Research into Rational Drug Prescribing in Yemen

Research into Rational Drug Prescribing in Yemen CHAPTER 1 1.0 Introduction In Yemen as well as in many other developing countries the quality of health services which constitute social indicators of justice and equity is far from being satisfactory. Inappropriate, ineffective, and inefficient use of drugs commonly occurs at different health facilities (Abdo-Rabbo, 1993; Abdo-Rabbo, 1997). Irrational prescribing is a habit, which is difficult to cure. This may lead to ineffective treatment, health risks, patient non-compliance, drug wastage, wasteful of resources and needless expenditure. According to the Yemeni constitution, â€Å"patients have the right to health care and treatment† i.e. appropriate care, consent to treatment and acceptable safety. Therefore, health workers should concentrate on making patients better and patients should concentrate on geting better. Health care in general and particularly the drug situation in any country is influenced by the availability, affordability, and accessibility of drugs as well as the prescribing practices. There are many individuals or factors influence the irrational prescribing such as patients, prescribers, workplace environment, the supply system, including industry influences, governments regulations, drug information and misinformation (Geest S. V. et al, 1991; Hogerzeil H. V., 1995).Improving rational use of drugs (RUD) is a very complex task worldwide because changing behavior is very difficult. The 1985 Nairobi conference on the rational use of drugs marked the start of a global effort to promote rational prescribing (WHO,1987). In 1989, an overview of the subject concluded that very few interventions to promote rational drug use had been properly tested in developing countries (Laing et al., 2001). The selection of drugs to satisfy the health needs of the population is an important component of a national drug policy. The selected drugs are called essential drugs which are the most needed for the health care of the majority of the population in a given locality, and in a proper dosage forms. The national list of essential drugs (NEDL) is based on prevailing health conditions, drug efficacy, safety, and quality, cost- effectiveness and allocated financial resources. WHOs mission in essential drugs and medicines policy is to help save lives and improve health by closing the huge gap between the potential that essential drugs have to offer and the reality that for millions of people particularly the poor and disadvantaged medicines are unavailable, unaffordable, unsafe or improperly used. The organization works to fulfill its mission in essential drugs and medicines policy by providing global guidance on essential drugs and medicines, and working with countries to implement national drug policies to ensure equity of access to essential drugs, drug quality and safety, and rational use of drugs. Development and implementation of national drug policies are carried out within the overall national health policy context, with care taken to ensure that their goals are consistent with broader health objectives. All these activities ultimately contribute to all four WHO strategic directions to: reduce the excess mortality of poor and marginalized populations reduce the leading risk factors to human health develop sustainable health systems,and develop an enabling policy and institutional environment for securing health gains. The greatest impact of WHO medicines activities is, and will continue to be, on reducing excess mortality and morbidity from diseases of poverty, and on developing sustainable health systems. The people of our world do not need to bear the present burden of illness. Most of the severe illness that affects the health and well-being of the poorer people of our world could be prevented. But first, those at risk need to be able to access health care — including essential medicines, vaccines and technologies. Millions cannot — they cannot get the help they need, when they need it. As a result they suffer unnecessarily, become poorer and may die young. A countrys health service cannot respond to peoples needs unless it enables people to access essential drugs of assured quality. Indeed, this access represents a very important measure of the quality of the health service. It is one of the key indicators of equity and social justice. (Dr Gro Harlem Brundtland, Director-General, World Health Organization Opening remarks, Parliamentary Commission on Investigation of Medicines, Brasilia, 4 April 2000). 