Knowledge, Attitude and Breast Cancer Screening Practices in Ghana Essay

INTRODUCTION   Ã‚   Breast cancer in its simplest definition is the cancer of breast tissue. It is the most common nonskin cancer that affects women in the United States and the highest fatality rates of cancer deaths among women in low-resource countries (Anderson et al 2006). Severity of breast cancer differs based on its level of tissue invasion. Ductal carcinoma in situ is the most common noninvasive breast cancer while infiltrating or invasive ductal carcinoma is the most common breast cancer that accounts for about 80% of invasive breast cancer. Breast lumps presentation is the commonest form of presentation regardless of the breast cancer type (ACS 2005). Epidemiologic factors are attributed to dietary and environmental risk factors, although association of diet and breast cancer had varied results. Environmental risk factors involve the exposure to several toxic elements which accounts for the increased incidence of breast cancer in Western countries. Alcohol intake is also considered to effect in the increase of the number of cases in the US population. Age is also considered as cancer risk factor and can be attributed to hormonal change. Genetic variation and ethnicity are not out of scope for the investigation of breast cancer risk factors (Barton 2005). Diagnosis and Pathology of Breast Cancer: In 2002, Breast Health Global Initiative (BHGI) together with panel of breast cancer experts and patient advocates develop a consensus of recommendations for the diagnosis of breast cancer in limited-resource countries (Shyyan 2006). Histopathologic diagnosis included fine-needle aspiration biopsy which was recognized as the least expensive, core needle biopsy and surgical biopsy and had a consensus of choosing the method based on the availability of tools and expertise. They gave emphasis on the correlation of histopathology, clinical and imaging findings. They agreed on the need of histopathologic diagnosis before breast cancer treatment. In 2005, BHGI panel recommended an additional strategy of breast cancer management. They stratify diagnostic procedure and histopathology methods into – â€Å"basic, limited, enhanced, and maximal—from lowest to highest resources†. Basic level includes medical history of the patient, clinical breast examination, tissue diagnosis and medical record keeping. Limited level includes the increasing resources that enable diagnostic imaging utilization such as ultrasound with or without mammography, tests that can evaluate metastasis, use of image-guided sampling and hormone receptor sampling. Enhanced level includes diagnostic mammography, bone scanning and an onsite cytologist. Maximal level includes mass screening mammography (Shyyan 2006). Treatment of Breast Cancer: Treatment includes surgery, radiotherapy or chemotherapy or combinations of these three treatment modalities. According to American Cancer Society (2005), treatment can be local or systemic. Local treatment of the tumor is done without affecting the rest of the body. Surgery and radiation are examples of this treatment. On the other hand, systemic treatment which includes chemotherapy, hormone therapy and immunotherapy, is given into the bloodstream or by mouth to reach the cancer cells that may have spread the beyond the breast.    Radiotherapy is a treatment of breast cancer with high-energy rays to help shrink the cancer cells. It can be given outside of the body (external radiation) or can be placed directly into the tumor as radioactive materials (ACS 2005). It may be given external to the body.   Radiotherapy requires safe and effective application requiring appropriate facilities, staff and equipment. Radiotherapy should be applied without delay, should be accessible to all but without prolongation of the overall treatment time exposure. It is part of an integral part of breast-conserving treatment. It is required in almost all women with the breast cancer, and therefore should be available (Bese 2006).   Ã‚  Chemotherapy is the use of anticancer drugs that are administered through injection in the vein or taken orally as a pill. It may be given before breast cancer surgery to reduce the size of the tumor or may be given after the surgery to reduce the chance of   recurrence (ACS 2005). This treatment is done in cycle the most common of which is 3-6 months. Most common side effects of these drugs usually stop   once the treatment is over such as in hair falling. Some of   drugs used as chemotherapy     are tamoxifen, cyclophosphamide, methotrexate, 5-fluorouracil doxorubicin, epirubicin, taxane and aromatase . These are usually prescribed in combination, and treatment is done with adjuvant therapy such as radiotherapy and pre- and post operation ( Eniu 2006).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Surgical management in breast cancer is very common. This is done to remove as much as the cancer as possible and to find out whether the cancer has spread to the lymph nodes under the arm. Surgery can also restore the appearance of the breast and relieve the symptoms of advanced cancer. ACS (2005) released some of the common surgical procedures in breast cancer. These are lumpectomy, partial or segmental mastectomy, simple or total mastectomy, modified radical mastectomy and radical mastectomy. RESULTS    Breast cancer patients in Ghana. The present study which included women with mean age population of 48 years   revealed an almost consistent perception with regards to breast cancer.  Ã‚   They were aware that breast cancer is highly increasing in their place but not informed of the cause of disease. All of the responders were not aware of family breast cancer history except one. Information about breast cancer was acquired through television and radio programs. Only after   consultation with doctors due to lumps or   pains in their breast and some due to liquid coming out of their breast, that they were informed that they have breast cancer. Most of them underwent breast tissue exam for confirmation of the disease. Afterwards, they were advised to undergo surgery with medical treatment. The responders were ignorant of the breast cancer screening and prevention. In fact, out of 10 responders, only 2 (20%) of them were aware of breast self examination and clinical breast examination and admitted that they occasionally practice BSE. None of the responders knew about mammogram except for one (10%) of them who has heard of it but never had tried one. The feeling towards the knowledge of acquiring the disease was also the same; the feeling of being a burden in the family was common. They were afraid to face the reality but have realized that they have to fight the disease through the encouragement and support of family members and   help of medical professionals. The sample population was aware of the herbalist and faith healers but they did not submit themselves into that kind of treatment because herbalist have not   proven cure for breast cancer.   The most common complaint of the responders was the high cost of therapies, hospitalization and doctor fees. The treatment cost ranged to    ¢250,000- ¢24 million except to one of them who received a free treatment for being enrolled to a clinical trial. Sentiments of the participants were the same. Delay of treatment was attributed to their distant place from the health clinics; some facilities like x-ray were not available in the clinics and   high cost of treatment. These people asked for the betterment of breast cancer management through education dissemination to the community by health care providers and a help from the government to provide financial support to those who cannot afford to submit themselves for treatment. Patients in breast cancer clinic. In this part of the study, women with mean age of 42 years who were in breast cancer clinic were included. Most common medical complaint was lump and pain in the breast while others submit themselves for screening because they have just heard it from the radio/TV.   The study revealed that women who were attending the clinic were not actually informed of the cause breast cancer but aware of its increasing rate of mortality. Misconception about the cause of breast cancer such as exposure to coins was not common but did not exclude the form of trauma due to manipulation of the breast. Others correlate breast cancer with smoking and taking alcoholic beverages. They were not aware of their family history of breast cancer.   Information regarding breast cancer was acquired through television and radio programs and others were through their friends and family members. Most of the respondents believed that early detection and prompt treatment of the disease can prevent the unfavorable outcome of breast cancer such as removal of their breast or the worst would be cancer death. Only one out of   10 participants (10%) actually practice breast self examination (BSE). Most of them were informed of BSE but not actually practicing it. They were also aware of healers and herbalist but they did not believe that they can cure breast cancer but did not disagree of the possibility that herbalist and healers could treat other diseases or illnesses like hypertension. The participants suggested that it would be better if the government would provide or establish more health care clinics for breast cancer screening and provide free screening programs especially to those who cannot afford to   pay for high cost of treatment of the disease and for an open-easy access to all especially to those in rural areas. One of the participants suggested   that doctors should study further about the treatment of breast cancer instead of resorting to breast surgery. Healers involved in breast cancer management. Many of the population of Ghana are still patronizing healers and herbalist as a resort   of treatment. Two healers from Ghana were interviewed regarding their management of breast cancer. The healers have been into this practice for about 20-50 years. According to them, breast cancer is very common in Ghana and they are aware of the increasing incidence of   the disease. They described breast cancer as an â€Å"obosam† disease and the other was a supernatural disease. Healers believed that their ability to cure   the disease inherited from their forefathers who taught them how to prepare herbs and provide them with dwarfs. They believed that doctors have no right treatment towards breast cancer because according to them they just remove the breasts of women   and subsequently die. According to the healers they do not promote breast   examinations to their patients because these are useless and cannot stop women from getting the disease. Despite the big machines available in the hospitals, women with breast cancer still die, according to them. Healers charge their patients with as much as  ¢200,000- ¢1( £15-60) million depending on the patients’ condition. The healers admitted that there were cases of recurrence of the disease due to lost to follow up and missed spiritual sessions. Healers do not refer patients to hospitals rather, they encourage hospital doctors to refer their patients to healers because they are more capable of treating breast cancer. Breast cancer consultants.   Medical health professionals play a significant role in the awareness of breast cancer. They have the power to influence their patients toward right management of the disease. In the present study, surgeon/breast cancer consultants were interviewed. Consultants as expected were aware of the increasing incidence of breast cancer but they cannot give an exact figure due to absence of cancer registry in the place however they were able to attend to 200-300 new cases of breast cancer annually with age range starting from 20 years and above. They revealed that women in Ghana associate breast cancer to death because after undergoing breast caner surgery they usually die. People in Ghana link medical intervention and death which made the women in this place afraid of   the disease and lead them to negative attitude towards the disease. Consultants believed that there were several misconceptions about the disease. They were also aware that healers and herbalist delay the   presentation of patients to   hospital which accounted for the late stage of diagnosis. National Screening Program would benefit the people in Ghana for early detection of breast cancer and prompt treatment, however, they did not deny the fact it would be difficult to establish such program due to lack of funds by the government at present time. Consultants were aware of the limited resources of the needed for the implementation of the program. They believe that it is much easier and feasible to educate the women on simple screening methods such as regular breast self examination and encourage practitioners to take advantage of examining the breasts of their patients. There are also NGOs who are engaged in some activities like providing health care assistance. Consultants revealed that they receive referrals from district regions and from private practitioners. All patients with breast cancer are candidates for surgery. There are just some procedures that lead to untoward incident which cause the people to blame the doctors. According to consultants, one big problem that they encounter is the delay of the result of tissue exam from the pathologists which sometimes lead them to acquire the high cost of private laboratory. According to consultants the 5-year survival rate in Ghan is 25% which is disappointing. According to radiology consultant, patients present themselves to treatment once they are already in advanced stage, most at stage 3 and 4. They revealed the common factors that influence the delay of treatment among Ghana women. Most of the patients were scared of the procedure of   breast cancer treatment like in breast surgery which have many social and marriage implications. The high cost of the procedure hinders the patient to go to the doctors. Consultants revealed that surgical procedure may cost    ¢2-3million   ( £ 150-200), radiotherapy is about    ¢3-4 million (  £ 200-300) and chemotherapy is around  ¢6 million ( £400). Although surgical treatment cost is covered in National Health Insurance, the cost of radiotherapy and chemotherapy are excluded. Mammography which is an effective tool in breast cancer screening costs  ¢400,000 ( £30) in private health institution and around  ¢250,000 ( £20). DISCUSSION WITH REVIEW OF RELATED LITERATURES   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The present study aimed to increase the awareness of the women in Ghana to breast cancer and the benefits that can be gained from breast cancer screening. The knowledge, attitude, behavior and practices of the women regarding early detection of breast cancer were analyzed. The ultimate aim of the study was to reduce the mortality rate of   breast cancer.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   The study revealed that there were still misconceptions about breast cancer despite the information gathered from televisions and radio programs. Attendance of Ghanaian women in breast clinic did not mean that they were informed of the nature of their disease. Only few of them were also aware of preventive procedure in detecting breast cancer. Local healers and spiritualists also delayed the presentation of the patients to the hospital which contributed to the late diagnosis of the disease. Difference in the disease management of health professionals can be attributed to the location of practice and availability of resources. Several factors   thought to affect the breast cancer screening program were the poor education of the Ghanaian towards prevention awareness against breast cancer; lack of initiative of the people to spread the knowledge of   breast cancer screening such as simple breast self examination and clinical breast examination; the inaccessibility of the of primary health care and the organizers; the unavailability of the appropriate screening tools like x-ray and mammography in the community and its high cost   and the lack of support from the government.   The following   review of related literatures will help in the understanding of breast cancer and breast cancer screening. Because of the continuous increasing prevalence of breast cancer and high cost of treatment, breast cancer screening remains the most cost effective way of cancer management (Parkin and Fernandez 2006).   