014). "Gallstone Disease: Diagnosis and Management of Cholelithiasis, Cholecystitis and Choledocholithiasis. Clinical Guideline 188": 101. PMID25473723. Liau, K. H., Teh, C., Serrablo, A. (2014). Management of acute cholecystitis and acute cholangitis in emergency setting. Central European Journal of Medicine, 9(3), 357-369. RUQ Acute Cholecystitis -The Medical University of South, (2017). Carolinaacademicdepartments.musc.edu/surgery/education/medstudents/.../ruqacutechole.pps. Accessed online 2017-05-04. Strasberg, SM, (2008). "Clinical practice. Acute calculous cholecystitis.". The New England Journal of Medicine. 358 (26): 280411. doi:10.1056/nejmcp0800929. PMID18579815.