1.1 Background 1.1.1 Brief history of antibiotics According to the original definition by Waksman, antibiotics substances which are produced by microorganisms and which exhibit either an inhibitory or destructive effect on other microorganisms. In a wider, though not universally accepted definition; antibiotics are substances of biological origin, which without possessing enzyme character, in low concentrations inhibit cell growth processes (Reiner, 1982). Up to now, more than 4,000 antibiotics have been isolated from microbial sources and reported in the literature, and more than 30000 semi-synthetic antibiotics have been prepared. Of these, only about 100 are used clinically as the therapeutic utility not only depends on a high antibiotic activity but also on other important properties such as good tolerance, favorable pharmacokinetics etc. These antibiotics are today among the most efficient weapons in the armoury of the physician in his fight against infectious diseases. They are therefore used a large extent and constitute the largest class of medicaments with respect to turnover value. Today, antibiotics are also used in veterinary medicine and as additives to animal feed. In the past they were used addition, as plant protection agents and as food preservatives. In this review we have confined ourselves to a brief description clinicallyuseful antibiotics. These belong to various classes of chemical compounds, differ in origin, mechanism of action and spectrum activity, and are thus important and representative examples of known antibiotics. 1.1.2 Problem Statement This study examines drug use in Yemen and factors leading to inappropriate use of medicines particularly antibiotics and the prescribing pattern. It defines rational drug use and describes policy developments, which aim to encourage appropriate use. In Yemen, as well as in many developing countries, the quality of health services is far from being achieved. Therefore, doctors should concentrate on making patients better and patients should concentrate on getting better. The rational use of drugs requires that patients received medications in appropriate to their clinical needs, in doses that meets their own requirements for an adequate period of time and at the lowest cost to them and their community (Bapna et al, 1994). This means deciding on the correct treatment for an individual patient based on good scientific reasons. It involves making an accurate diagnosis, selecting the most appropriate drug from these available, prescribing this drug in adequate doses for a sufficient length of time according to standard treatment. Furthermore, it involves monitoring the effect of the drug both on the patient and on the illness. There is plentiful evidence of the inappropriate use of drugs, not through self-medication or unauthorized prescribing, but inadequate medical prescribing and dispensing. Normally, patients in Yemen enter health facilities with a set of symmetrical complaints, and with expectations about the care they typically receive; they typically leave with a package of drugs or with a prescription to obtain them in a private market. In previous study in Yemen (misuse of antibiotics in Yemen, a pilot study in Aden) (Abdo-Rabbo, 1997) showed that imported quantity and total consumption of antibiotics is increasing. There is a lack of information about the problems created from antibiotics among the community and about the proper efficacy, safety, and rational use of antibiotics among health authority and workers. No supervision or strict rules are applied in the use of antibiotics. They are easily obtained without prescription and available in some shops. The percentage of prescriptions containing antibiotics was more than a quarter of the total prescriptions contained antibiotics, also antibiotics constituted about 25% of all prescribed drugs. 1.1.2.1 Inappropriate Drug Use Increasing use of medicines may lead to an increase in the problems associated with medication use. The use of medicines, as well as improving health, can lead to undesirable medical, social, economic and environmental consequences. Aspects of drug use, which lead to such undesirable consequences, have been called inappropriate drug use (DHHCS, 1992; WHO, 1988). Inappropriate drug use may include under-use, over-use, over-supply, non-compliance, adverse drug reactions and accidental and therapeutic poisoning (DHHCS, 1992). It also includes medicating where there is no need for drug use, the use of newer, more expensive drugs when lower cost, equally effective drugs are available (WHO, 1988) and drug use for problems which are essentially social or personal (Frauenfelder and Bungey, 1985). 1.1.2.2 Quality Use of Medicines In an attempt to encourage the appropriate use of medicinal drugs and to reduce the level of inappropriate use in Yemen, a policy was developed on the quality use of medicines. The stated aim of the policy is: to optimise medicinal drug use (both prescription and OTC) to improve healthoutcomes for all Yemenis. The policy endorses the definition of quality drug use as stated by the World Health Organisation, Drugs are often required for prevention, control and treatment of illness†. When a drug is required, the rational use of drugs demands that the appropriate drug be prescribed, that it be available at the right time at a price people can afford, that it be dispensed correctly, and that it be taken in the right dose at the right intervals and for the right length of time. The appropriate drug must be effective, and of acceptable quality and safety. The formulation and implementation by governments of a national drug policy are fundamental to ensure rational drug use (WHO, 1987 ; DHHCS, 1992). The rational use of drugs can be impeded by the inappropriate selection of management options, the inappropriate selection of a drug when a drug is required, the inappropriate dosage and duration of drug therapy and the inadequate review of drug therapy once it has been initiated. 