Most of the world faces resource constraints that hinder the capacity to improve early detection, prompt diagnosis and sufficient treatment of the breast cancer. Every country finds its way to develop evidenced based, economically feasible and culturally appropriate guidelines that can be utilized by countries of limited health care resources to improve breast cancer outcomes (Anderson 2006). Adaptive strategies should be applied to ease the growing burden of breast cancer. In 2005, according to Smith and his colleagues (2006), the Breast Health Global Initiative (BHGI) held its second summit in Bethesda, MD with the intention of reaffirming the principle of requiring all women of all resource levels to support in seeking health care and assuring the access to affordable and appropriate diagnostic tests and treatment intervention against breast cancer. They recommended breast health awareness to all women including the basic resources. They enhanced the basic facilities for effective training of relevant staff in clinical breast examination (CBE) or breast self examination and even the feasibility of mammography. MRI: Magnetic resonance imaging is one of the breast cancer screening procedures. It has been increasingly used as tool for early diagnosis of breast cancer. This screening tool has shown to detect cancers even they are small and potentially proven to be more curable than mammography alone. However, MRI is more costly than mammography and can lead to unnecessary breast biopsies, thus causing anxiety and discomfort to patient. On the other hand, a research study about the cost-effectiveness of breast MRI screening by cancer risk where they included the cancer detection ability of MRI, characteristics of women with dense breast tissue and women with high inherited breast cancer risk, revealed mortality reduction and cost effectiveness of breast MRI screening added to mammography in BRCA1 and BRCA2 mutation carriers (Kurian 2006).    The hallmark of morality and morbidity of breast cancer can be attributed to the late presentation of the patients at an advanced stage of breast cancer. It is when there is no or little benefit that can be derived from any treatment modality. In a study conducted by Okobia and colleagues (2006), the knowledge, attitude and practice of community dwellers of Nigeria towards breast cancer were analyzed. They recruited urban-dwelling women with conducted an interviewer-administered questionnaires to elicit sociodemographic information regarding knowledge, attitude and practice towards breast cancer. It was found out that the participants had poor knowledge of breast cancer. Only 214 out of 1000 participants knew that breast cancer is presented initially with breast lumps. Breast cancer examination practices were low. Only 432 participants were able carry out breast self examination while only 91 participants had clinical breast examination. This study revealed that participants with higher level of education were significantly more knowledgeable about breast cancer. Ethnicity or race-related culture and beliefs are factors that affect the increase in prevalence of breast cancer mortality. Paterniti (2006) investigated how ethnically diverse women who are eligible for tamoxifen prophylaxis because of their breast cancer risk decide about tamoxifen use for risk reduction. Prior to the study, there was discussion of the benefits and risks of tamoxifen as prophylaxis. The study which included African-American, White, and Latina women, of 61–78 years, revealed that fear of breast cancer was not prominent and they were not inclined to take tamoxifen as preventive therapy after receiving the information. Participants showed limited unwillingness to take the medication with potential adverse effects. This study revealed that women felt that they had other options other than taking the risk of tamoxifen to reduce their risk of breast cancer, including early detection, diet, faith and other alternative therapies.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Graham (2002) conducted a research about   the relationship between beliefs and practice of breast self examination (BSE in a black women population of 20-49 years of age. It was found out that health beliefs were much stronger in determining BSE performance for a given individual than were demographic characteristics. Breast self examination was related to increased perceived seriousness of breast cancer, benefit of the procedure and health motivation and was noted to have inverse relationship with perceived barriers. A related study was reported by Mitchell and colleagues (2002), about the effects of religious beliefs with other variables on breast cancer screening and the intended presentation of self-discovered breast lump. This study included women aging 40 years and above and were interviewed in their homes. Most of the interviewees believed that doctors cure breast cancer with God’s intervention which was labeled as â€Å"religious intervention with treatment†. This dimension was found out to be correlated with self-reported mammography but no clinical breast examination or intention to delay presentation of self-discovered breast lump. Minority of them believed treatment of breast cancer was unnecessary because only God could cure the disease which was labeled as â€Å"religious intervention in place of treatment†, and was significantly more common among African-American women who   are less educated and older. This was correlated with the strong intention of delaying the presentation of self-discovered breast lump. It was concluded that   religious intervention in place of treatment contributes significantly the delay presentation of breast cancer among African-American that contribute largely to the advanced-stage cancer diagnosis. The cause of breast cancer is still unclear. Adjei (2006) who grew up in Ghan and had some work about breast cancer. In his letter, he revealed his sentiments about the genetic differences in breast cancer. He had been aware of the incidence of breast cancer in Ghana since 1974 to 1999. He noted that the peak incidence of breast cancer in Ghana is in younger women with age range of 40-45 years while in United States and Caucasians, the peak incidence is in older age groups. Adjei (2006) pointed out that women of different places and environments, with different diets have similar epidemiology of breast cancer. In an argument which revealed number of breast cancer in African-Americans but rare in native African has been used to suggest that ethnicity is one factor of acquiring the disease, however, according to Adjei (2006), this information is leading because cancer has not been well-studied in Africa. Researchers are still finding their ways to fully disclose the correlation of genetic signature in breast tumors that are presently noted   to be a powerful predictor of cancer spread and cancer death. In a limited study conducted by Kolata (2002), she included few patients who are relatively. As she stated in her report, scientists said that the activity of a collection of 70 genes appear to predict cancer mortality   better than traditional measures like tumor size, cancer stage or lymph node spread to the axilla of women. She revealed in her study that 5.5% of women with good genetic signature died within the next decade while 45% of women are those of with bad genetic signatures. Adherence to the treatment regimen of breast cancer plays a big role in the improvement of disease outcome. There are no much literature about the factors associated to the behavior that influence the patient to delay or cause an incomplete adherence to the recommended follow up in patients with breast cancer. In a study conducted by Kaplan (2006), race/ethnicity, country of birth, financial issues fear of pain and difficulty of communicating with the healthcare providers are the barriers to seek follow up consultation Breast Cancer Screening: There was decline in breast cancer mortality rate of 0.9% in African American women while 2.1% was the decline in breast cancer mortality rate in non-Hispanic White women (Stewart et al 2004 as stated by Settersten , Dopp, and Tjoe, (2005).    On the contrary, De Koning (2000), questioned in his study the cost effectiveness of breast cancer screening. His idea came out when he analyzed his expectations of the reduction of breast cancer mortality after breast cancer screening. He stated in his study that the Dutch program of 2-yearly screening for women aged 50-70 would produce a 16% reduction in the total population. As stated in his research paper, the actual benefit that can be achieved from breast cancer screening programs is overstated. According to him breast cancer screening need to be carefully balanced against the burden to women and health care system. De Koning (2000) stated that â€Å"effects of breast cancer screening program depend on many factors such as epidemiology of the disease, the health care system, costs of health care, quality of the screening program and the attendance rate†. Groot, M. T. et al (2006) estimated the costs and health effects of breast cancer interventions in epidemiologically different regions of Africa, North America and Asia. They developed a mathematical simulation model of breast cancer using the different stages of cancer, its distribution and case fatality rates in the absence and presence of treatment as predictors of survival. The study resulted to a conclusion that untreated patients were the most sensitive to case fatality rates. This study suggest that treating breast cancer at stage 1 and introduction of an extensive breast cancer program are the most cost effective breast cancer interventions.   Ã‚   This study is supported by the research done by Aylin and colleagues (2005). They recruited women at the mammography clinic to evaluate the knowledge about breast cancer and mammography as breast cancer screening procedure. The striking result of this study is that most of the participants (95.3% of the total participants) were aware that women should have mammography screening periodically. They were informed of the fact that breast cancer screening such as mammography could help in the early detection of breast cancer. However, less than 50% of them admitted that they had never had mammography screening. Majority of the respondents (71.1%) were practicing breast self-examination. Another related study was conducted by Dundar and colleagues (2006), since breast cancer is the second leading cause of cancer deaths in Turkey , they determined the t the knowledge and attitudes of women in a rural area in western Turkey about breast self examination and mammography. They recruited women with age ranging from 20-64 years. Although majority of the participants have heard or read about breast cancer only 56.1% of them had sufficient knowledge about breast cancer and some admitted that they acquired the information from their health care professionals. Those with information of beast cancer were also those who practice breast self examination. This study revealed that health care professionals play a big role in information dissemination about breast cancer. Table 1. Recommendations for routine mammographic screening in North American women aged 40 years or older who are at average risk for breast cancer* Group (date of recommendations) Frequency of screening (yr) Included ages (yr)       40-49 50-69 >70 Government-sponsored and private groups US Preventive Services Task Force (2002)** 1-2 Yes Yes Yes*** Canadian Task Force on Preventive Health Care (1998, 1999, 2001) 1-2 No Yes No National Institutes of Health consensus conference (1997)    No+ — — American Cancer Society (1997) 1 Yes Yes Yes National Cancer Institute (2002) 1-2 Yes Yes Yes Medical societies American College of Obstetricians and Gynecologists (2000) 1-2 if aged 40-49 yr 1 if aged >50 yr Yes Yes Yes American Medical Association (1999) 1 Yes Yes Yes American College of Radiology (1998) 1 Yes Yes Yes American College of Preventive Medicine (1996) 1-2 No|| Yes Yes American Academy of Family Physicians (2001) 1-2 No+|| Yes No American Geriatrics Society (1999) 1-2 — — Yes*** Advocacy groups National Breast Cancer Coalition (2000)    No –+ No National Alliance of Breast Cancer Organizations (2002) 1 Yes Yes Yes Susan B. Komen Foundation (2002) 1 Yes Yes Yes The above table   was taken from the study conducted by Barton (2005) There are several ways presented and studied for breast cancer screening. Its concern is to reduce the prevalence of cancer mortality and to improve the quality of life as a result of early detection, however, there are still people that are not aware of breast cancer screening In response to increase the worldwide awareness of breast cancer, breast cancer advocacy movement has been analyzing the common experiences of women with breast cancer around the world especially those with limited resources. They found out that although there are language barriers, sentiments were consistent across cultures; cancer survivors have the same experiences and fears. The beliefs and taboos about breast cancer hinder the awareness programs and treatment. There are also limited resources for public education and awareness. Difficulty in understanding and translating the concept of the disease into English also hinders them in the public awareness of breast cancer (Errico and Rowden 2006). In accordance with this, sociological review of the barriers experienced by the women from different traditional cultures is essential not just to understand patterns of late breast cancer diagnosis but also the importance of interventions and programs. This is necessary for them to understand the preventive health care, specifically in breast cancer. This is because many are still ignorant of the breast cancer. According to Remennick (2006), health care providers and policymakers should try to understand and influence women especially those who are cancer risk to be aware of the disease to detect and treat breast cancer early. There are many structural barriers that hinder women especially those living in rural areas. Socioeconomic factors include poor health insurance, distance to medical facilities and inability to take time off work. Organizational barriers include difficulty in navigating complex health care systems and interacting with medical staff. Psychological and sociocultural barriers are poor health motivation, denial of personal risk, fatalism mistrust of cancer treatments and fear of becoming a burden on the family members. Still in other cultural behavior, especially in Muslims, women are strongly controlled by men and therefore may prohibit women in breast cancer screening. Remennick (2006) includes in his study the different approaches that lower the mentioned barriers, including implementation of uplifting the educational programs that would enlighten people regarding cancer myths and fallacies. He suggests that health care professional must outreach to their co ethnics. Primary health care providers play a critical role in   determining the compliance with treatment and preventive practices through direct recommendations to their patients. Family physicians and general internists showed that 70% of women who received a provider referral completed a screening mammography within one year versus only 18% of self-referred women (Grady   et al 1997 as stated by Santora 2003). However, Over 90% of rural women report that a doctor’s recommendation to have breast cancer screening is â€Å"important† (Sparks et al 1996 as stated by Santora 2003). It should be noted that clinician compliance is contributed by several factors such as relation with provider, guideline of the treatment, patient’s behavior and environmental factors. Several studies have been conducted to report the   differences of health services in rural, urban and suburban areas with regards to their   health care services in the family practice clinics. It has been pointed out that lower utilization has been a significant factor. Those rural health practitioners have less access to health care services.   In a study done by   Pol and his colleagues (2001), suggested that rural health services do not lag for patients with access after revealing that 9 out of 16 services examined were as high or higher in rural areas. Another   study to examine the variations in breast cancer screening among primary care clinicians by geographic location of   clinical practice was done by Santora (2003). Physicians, nurse practitioners and physician assistants were included in the study and were classified into urban, rural and suburban categories based upon practice location. The study revealed that although there was no significant difference in the practice location, there was evident variation in the practice of   breast screening. It was reported that urban and suburban health practitioners were less compliant with the use of breast cancer guidelines as compared to clinicians in rural areas.   Primary care clinicians, including physicians, nurse practitioners and physician’s assistants lack a consistent. This study revealed   that geographical location is not the main factor of inconsistent medical approach to breast cancer screening. Although the difference in the approaches to the procedure is uncertain in this study. A related study about General Practitioners’ (GP’s) knowledge, beliefs and attitudes toward breast screening, and their association with practice based-organizations of breast cancer screening, was conducted by Bekker, Morrisona and Marteau (1999). This study revealed that women’s attendance for breast cancer screening may be increased due to raising GP’s perceptions of the   threat of breast cancer. 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Literary Analysis of an Unseen Extract Essay

Literary analysis of an unseen extract: how does the author engage the reader through the use of literary devices in your given extract? The first line † In the middle of nowhere†¦ † grabs the readers attention because it gets the reader wondering why this person is in the middle of nowhere, It gives the reader something to think about creating different feeling and emotions towards the reader. As you begin to read on you are given the weathers description â€Å"left behind its feeble breezes, but the heat scorched and smothered them† this shows how hot the country is but with a cool breeze, this creates quite a different affect on the reader because it sets a less mysterious scene to the first line. Near to the end of the first paragraph the word dereliction is used, this means a snse of abandonment is prevailed in the setting as it says â€Å"A deathly silence pervades the dereliction as far as the eye can see. † this shows quite a mysterious and creepy feeling towards the reader, makes you want to read on because it lures you in with the suspicion and suspense. On the second page the atmosphere is described, creating a shocking effect to the reader which again lures the reader to read on and find out more, the use of decriptive words that are used in such small sentences create a dramatic effect. â€Å"†¦ bare of breath of raging battles, rises kabul, or rather whats left of it† this shows a completely different side to Afghanistan to what we was hereing before. Grabbing the readers attention with detailed description of the way the surroundings look, â€Å"Nothing will ever be the same again† this shows a negative feeling that the reader could feel sympathy for the characters involved and this could make the reader want to read on because he/she will want to find out what happens to the characters. Within this extract there is a lot of horrific imagerey used to describe the charcters surroundings â€Å"the ruin of the city walls has spread in to the peoples souls† this is really negative and not quite a pleasant thing to imagine, to me this would pull me into reading the book more because its so strongly written that you can almost imagine every detail in your head, just like your there as one of the characters. The feelings that this extract causes the reader to feel are mixed emotions mostly quite disturbing and negative but definitely grabs the reader to read on, makes you want to keep reading because it snatches the reader from all distractions keepiing them directly focused on whats going to happen next. There is a lot of nature referrances in this extract which  could get the attention of a reader who for example like nature. In my opinion this extract s very good at grabbing the readers attention through descriptive language, It sets the scene and describes almost every detail about what happening around the characters. This would be so interesting to read because you can imagine yourself being there, feeling exactly what every character feels and sees.