1.1.2.3 The Requirement of Drug Information for Quality Use of Medicines A medicine has been described as an active substance plus information. (WHO, 1994). Education, together with, objective and appropriate drug information have been two of the factors consistently identified as necessary for rational drug use (Naismith, 1988; Soumerai, 1988; Carson et al, 1991; Dowden, 1991; Henry and Bochner, 1991; Tomson and Diwan, 1991). The WHO guidelines for developing national drug policies also identify the importance of information provision for facilitating drug use: Information on and promotion of drugs may greatly influence their supply and use. Monitoring and control of both activities are essential parts of any national drug policy (WHO, 1988). Objective and appropriate drug information is a necessary factor for quality drug use. It is the basis for appropriate prescribing decisions by medical practitioners. Medical practitioners require objective product, specific drug information and comparative prescribing information. Objective drug information is avai lable to medical practitioners through continuing education programs co-ordinated by professional bodies, medical and scientific journal articles, drug information services and drug formularies and guidelines. 1.1.2.4 Problem with antibiotic use The concerns regarding inappropriate antibiotic use can be divided into four areas: efficacy, toxicity, cost, and resistance. Inappropriate use of antibiotic can be due to: Antibiotic use where no infection is present, e.g. continuation of peri-operative prophylaxis for more than 24 hours after clean surgery. Infection, which is not amenable to antibiotic therapy, e.g. antibiotics prescribed for viral upper respiratory infection. The wrong drug for the causative organism, e.g. the use of broad anti-Gram negative agents for community acquired pneumonia. The wrong dose or duration of therapy. Such inappropriate use has a measurable effect on therapeutic efficacy. For example, one study showed that mortality in gram-negative septicemia is doubled when inappropriate empiric agents were used (Kreger et al., 1980). Since most initial antibiotic therapy is empiric, any attempt at improving use must tackle prescribing habits, with particular emphasis on guidelines for therapy based on clinical criteria. Inappropriate antibiotic use exposes patients to the risk of drug toxicity, while giving little or no therapeutic advantage, antibiotics are often considered relatively safe drugs and yet direct and indirect side effects of their use are frequent and may be life-threatening, allergic reactions, particularly to beta-lactam agents are well recognized and have been described in reaction to antibiotic residues in food (Barragry, 1994). Life threatening side effects may be occur from the use of antibiotics for apparently simple infections, it is estimated, for example, that eight people per year in UK die from side effects of co-trimoxazole usage in the community (Robert and Edmond, 1998). Indirect side effects are often overlooked: especially as may occur sometime after the antibiotic has been given. These include drug interactions (such as interference of antibiotic with anti-coagulant therapy and erythromycin with antihistamine) (BNF, 1998), side effects associated with the administration of antibiotics (such as intravenous cannula infection) and super-infection (such as candidiasis and pseudomembranous colitis). Each of these may have a greater morbidity, and indeed mortality, than the initial infection for which the antibiotic was prescribed (Kunin et al., 1993). The medical benefit of antibiotics does not come cheap. In the hospital setting, up to fifty percent of population receive one antibiotic during their hospital stay, with surgical prophylaxis accounting for thirty percent of this (Robert and Edmond, 1998). The first penicillin resistant isolate of Staphylococcus aureus was described only two years after the introduction of penicillin. Within a decade, 90% of isolates were penicillin resistant. This pattern of antibiotic discovery and introduction, followedby exuberant use and rapid emergence of resistance has subsequently been repeated witheach new class of antibiotics introduced. Bacteria can so rapidly develop resistance due to two major evolutionary advantages. Firstly, bacteria have been in existence for some 