Marketing part 1 Essay Example | Topics and Well Written Essays - 1250 words

Marketing part 1 - Essay Example It also has flights that carry luggage over a short distance especially when dealing with perishable goods. The market segment of Qantas airline is divided into two: The domestic segmentation and the international segmentation. The international segmentation of the company aims at reaching customers all over the world. The main targeted customers are people who travel overseas country for business trips or vacations. It targets international travelers who are the major target of the company. Such include business people and individuals who love travelling across the globe. The second target is the domestic segment which involves offering airline services to people within the country. The services are offered to people who travel over various areas in the country and people travelling for vacations. Qantas has lowered the prices of this segment making it accessible for the local people. The travels involve short hours, unlike the international travels. The features of the airline do not offer many services because they operate at short hours with a maximum of 3 hours. The company provides a wide selection of services which it offers to its customers. The company offers comfortable and reliable flights to its customers especially in the long-hour flights. The company is diverse and offers both domestic and international aviation services to its customers making it more competitive in the market share. It can meet the need of both the local people and international travelers something that a number of airlines in Australia have not been able to offer. The company also has a strong backbone that supports its activities. The fiscal position of the company is stable enough to support all of its operations. It also uses the most recent technology to make its services more convenient and of quality. The company also has a good technical support which ensures

Community Health Nursing Essay Example | Topics and Well Written Essays - 1000 words - 1

Community Health Nursing - Essay Example This paper provides you the most up-to-date information and also the basics of diabetes. This will effectively instruct patients and will help them to control their diabetes. For a successful maintenance and self-regulation of diabetes, the paper must address the important and current topics. Community: India, being the second highly populated country has more than 50 million people with type 2 diabetes. This kind of disease results from a genetic susceptibility and also from lifestyle to which mankind adapted to. For example, the western lifestyle and they are characterized by high calorie intake and little exercise. Some of Indians were brought to Mauritius in the year 1830 to work in the sugar plantations for physically demanding work. The Mauritian government was forced to promote industrialization and the export of manufactured goods due to decline in world sugar prices in 1980s, leads to increased prosperous and decreased physical activity among the local population. â€Å"So the death rate between 1982 and 1986 due to diabetes was increased three times and reached 13% by 1987 in the Mauritius Indian community† (Diamond, 2011). Demographic and Epidemiological Data: International Diabetes Federation published Diabetes Atlas in the year 2006. According to that around 40.9 million people in India were diabetic and are likely expected to increase up to 69.9 million by the year 2025 unless urgent preventive steps are taken. The stage of this disease has changed from slight disorder of the elder persons to one of the major reason for the â€Å"illness and death among the young and middle aged people† (Policy Documents, 2006). The increase in commonness of the disease is seen in all six inhabited continents of the globe. In between 1972 and 1975 the first national study was done by the Indian Medical Research on the prevalence of type 2 diabetes in India. It was 2.1% in urban and 1.5% in rural population. In people above 40 yr of age it was 2.8% in rural and 5% in urban. In between the year 1989 and 1991 a National rural diabetes survey was done in different parts of the country in selected rural population. To diagnose diabetes this study uses the 1985 WHO criteria and reported a crude predominance of 2.8% In Andhra Pradesh, the Eluru survey showed a prevalence of 1.5 % when looked for familiar diabetes in four. A Prevalence of 8.2% in the urban and 2.4% in the rural was reported in the year 1988 in Chennai. Across India a study based on population was conducted in six metropolitan cities by the National Urban Diabetes Survey (NUDS).It also recruited 11,216 subjects aged 20 yr and above representative of all socio-economic strata. Age standardized prevalence of 8.6% in urban population showed in western India. Recent studies reported a prevalence of 9.3% in rural Maharashtra. In Ernakulum district located in Kerala, a community based cross-sectional survey was done in urban by The Amrita Diabetes and Endocrine Population Sur vey (ADEPS). The survey has revealed a very high prevalence of 19.5%. 15.5% of overall crude prevalence of diabetes was reported using WHO criteria 14 in CURES(age standardized: 14.3%) and 10.6% with IGT(age-standardized: 10.2%).In Chennai, the commonness of the disease was increased by 39.8 per cent (8.3 to 11.6%) in between the year 1989 to 1995 and in between the year 1995 to 2000 it was 16.3 per cent (11.6 to 13.5%) and between 2000 to 2004, it was 6.0 per

Compare and contrast Code of Hammurabi and Tao Te Ching Essay

Compare and contrast Code of Hammurabi and Tao Te Ching - Essay Example Again, he advocated for self-mastery in that he considered one as having true power in mastering himself. He was outspoken to criticize those leader with high egos but rather cherished the works of leaders who inspired people to realize their capability and work to achieve success. He also had an advice to those who give up so easily when things get tough. He sees the reason and importance of perseverance in that by incorporating the quotation on the long journey starting by a single stride. From my analysis, an essential message can be derived from Tao’s works. Firstly, the philosopher naturally came out to present a reasoned source in his claims. Occasionally it is not always what that source is, however, it is not advisable to presume that he wrote strictly from his own view or urge. Tao’s thoughts were decisively supported and intricately linked. I think this is one of the reasons as to why his philosophical vision has been so successful. Tao Te Ching was strongly contributes to today’s ethical catch-22, he provides solutions as well as causing such dilemmas. According to Tao Te Ching, human beings need to all live a unbiased life. Despite the fact that Tao and teaches about humans living in harmony, he does not reveal the penalty, and a strong base of correct and erroneous. He edifies that there truly no sin. This portrays how Tao’s verses lacked the moral sense hence he does not provide a basis for human to lay their lives on. Tao enlightens us on making ourselves happy rather than looking on to other people for us to find happiness. In comparison to Hammurabi who was a leader of the Babylonians, he enthusiastically understood the importance of justice. And in an effort to realize his goal, he required a single collective set of rules for all of the different kind people he dominated. Consequently, he sent legal

Conservation biologist Assignment Example | Topics and Well Written Essays - 250 words

Conservation biologist - Assignment Example I.  The demand for metals, as well as other natural resources has outstripped supply (Blogger 1). Such a situation has occurred because of the increase of the surge for these essential resources. II.  Discovery of new deposits results in exploitation as a means of offering solutions to the need for the natural resources. However, implementation of such actions does not contribute in the attainment of success in the international trade since they lead in the development of complexities and political constraints. III.  Ore deposits should not be degraded because of the impact of their exploitation and societal conditions.IV.  The sea floor is one of the essential human resources on the earth’s surface, which demands an effective stewardship. V.  As the terrestrial environmental, the sea floor has plateaus, mountain ranges, vast plains, canyons and volcanic peaks. It has similar minerals to the ones on land in enriched forms.VI.  Deep mining is a strategy that should be avoided at all times to preserve these natural resources and eliminate their exploitation. VII.  Critics argue that mining is essential to provide the minerals, metals and other resources that man needs. Such should occur through the use of intensive technological means of mining and processing. VIII.  However, these individuals are wrong since they fail to comprehend the need to preserve these natural sources of minerals for further exploitation in the future. IX.  Conservation of biology is a good act towards ensuring.

Macroeconomics problems Essay Example | Topics and Well Written Essays - 2000 words

Macroeconomics problems - Essay Example b) Assume the exchange rate changes. Now, ‘1 euro=$1.20’. Showing all work, what does Wanda pay for the wine? What does Pierre pay for the computer? In this case, there is a change in the individual rates of exchange between the euro and the dollar. Currently, ‘1 euro=$1.20’ hence Wanda will spend (1000*1.20) 1200 dollars on a bottle of French wine. On the other hand, Pierre will spend (2000/1.20) 1,666.67 Euros on the purchase of an American computer. c) Which currency appreciated? Explain. Taking a closer look at the two currencies, it is evident that the Euro appreciated against the dollar. According to macroeconomic theory, appreciation of a currency refers to the increase in the value of one international currency against the other in the sense that the appreciating currency is able to purchase more of the other currency (Krugman & Wells 100). In the above mentioned case, the dollar and the Euro are international currency that had an initial exchange ra te of ‘1 euro=$1.08.’ However, there was a change in the exchange rates and the current rate stands at ‘1 euro=1.20.’ This means that the dollar has to fetch more additional units to purchase a single unit of a Euro. This is evident in the case of an American purchasing a bottle of wine and has to pay an initial price of 1080 dollars. Since the euro has appreciated, the American will have to pay a higher price of 1200 for the same bottle of French wine. Consumers using the Euro have a higher purchasing power compared to those using the dollar. SECTION TWO: a) In this section, you will set up a balance of payments table. Please read chapter 26. A BOP has three accounts. You will need to place each item in its proper account and have a dollar value for the total of each account. The table will be in billions. Please indicate, plus or minus, for each number. Credits ‘000,000 ($) Debits ‘000,000 ($) A. Current Account (1) Exports (2) Imports (3) Net Transfers (4) Net Interest Income Balance B. Capital Account (5) Foreign Investments in the U.S. (6) U.S. Investments Abroad Balance (7) Statistical Discrepancies Overall Balance C. Official Reserve Account +2,421 +150 +220 +1150 +250 +30 -2,971 -180 -900 -40 -30 b) What does the official settlements number indicate? Be precise in explaining this. Based on the above table, the official settlements number is -30 and this indicates that the US has an increase in its foreign reserves and that there is also a decrease in the dollar reserves held by foreign central banks (Krugman & Wells 113). The decrease in dollar reserves among foreign central banks count as debits in the Balance Of Payments account. SECTION THREE: a) Under what conditions would the Fed sell government securities? The Fed would sell government securities under conditions such as inflation, employment and national output. Under such cases, the Fed does not have control but can only influence such conditions to its fav or. The Fed can create an effect on such conditions by increasing or reducing the short term rate interest especially through open market operations. Some of the government securities used during open market operations includes treasury bills, bonds and notes (Krugman & Wells 119). The control of money supply offers tangible solutions to the conditions mentioned above. When the Fed is targeting to increase the supply of money in the economy, there will be the purchase of securities. On the