3.8 billion years and resistance mechanisms have evolved over this time as a protective mechanism against naturally occurring compounds produced by other microorganisms. In addition, they have an extremely rapid generation time and can freely exchange genetic material encoding resistance, not only between other species but also between genera. The vast quantities of antibiotics used in both human and veterinary medicine, as a result present in the environment, have lead to eme rgence of infection due to virtually untreatable bacteria. Multiply drug resistant tuberculosis is already widespread in parts of Southern Europe and has recently caused outbreaks in hospitals in London (Hiramatsu et al., 1997). Anti-infective are vital drugs, but they are over prescribed and overused in treatment of minor disorder such as simple diarrhea, coughs, and colds. When antibiotics are too often used in sub-optimal dosages, bacteria become resistant to them. The result is treatment failure where patient continue to suffer from serious infections despite taking the medication (Mohamed, 1999). Drugs prescribed are in no way beneficial to the patient s management if there are some negative interactions among the various agent prescribed, over prescribed, under prescribed or prescribed in the wrong dosage schedule. How does one ensure that good drug are not badly used, misused, or even abused? How can drugs be used rationally as intended? What is rational use of drugs? What does rational mean? 1.1.3 Rational Use of Drug Rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and the lowest cost to them and their community (Bapna et al., 1994). These requirements will be fulfilled if the process of prescribing is appropriately followed. This will include steps in defining patients problems (or diagnosis); in defining effective and safe treatments (drugs and non-drugs); in selecting appropriate drugs, dosage, and duration; in writing a prescription; in giving patients adequate information; and in planning to evaluate treatment responses. The definition implies that rational use of drugs; especially rational prescribing should meet certain criteria as follows (Ross et al., 1992): Appropriate indication. The decision to prescribe drug(s) is entirely based on medical rationale and that drug therapy is an effective and safe treatment. Appropriate drug.The selection of drugs is based on efficacy, safety, suitability, and considerations. Appropriate patient. No contraindications exist and the likelihood of adverse reactions is minimal, and the drug is acceptable to the patient. Appropriate information. Patients should be provided with relevant, accurate, important, and clear information regarding his or her condition and the medication(s) that are prescribed. Appropriate monitoring. The anticipated and unexpected effects of medications should be: appropriately monitored (Vance and Millington, 1986). Unfortunately, in the real world, prescribing patterns do not always conform to these criteria and can be classified as inappropriate or irrational prescribing. Irrational prescribing may be regarded as pathological prescribing, where the above- mentioned criteria are not fulfilled. Common patterns of irrational prescribing, may, therefore be manifested in the following forms: The use of drugs when no drug therapy is indicated, e.g., antibiotics for viral upper respiratory infections, The use of the wrong drug for a specific condition requiring drug therapy, e.g., tetracycline in childhood diarrhea requiring ORS, The use of drugs with doubtful/unproven efficacy, e.g., the use of antimotility agents in acute diarrhea, The use of drugs of uncertain safety status, e.g., use of dipyrone, Failure to provide available, safe, and effective drugs, e.g., failure to vaccinate against measles or tetanus, failure to prescribe ORS for acute diarrhea, The use of correct drugs with incorrect administration, dosages, and duration, e.g., the use of IV metronidazole when suppositories or oral formulations would be appropriate. The use of unnecessarily expensive drugs, e.g., the use of a third generation, broad spectrum antimicrobial when a first-line, narrow spectrum, agent is indicated. Some examples of commonly encountered inappropriate prescribing practices in many health care settings include: (Avorn et al., 1982). Overuse of antibiotics and antidiarrheals for non-specific childhood diarrhea, Multiple drug prescriptions, prescribe unnecessary drugs to counteract or augment, Drugs already prescribed, and Excessive use of antibiotics in treating minor respiratory tract infection. The drug use system is complex and varies from country to country. Drugs may be imported or manufactured locally. The drugs may be used in hospitals or health centers, by private practitioners and often in a pharmacy or drug shop where OTC preparations are sold. In some countries, all drugs are available over the counter. Another problem among the public includes a very wide range of people with differing knowledge, beliefs and attitudes about medicines. 