Schools for the Underprivileged Assignment Example | Topics and Well Written Essays - 3750 words

Schools for the Underprivileged - Assignment Example Secondly, the school must serve as an example for the existing public schools in the region (Shabnam, 2010). The public school system in the US is struggling to give the most basic levels of knowledge. The educational method in the US is predominantly based on the memorization of content rather than an intellectual development of the students. There is little emphasis on gaining an in-depth understanding of the contents and an acquisition of practical knowledge. A majority of students in underprivileged regions of the US have spent five years or more in a public school. These students are unable to identify basic scientific concepts, even though, these concepts are taught in the school. Test scores of these students are often lower than 35% (equivalent to 7/20), and many students fail to final exams for passing to the next grade (Muda, 2014). The organization has been created with the objective to provide schooling for underprivileged children. The mission includes providing high-quality education in basic subjects such as mathematics, science, and arts with an emphasis on understanding and practice of newly acquired knowledge. The program objectives comprise of: - Involve children, parents, school staff, volunteers and the community in a common project that would impart a sense of civic service, morality and respect for the traditional culture in which they were raised. The need for this program arises from the inequality of the US educational system. There is a considerable amount of research literature available which indicates the high level of inequality in the educational system of the United States. Children who grow up in low socioeconomic areas are more at the risk of experiencing difficulties in school and to drop out later. According to Goos, Damme, Onghena, & Petry (2004), elimination of these inequalities requires a concerted effort.

Provide a critical analysis Essay Example | Topics and Well Written Essays - 1000 words

Provide a critical analysis - Essay Example He apparently inhabits a stripped off office with an outdated laptop without internet connection as he had mutilated its Ethernet cable or even a single game (Grossman 2010). As with many other great poets Samuel Taylor Coleridge found a kindred spirit and a comrade in the arts through fellow English poet William Wordsworth. It was through their friendship and first attempt at collaboration that ‘The Rime of the Ancient Mariner’ was born. Final lines of the poem are attributed to Wordsworth and his sister at the time when their walk instigated its inspiration. Coleridge initiated writing the poem as they have planned when Wordsworth saw that he is better able to finish it completely and so the poem took on one of the major points the two had in mind for poetry. They were determined to demonstrate â€Å"two cardinal points of poetry, the power of exciting the sympathy of the reader by a faithful adherence to the truth of nature, and the power of giving the interest of novelty by the modifying colours of imagination† (Coleridge 1908, 12). The previous being exemplified by Wordsworth and Coleridge for the latter. That there is the occasional possibility of being under the state of being that influences the yearning for the creation of something sublime and transcending the ephemeral. At the same time, there is also there is also moments wherein the most benign occurrences could induce creativity that propels writing. Such is the romantic undertone which instigated the Ancient Mariner as Coleridge himself expounds. Initiated with a plan he and Wordsworth had devised. Coleridge’s poetry took on a form of its own which is an intricacy of both ideas. This is where, though he may not have attained the parallel veneration as those enjoyed by his contemporaries, he remains a classic worthy of consideration and study. In his subsequent Bibliographia, we are presented with an identifiable Coleridge devoid of ill-feelings

PEST Analysis Of AirAsias Essay Example for Free

PEST Analysis Of AirAsias Essay 1.1Background AirAsia was set up by Dato Tony Fernandes in 2001. In December 2001, Fernandes and his partners set up Tune Air Sdn Bhd (Tune Air), an airline holding company then bought over AirAsia. Now, AirAsia has become one of the most successful airlines in the Southeast Asian region and the pioneer of low cost and no frills travel in Malaysia. The leading low fare airline in the Asia AirAsia has been expanding rapidly since 2001, to become an award winning and the largest low cost carrier in Asia. With a fleet of 72 aircrafts, AirAsia flies to over 61 domestic and international destinations with 108 routes, and operates over 400 flights daily from hubs located in Malaysia, Thailand and Indonesia. To date, AirAsia has flown over 55 million guests across the region and continues to spread its wings to create more extensive route network through its associate companies, Thai AirAsia and Indonesia AirAsia. AirAsia believes in the no-frills, hassle-free, low fare business concept and feels that keeping costs low requires high efficiency in every part of the business. Efficiency creates savings which are then passed on to guests so that affordable air travel can become a reality. Through our philosophy of ‘Now Everyone Can Fly’, AirAsia has sparked a revolution in air travel with more and more people around the region choosing AirAsia as their preferred choice of transport. As AirAsia continuously strives to promote air travel, we also seek to create excitement amongst our guests with our range of innovative and personalized service. The aim of the investigation The aim of this analysis is to conduct a PEST and SWOT analysis in the context of AirAsias international business operations, identifying the major variables involved and the impact of the specific threats and opportunities confronted by AirAsia .Besides that, The purpose of this report is to identify its stakeholders and core competencies, carry out a investigation of its external environment, review a strategic analysis of Airasia to identify opportunities and threats it might face, and to isolate key strengths and any weaknesses that need dealing with. Moreover a SWOT analysis will be carried out to assess the extent to which its strategies are suitable to what is happening in its present environment. Finally, after  identifying competitive strategy a Strategic plan will be made to gain competitive advantage. Chapter 2 DISCUSSION 2.1 Company Overview AirAsia is currently one of the leading low cost airlines in South East Asia which has expanded rapidly and it’s still the second largest air carrier in Malaysia. It dynamic nature of business is based on domestic and international flights, holiday and business arrangements for its customers domestically and internationally around the region with the low fare, safe and convenience means of transportation. (www.airasia.com). AirAsia’s vision To be the largest low cost airline in Asia and serving the 3 billion people who are currently underserved with poor connectivity and high fares. AirAsia’s mission To be the best company to work for whereby employees are treated as part of a big family Create a globally recognized ASEAN brand To attain the lowest cost so that everyone can fly with AirAsia Maintain the highest quality product, embracing technology to reduce cost and enhance service levels AirAsia’s values AirAsia make the low fare model possible through the implementation of the following key strategies: SafetyFirst: Partnering with the world’s most renowned maintenance providers and complying with the with world airline operations. High Aircraft Utilisation: Implementing the regions fastest turnaround time at only 25 minutes, assuring lower costs and higher productivity. Low Fare, No Frills: Providing guests with the choice of customizing services without compromising on quality and services. Streamline Operations: Making sure that processes are as simple as possible. Lean Distribution System: Offering a wide and innovative range of distribution channels to make booking and travelling easier. Point to Point Network: Applying the point-to-point network keeps operations simple and costs, low. Products and Services offered By Air Asia In-flight services: †¢ Air Asia offer food and drinks on board programme . †¢ In-flight services customise meals and merchandise package upon request e.g. caps, T-shirts, and pants. Online services: †¢ Online booking makes it more convenient for its customers to book online anywhere anytime. †¢ Flight information is available to help customers make enquiries on flight schedules arrival and departure time and date. †¢ Chatter –flight: Created for a group of people, business travellers for purposes like meetings, conventions, leisure or even exhibition. Channels of distribution A number of alternate channels of distribution may be available: Selling direct: †¢ Outbound sales forcer †¢ Via mail order, Internet †¢ Telephone sales Selling indirect: †¢ Agent, who typically sells direct on behalf of the producer †¢ Distributor (also called wholesaler), who sells to retailers †¢ Retailer (also called dealer or reseller), who sells to end customers Sales and Marketing AirAsia is an international company, and going global invites a lot of competition. AirAsia has to deal with the competition of local companies in the same field- Airline services. Competition for AirAsia would also be encountered in the virtual world-the internet. As they entered into the use of modern technology such as the public domain would invite competition on the global scale. Different localities and countries have different technological standards, and quality control policies, which AirAsia would have to adhere to, by adherence to these policies; certain intended developments may be possible in certain communities but not acceptable in others. According to CEO’s of the company, Mr. Fernandez, there are a lot workers or low pay salaries earners who would like to travel often to meet their families especially during special occasions but due to how expensive it was that time, their desire are not fulfilled. By introducing a low fare will give all those people opportunity to travel if not more than once in a year. This enables them to identify their target market. Reduced price sales  is one of the basics of securing a target market for AirAsia. They reduce their price to suit their class of customers Branding AirAsia went into intensive General advertisements and other high profile activities, which contributed to the high offering of their companys image. They came with a brand â€Å" Now every one can fly† These points of contact with their target customer help them to build their image, which in turn created loyalty from their customers. Group Discounts and Offers Discounts or other offers can help exposure business to new customers, resulting in a sales increase . AirAsia is a ticketless Airline that allows customers to purchase their ticket online with at a discounted rate. They also have a scheme of group discount and this help to get more target market, especially internet based customers. 2.2Core competencies: Computer Reservation System (CRS) AirAsia’s CRS (Open Skies by Navitaire) has helped it to grow at a dramatic pace in the past couple of years. Tony Fernandes, CEO AirAsia described that Navitaires Open Skies technology has truly enabled Airasias growth from 2 million passengers to 7.7 million passengers in less than two years. Open Skies scaled easily to accommodate our growth. It is an integrated web-based reservation and inventory system. It includes Internet, call center, airport departure control and more. It is a direct sales engine that effectively eliminates the middleman (travel agents) and the sales commissions that need to be paid to them. Enterprise Resource Planning System (ERP) AirAsia has recently (May 2005) opted for a full fledged ERP system implemented by Avanade consultants. By implementing this package AirAsia is looking to successfully maintain process integrity, reduce financial month-end closing processing times, and speed up reporting and data retrieval processes. Self Check In With the use of the new self check in service a quicker and more convenient way to check in using mobile phones, laptops etc, connecting to the internet. This system is easier and faster for customers and their family to  check in at or before they get to the airport without having to queue up at the counter to check in. Air Asia credit card Air Asia offers a choice of credit card facilities to fit in their customers travel life style be it business, leisure, training or holidays. With an Air Asia credit card a customer can purchase any goods or services while travelling anywhere in the world online. Go Holiday services Air Asia has a product called Go Holiday, with the help of E-commerce Air Asia is able to display their coverage maps, holiday resorts, first and average class hotels, car rental services, and activities in different countries with their different rates and prices on Air Asia’s web page.. Using E-commerce, customers are able to select and make a holiday and travel arrangement with a hotel of their choice and class, a pick up car and even medical services. And payments for all this can be done on the internet using credit cards or other online E-payment methods ahead of travel time. Foreign workers and Contractors strategy AirAsia also target most foreign workers from Indonesia, Singapore, Thailand, China, Macau who may not afford the expensive flight home and offer them the cheap fare which attracted most of them as would go home very often without paying much. 2.3 The Competitors Companies in all industries have direct as well as indirect competitors. Direct competitors in the aviation industry are companies that offer flights to similar destinations on comparable terms of travel. Direct competitors include: Malaysia Airlines: offering flights in same routes . Singapore Airlines: offering flights on same routes between London and Kuala Lumpur. Thai Air : operating flights between Bangkok an Kuala Lumpur. Air Srilanka: operating flights between Colombo and Bangkok. AirAsia are facing strong competition with major international and national airlines on the market shares In contrast to other airlines ,AirAsia offers better value for money 2.4Analysis of Environmental Factors In analyzing the macro-environment, it is important to identify the factors that might affect a number of vital variables that are likely to influence the organization’s supply and demand levels and its costs (Kotter and Schlesinger 1991). The external environment of any organization can be analyzed by conducting a PEST analysis. The acronym PEST is used to describe a framework for the analysis of a range of macro environmental factors including the Political, Economical Social and Technological environment. PEST Analysis for AirAsia: Political Flying outside Malaysia is difficult. Bilateral agreement is one of the main obstacles in the way of low cost carriers. Landing charges is also another big influencing factor on costing of low fare airlines. The low- cost airline industry in south-east Asia has been underdeveloped because the aviation market is tightly regulated by bilateral air rights agreements. Threat of terrorism, people is afraid to fly after the September 11 terrorist attacks incident. Economic In spite of strong competition from Malaysian Airline (MAS), AirAsias low-cost carriers offering cheap tickets and few in-flight services are gaining attraction in the region. Current recession hit the aviation business. But with this economy slowing down, more people will want to enjoy its cheap tickets. Oil prices is another regulatory factor for this type of airlines. If oil prices go high, it is very difficult to control cost of operation. Social Passengers are reluctant to board a no-frills airline for a long-haul flight. Increasing worlds population, tourists and number of educated people helpful for the growth of aviation industry. Outbreak of the Severe Acute Respiratory Syndrome (SARS) has scare people to fly. AirAsia commit to Safety First; comply with all regulatory agencies, set and maintain consistently high standards; ensure the security of staff and guests. Technology AirAsia provides online service that combines air ticketing with hotel  bookings, car hire and travel insurance. To help keep costs in check, Air Asia has pushed internet booking services. AirAsia also recently introduced GO Holiday, the airlines online programme where guests can book holiday packages online in real time AirAsia has bought in A320 to replace Boeing 737. The Airbus A320s improved fuel efficiency and extra capacity which leads to better performance and reliability. SWOT analysis for AirAsia Strengths Low operational and maintenance cost by having a single aircraft type fleet i.e. from Boeing 737 to Airbus A-320. Economy of scales benefits. Low operating cost due to being No Frill, online reservations system, quick check in etc. There is huge untapped market in the region, especially for business travellers and for-the-first-time-flying segment. As it is low cost airlines, it can target customers who are currently using non-aircraft modes like, Bus, Trains, car to travel to distances. Weakness Huge investment to purchase air planes and implementing latest technologies there is high amount of operational cost. Rising fuel price. Increased the operational cost. The flight times are more or less limited to 2.5 hours. So they cannot operate flights of longer duration without any Frill, so No-Frill becomes impossible to implement for passengers. Opportunity Low fares offer by AirAsia has encourage people from all walks of life style to fly. Especially, during economy down turn. Airbus A320 would encourage greater passenger capacity and offer comfortable service to customers. Introduction of SMS booking allows customer to book their seat at anytime and anywhere. With the commitment in ensuring the security of staff and customers, customer will have more confident to fly via AirAsia. Threats There are more no-frills airlines may take off in Asia to meet increasing consumer demand following the success story of Malaysias budget carrier AirAsia. Singapore Airlines plans to launch a budget carrier, they see the success of AirAsia. They know how big the market is and how good the opportunity is in Asia. Travelers may not choose AirAsia if they are to  travel long distance flight. They will prefer airlines such as MAS or SIA which provide better services. Demand to fly decreased via terrorism and outbreak of the SARS. 2.5 Marketing Plan Cost advantages activities: AirAsia already introduced cost advantages activities. Some of them describe below: Utilising one type of aircraft (Boeing 737-300 which will be fully replaced with Airbus A320) results in reduction of maintenance cost (one of the major expenses in airline industry), scheduling cost, administrative cost, and inventory of parts. Creative and low-cost advertising significantly reduces marketing cost. On the other hand, AirAsia direct sales through internet, call centres, walk-in airport sales, and sales offices significantly reduce the commission fee to travel agents as AirAsia only assigned its sales to limited travel agents AirAsia assigned multi-skilled cabin crews (2-3crews/flight), cost-effective training, performance based reward and incentives systems Target Market: Low- income Customers and tourism segment Malaysia emergence as a regional business and tourism hub has provided AirAsia plenty of room for growth and has fuelled regional air passenger traffic. Transit passengers Kuala Lumpur is the operational hub for AirAsia, which is the best connection point between Europe and Asia/Australia has supported the growth of their business. AirAsia has been using this connection point to promote their business. 2.6 Proposed Strategy for further expansion of AirAsia Extending New Routes: Extending current services into new markets may be helpful to further growth of this company. It is possible to achieve this strategy by launching existing services into new geographical area or new market segments. Adding new routes and destinations are possible; especially there is growth Malaysia and East Asia tourism. Activities related to this strategy: Marketing research Feasibility Study Contract with hotels and tourist agency at new destinations Finding out strategic partner Marketing new routes and destination Time frame and cost: It will take 1 to 2 years to start a new route and estimated cost around $200 million to new aircraft and for marketing cost. Organizational change: Recruiting new employees Arranging training for new employees Opening new office in new destination Evaluation criteria: New destinations are implemented to achieve new market development. Flight number in new destination is the best way to measure result of this strategy. Private Suite for business customer: Introducing new services into existing markets implies product development. This strategy involves the development of fresh competencies and requires business to expand customized services which can apply to current markets. That’s why Emirate Airlines introduce high quality first class private lounges to attract business travelers. Activities related to this strategy: Technical and feasibility Study Allocated budget Contract with a company to install new facility. Installation and modification of aircraft’s onboard facilities Time frame and cost: It will take 6 months to 1 year to complete installation new facilities in a single aircraft and estimated cost around $0.2 million to new aircraft and for marketing cost. Organizational change: Recruiting new employees to serve business customer Contract with new or existing company for catering service for business customer. Evaluation criteria: Quantitative measurement of this product would be number of booking or occupancy. Chapter 3 CONCLUSION 3.1 Conclusion By studying PEST, SWOT and marketing analysis, it could be said that AirAsia  is situated in standard cycle markets where it get competitive advantage for its business policy and strategy. Providing customers with superior products and services with low fare is synonymous to the AirAsia brand. However, it is necessary that Airasia should re-evaluate its strategies and focus on core values and competencies. For this why, AirAsia should reconsider their market and specific routes to obtain value other than price and survive the competition. From this study, it is possible to say that still there is some other option to expand this company. Adding new route and introducing business class suite may be suitable option for AirAsia for further growth. 3.2 Recommendations To remain leader in the market in serving customers, AirAsia has to re-evaluate their current strategy. Recommendation for improvement can be outlined as follows: AirAsia should make any major changes to their strategy after proper technical and feasibility study to avoid unnecessary risks. Oil price is a big factor to low fare airlines. So this company should make longer contracts with fuel suppliers for more stability As Airasia operates their fight very frequently, so they should have a spare aircraft at each location to avoid delays. AirAsia should consider environmentally friendly operation system as such as carbon offsetting to save environment. REFFERENCE Daniels, J. D. Radebaugh, L. H. (1998), International Business ‘Environments and Operations, 8th edition, Addison-Wesley, USA. Peng Mike W, 2006, Global Strategy, Thompson, United States Porter Michael E, 1998, Competitive Advantage, The Free Press, United States. Websites: www.airasia.com www.navitaire.com/res

Biogas Production From Various Fruit Peels Environmental Sciences Essay

Biogas Production From Various Fruit Peels Environmental Sciences Essay Analysis of the various process conditions for the production of biogas (bio-methanation)from mango peel, papaya peel and banana peel were done. Based on the analysis the process conditions were varied accordingly and the comparative study of biogas production from mangopeel, papaya peel and banana peel in terms of pH, inoculum to substrate ratio and temperature was carried out. The major problem in the bio-methanation process was blockage and scum formation. Temperature and pH fluctuations also affect the production of biogas. High temperature(55à Ã‚ ¦ C) causes accumulation of fatty acids which affects the process stability and influences the pH ( Nagamany and K Ramasamy, Biogas production technology: An Indian perspective). If cow dung is used as the inoculum the stability of the digester is monitored. The pH at 5 the population of microbes is lowered and the activity is reduced ( Sahota and Ajit Singh).The ratios of cow dung to peels (1:2, 1:5, 1:10) were used in different setups and the production of biogas was observed. Peels of various fruits were used in the same ratio and their production rate was measured.The C/N ratio varies for different peels and was adjusted by addition of nitrogen sources for optimization of production . The measurement of volume of biogas produced was done using the downward displacement technique of water. Different parameters that were considered to affect the rate of production were observed for different setups. The comparison of production from different peels aims at identifying the ideal raw material source and the optimization of the process parameters for the maximum production of the gas. Keywords: Bio-methanation, process parameters, process stability, downward displacement of water Introduction The realization that the existing fuel resources are getting exhausted faster than expected and with the current developmental activities being at its high ,the situation demands more conservative action. The demand for the conventional fuel is on an all-time high and the demand can be controlled using alternative fuel sources. The extensive use of conventional sources over all these years has led to degradation in the environment. Since the global climatic stability is at stake the usage of renewable and cleaner fuel sources is being recommended. The usage of renewable fuel sources helps to conserve the existing conventional fuel and protect the environment. Renewable sources can be direct (such as solar energy) and indirect (such as biomass): energy of the wood and the other biomass obtained from plants has solar energy fixed by the process of photosynthesis (Chang, 2003). Anaerobic digestion is a process of biodegradation which uses bacteria to convert biomass into energy. Energy is in the form of biogas which is a mixture of methane and carbon dioxide which is used for generation of power. Fruit peels are biodegradable in nature and are a potential source for the production of biogas. The fruit peels mainly consist of cellulose, reducing sugar, non-reducing sugar, moisture etc these acts as a source of carbon and energy for the microorganisms taking part in the bioconversion and by enzymatic hydrolysis converts the polymeric components of the peels into monomers. The monomers are converted to soluble organic acids mainly acetic acid, (methanogenic bacteria) converts it to methane and carbon-dioxide and various by products. Maishanu and Seekimpi (1988) and Anonymous(1992) observed that microbes require neutral or mild alkaline condition for optimal biogas production. Various parameters such as pH, ratio of substrate: inoculum , temperature affects the production. Materials and Methods The peels of mango, papaya and banana were collected from VIT, were cut into smaller fragments and dried. The moisture content of the various peels was determined by standard method. The peels were grinded, the pulp was prepared and the slurry was prepared in the ratio in accordance to the respective moisture content of the peels. Sieve was done to obtain desired particle size and stored at room temperature. 2litre anaerobic bio-reactor was used to perform the experiment. BMP Test Lab Digester: Experiment was performed in 2 litre anaerobic bioreactor capped with rubber stoppers. Nine reactors were set up and each one was seeded with 20ml of inoculum. For each reactor different cow-dung to peel ratio of (1:2, 1:5, 1:10) were added. The pH was maintained by using alkali. Based on the C/N weight ratio of the peel urea was added to optimize the microbial activity. Nutrients (FeCl3 1g) were added for optimum growth of microbes. Water was added to the reactors after addition of substrates. Reactors were kept at 33-37à Ã‚ ¦C under incubation and the production of gas in each reactor was measured by water displacement method. Analysis The moisture content of the peels, solid content, volatile content and pH were determined by Standard method. Total volume of gas production from various peels was measured at fixed time in each day by water displacement method. Result and Discussion Improper preparation of solids leads to blockage and scum formation: proper milling and dilution ratio of solid is necessary to prevent scum formation and stratification. The C/N ratio (i.e. carbon and nitrogen sources for micro-organisms) should be 25-30:1and the loading rate is varied based on it. The gas production depends on the pH, as a pH of 5 reduced the bacterial population and the activity. Optimum pH for methanogenic microbes was slightly acidic (7-7.2 range). pH can be maintained by removing the carbon-dioxide produced during methanation. Higher temperature increased production but the process becomesunstable due to accumulation of fatty acids. Concentration of the volatile fatty acid in terms of acetic acid should not exceed 2000-3000 mg/l. Stability of the digester depends on carbon-dioxide reduction (either by microbes or artificially) and the accumulation of hydrogen takes place due to the higher production rate of hydrogen than carbon-dioxide reduction rate, it inhibits methanogenesis. Retention time of slurry depends on the dilution ratio, loading rate and digestion temperature. Carbon-dioxide reduces the calorific value of biogas produced hence the gas is passed through lime water to remove carbon-dioxide. Table 1. Various parameters and biogas production rate Sno: Fruit peel used for production Ratio of inoculum to substrate Loading rate of the substrate Volume of flammable gas (stp) in litre. Flammable gas production rate (litre/day). 1. Mango 1:2 1:5 1:10 2. Papaya 1:2 1:5 1:10 3. Banana 1:2 1:5 1:10 Conclusion The analysis of the production rate of biogas from three different fruit peels (mango, papaya, and banana) was done. The process conditions that affect the production of biogas in bioreactor were analysed. The effect of parameters such as pH, temperature, inoculum to substrate ratio, slurry ratio was studied and the problems that occur due to the fluctuation of these parameters during the process of bio-methanation were identified. The solutions for these problems were identified and the implementation of optimized process conditionsand the production rate of biogas from various fruit peels are to be measured and compared.

Changing Gender Roles - The Battle of the Sexes Continues Essay

It is the war of all wars. It’s lasted longer than all the ancient wars, the world wars, and the civil wars of all nations put together. The battle lines have been clearly drawn and the two sides have never rested while on the battlefield. It is the famed â€Å"battle of the sexes† and it is anything but resolved. The war has been happening for a long time, but now it seems to have hit a point where the world wonders what to do now. This is due to the current changes in gender roles which are manipulating society and changing relationships. These changes are both negative and positive; many advances have been made with women finding equality with men, but have traditional values been underestimated? It is a highly controversial and complicated subject that affects virtually all members of society. In order to understand some of the opinions on the topic of gender roles and relationships, it is necessary to understand the definitions of some words as they will be used in this essay. First there are many definitions for the term â€Å"gender.† However, in this paper the words sex and gender will be used interchangeably and refer simply to male and female. Also important to note is that while society has more options than a male and female relationship, the emphasis in this essay is only on heterosexual relationships and the way they are perceived in society. By keeping these basic definitions and ideas in mind, one can understand that the word â€Å"role† refers to the individual’s place in society and position within a relationship. Along with this, the â€Å"traditional roles† would be defined as women being the homemakers while men being the main breadwinners. When labeling traditional roles dealing with dating and rel... ...ana. â€Å"Dating Among College Student Is All But Dead, Survey Finds.† The Chronicle of Higher Education Aug. 10, 2001: 51. Academic Universe. Lexis Nexis. EBSCO Publishing. Colorado State University Lib. Apr. 2003 http://lib.colostate.edu/databases/> Piper, John. What’s the Difference? Manhood and Womanhood Defined According to the Bible. Wheaton: Crossway Books, 1991. Wentworth, Diane Keyser. â€Å"The Role of Househusband and Housewife as Perceived by a College Population.† The Journal of Psychology 2001 (135): 639-650. Academic Search Premeir. EBSCO Publishing. Colorado State University Lib. Mar. 2003 http://lib.colostate.edu/databases/> William, Armstrong. â€Å"Colliding Bodies.† The Washington Times Aug. 11, 2001. Academic Universe. Lexis Nexis. EBSCO Publishing. Colorado State University Lib. Mar. 2003 http://lib.colostate.edu/databases/>

Gun Control: Should the Second Amendment of the Constitution be Updated

According to the F.B.I., 14,369 murders involving firearms took place in the year 2013 within the United States. We as Americans have the right to â€Å"bear arms,† however there can be some changes to at least try to minimize these casualties. The 2nd Amendment states â€Å"A well regulated Militia, being necessary to the security of a Free State, the right of the people to keep and bear Arms, shall not be infringed.† This may be outdated now that we have a strong military (that is our â€Å"well regulated Militia,†) to protect our security, but can a right be scratched off the Constitution because of someone’s interpretation?   Ã‚  Ã‚  Ã‚  Ã‚  Perhaps there can be some changes to the laws to determine who can own a firearm and what types of weapons can be sold. In Arizona and many other states there are no permits required to purchase any type of firearm. While other states have more laws to determine who can own a gun. New York requires you to have a permit to purchase and then register a handgun. The permit may be issued if the applicant is over 18 years of age, has not been convicted of a felony or spent more than one year in prison, and is not an addict, alcoholic or convicted of a narcotics offense. New York also requires the gun stores selling rifles, shotguns, or handguns, provide with the gun a locking device and a label on safe storage. As of March, 2001, any firearms dealer licensed in the state of New York must provide to the state police, along with the original receipt of sale, a sealed container enclosing a shell casing from the handgun sold within ten days of the transfer of a handgun.   Ã‚  Ã‚  Ã‚  Ã‚  Gun control groups are requesting a bill that would create a national handgun licensing and registration system, and that would extend the Brady law to the secondary market of handgun purchases such as gun shows. Under the Brady II legislation it will be illegal to sell, deliver, or otherwise transfer a handgun to someone who does not have an FFL (Federal Firearms License), unless the dealer verifies that the buyer has a valid state handgun license. It will also make it a violation of the law for anyone who does not hold an FFL to obtain, either through purchase or as a gift, a handgun or handgun ammunition unless they possess a valid state handgun license. Brady II would require state officials to set up and manage a license sys... ...fense is not an acceptable reason. In the years 1996-1997, Australia destroyed almost 700,000 guns, which are about one-seventh the guns in Australia. In America that number would be around 30 million. By 1998, homicides by firearms were down thirty percent in Australia. In 1991 and 1995 Canada established new gun laws reducing the number of deaths caused by guns to a thirty year low. The UK banned handguns and destroyed the guns the government bought from the citizens. Within a year later, gun-related violations have decreased by thirteen percent in England and Wales. Some say that Americans are fifty times more likely than British citizens to be killed by a firearm. Many people in America do not want to see a ban on firearms, but if that is not the answer what is? Perhaps what we need is for the anti-gun groups and the pro-gun groups to come together and reach some sort of a compromise that could help reduce our nation’s homicide rates. References: National Center for Health Statistics Center for Disease Control and Prevention FBI (Federal Bureau of Investigation) NRA (National Rifle Association) John McCain @ mccain.senate.gov www.guncite.com www.converge.org

Archimedes Essay -- essays research papers

Archimedes was a Greek mathematician and scientist. He was born in Syracuse, Sicily in the year 287 B.C. He was educated in Alexandria, Egypt. Due to the lack of information about Greek mathematics, many Greek mathematicians and their works are hardly known. Archimedes is the exception. Archimedes was very preoccupied with mathematics. For instance, he often forgot to eat and bathe because of his always wanted to solve problems. He found areas and volumes of spheres, cylinders and plain shapes. He showed that the volume of a sphere is two-thirds of the volume of the smallest cylinder that can contain the sphere. Archimedes was so proud of this concept that he requested that a cylinder enclosed a sphere, with an explanation of this concept, be engraved on his grave. Archimedes also gave a method for approximating pi. He was able to estimate the value of pi between 3 10/71 and 3 1/7. Math wasn’t as sophisticated enough to find out the exact pi (3.14). Archimedes was finding square roots and he found a method based on the Greek myriad for representing numbers as large as 1 followed by 80 million billion zeros. One of Archimedes accomplishments was his creation of the lever and pulley system. Archimedes proved his theory of the lever and pulley to the king by moving a ship, of the royal fleet, back into the ocean. Then, Archimedes moved the ship into the sea with only a few movements of his hand, which caused a lever and pulley device to move the ship. This story has become f...

Investigating Effect Essay

Plan Aim: The aim of the experiment is to find out what effect temperature has on the action of a protease enzyme on exposed developed film. Enzymes are biological catalysts. They are made in livings things built up by amino acids to make protein. Enzymes are able to speed up reactions and can repeat reactions. There are various factors that affect the activity of enzymes they are: â€Å"Y Temperature â€Å"Y pH â€Å"Y Specificity â€Å"Y Concentration of enzyme or substrate Enzymes are specific, this means that they only work on one substrate molecule. A substrate molecule is what the enzyme actually works on. The factors I have chosen to investigate are temperature. This therefore means that the temperature will be the independent variable. In the experiment there will be a transparent plastic backing of developed film, which will have a black gelatine coat on it. The gelatine coat is protein, which is the substrate molecule. I will put the film into protease solution, which is the enzyme. By having the gelatine coat I am able to see what happens to the gelatine coat when the temperature increases. I can find out if temperature affects the action of a protease enzyme. Prediction: Enzymes have an optimum temperature, which is generally below 400C. The optimum temperature is when enzymes works best and fastest at. When the temperature rises the rate increases. This is because the substrate and enzyme molecules are moving faster because the temperature has increased. This means that the molecules have more energy. They therefore are likely to collide more often with each other and a reaction will take place. However if the temperature goes over the optimum temperature the reaction slows down and the enzyme denatures. This means that it has changed shape and therefore the substrate can no longer fit into the enzyme. The diagram below shows how the substrate molecules which is protein fits into the enzyme, which is a protease molecule. This type of mechanism is called the lock and key hypothesis. If the active site, which is the enzyme, is heated too much it will change shape and no longer fit the substrate. The substrate therefore no longer is able to react if there is no active enzyme. I predict that when the temperature increases the time taken for the gelatine to be broken down will decrease. This is because temperature is a catalyst, which helps to speed up the enzymes, which are biological catalysts. When the temperature is 300C I predict that it will take longer for the film to become transparent than when the film is in a temperature of 600C. However at a certain temperature in the experiment I predict that there will be an optimum temperature. This is when the enzyme works best at. After this point the enzymes start to slow down and eventually denature which means it is harder for the substrate molecules to fit into the enzyme molecules. As I predict that when the temperature increases the time taken for the gelatine to be broken down decreases until it reaches the optimum temperature I therefore predict that the rate of reaction will increase when the temperature increases until it reaches the point when the enzymes start to denature. When the temperature is increased the enzyme molecules will break down the black gelatine coat quicker and therefore the developed film will become transparent faster. When temperature is increased the substrate molecules of protein will collide more frequently with the enzyme molecules. So if the temperature is increased from 300C to 600C the enzyme molecule will break the black gelatine down faster to leave the transparent plastic backing. The two diagrams show the effect of temperature between substrate molecules and enzyme molecules. They are only rough diagrams of what will happen between the two molecules. â€Å"Y Substrate molecule- â€Å"Y Enzyme molecule- Method: Apparatus: The apparatus that I am going to use for the experiment will be a test tube, developed film with a gelatine coat, splint, syringe, stopwatch, thermometer and electric water baths. This equipment is suitable for this experiment because it is easily available, it is easy to set up and use and it is easy to collect results with. This is how the experiment will be set up I will firstly measure the volume of protease solution by using a syringe, which will be 10cm3 and then put it into a test tube. I will then get two developed films and hook wire onto each so I am able to get them out of the tube easily. The wire will be labelled so it is easy to see which film is which. I will then put the test tube into an electric water bath, which is at a specific temperature for example 300C. I will leave it in the bath for three minutes and then put the two films into the test tube. Every 30 seconds I will check to see if the film has become transparent. When the two films have become transparent I take them out of the test tube. I then check  the pH of the protease solution by getting a glass rod and dipping it into the solution and then put the solution onto pH paper. Preliminary experiment: For my preliminary experiment I set up the apparatus as above. As it was only preliminary I used one film. I chose two temperatures to put two test tubes of protease into, they were 600C and 300C. I put the two test tubes into the two different electric water baths and then after three minutes put film in each. This is how the results turned out: Temperature of water bath/0CTest tube in water bath with no developed film/secsTime taken for film to become transparent/secsRate of reaction/ 1/secs (S-1) 301808000.0013 601803000.0033 This table of results indicates that when the temperature increases the time taken for the film to become transparent is less. It also shows that when the temperature increases that rate of reaction also increases until it reaches the optimum temperature. This is what I expect will happen to the results in my final experiment. Variables: In this experiment the independent variable will be the temperature, the dependent variable will be the time it takes for the films to become transparent and the controls are: â€Å"Y Concentration of protease â€Å"Y Volume of Protease â€Å"Y Film size The experiment should be carried out the same for each test tube and the pH should stay the same for all test tubes. The concentration of the protease solution will be 0.5% and the volume of each protease solution will be 10cm3. Range: The range of temperatures that I am going to use will be 300C, 400C, 500C, 600C, 700C. If I have a temperature any higher than 700C the enzyme would most probably denature. I haven’t got a temperature any lower than 300C because it would take too long for the gelatine to break down in the time given. Reliability: In my final experiment I am going to use a syringe to measure out the volume of protease needed. A syringe is accurate enough for this experiment. I will put two developed films into each test tube to improve reliability of my results. I will also use a stopwatch to time when I put the films into the test tube and when to check the films. The electric water baths are really easy to use and they control the variables very precisely unlike heating the test tube with a bunsen burner, as the temperature can go slightly up and down. Safety: Whilst doing the experiment I will have my hair tied back, I will wear a lab coat and I will also wear safety goggles throughout as I am using protease which if gets into your eyes it can be dangerous.