1.1.3.1 Factors Underlying Irrational Use of Drugs There are many different factors that affect the irrational use of drugs. In addition, different cultures view drugs in different ways, and this can affect the way drugs are used. The major forces can be categorized as those deriving from patients, prescribers, the workplace, the supply system including industry influences, regulation, druginformation and misinformation, and combinations of these factors (Table 1.1) (Ross et al., 1992). Table 1.1: Factors affecting irrational use of drug Impact of Inappropriate Use of Drugs The impact of this irrational use of drugs can be seen in many ways: (Avorn et al., 1982). Reduction in the quality of drug therapy leading to increased morbidity and mortality, Waste of resources leading to reduced availability of other vital drugs and increased costs, Increased risk of unwanted effects such as adverse drug reactions and the emergence of drug resistance, e.g., malaria or multiple drugs resistant tuberculosis, Psychosocial impacts, such as when patients come to believe that there is a pill for every ill. This may cause an apparent increased demand for drugs. 1.1.3.2 The Rational Prescription (i.e. the right to prescribe) The rights to prescription writing must be ensuring the patients five rights: the right drug, the right dose, by the right route, to the right patient, at the right time. Illegible handwriting and misinterpretation of prescriptions and medication orders are widely recognized causes of prescription error. The medicines should be prescribed only when they are necessary, should be written legibly in ink or, other wise, should be led, and should be signed in ink by the prescriber, The patients full name and address, diagnosis should be written clearly, the name of drugs and formulations should be written clearly and not abbreviated, using approved titles only. Dose and dose frequency should be stated; in the cases of formulations to be taken as required, a minimum dose should be specified (British National Formulary, 1998). 1.2 Overview on Essential Drug Concept (EDC) Essential drugs relate to an international concept proposed by the World Health Organization (WHO) in 1977. WHO in that year published the first model list of essential drug and WHO has put in enormous resources into the campaign to promote the concept of essential drugs (EDL). Essential drugs were defined as a limited number of drugs that should be available at any time to the majority of population in appropriate dosage forms and at affordable prices. In other words, it meets the criteria generally abbreviated as SANE [that mean safety , availability, need efficacy] (John, 1997). The essential drug concept is important in ensuring that the vast majority of the population is accessible to drugs of high quality, safety and efficacy relevant to their health care needs, and at reasonable cost (New Straits Times, 1997a). In support of this concept, the WHOissued a model drug list that provided examples of essential drugs. The list is drawn up by a group of experts based on clinical scientific merits, and provides an economical basis of drug use. This list is regularly, revised and, since 1997, eight editions have been published. This ensures that the need for essential drugs is always kept up-to-date with additions and deletions. Despite such rigorous revision, the number of drugs in the list remains at about 300, although the initial list comprised less. Most of the drugs are no longer protected by patents and can therefore be produced in quantity at a lower cost without comprising standards (WHO, 1995). This is indeed important for countries like Yemen not only because health care are rapidly escalating, but also because the country is still very dependent on imports of strategic commodities like drugs. The EDC will enable Yemen to focus on becoming self-reliant where generic equivalents of essenti al drugs can be manufactured and popularized to meet the health needs of the majority of the people. The limited number of drugs regarded as essential on the list offers a useful guide for practitioners as well as consumers. It underscores the general principle thata majority of diseases can be treated by similar drugs regardless of national boundaries and geographical locations (New Straits Times, 2000) Moreover, certain self-limiting diseases may not need drug treatment as such. For example, in the case of diarrhea, certain so-called potent anti-diarrhoeal drugs (including antibiotics) are not generally recommended. The more preferred treatment is oral rehydration salt that could easily be obtained or prepared at a fraction of the cost while giving the most optimum outcome. The goal of the Yemen Drug Policy was to: Prepare a list of essential drugs to meet the health of needs of the people. Assure that the essential drugs made available to the public are of good quality Improve prescribing and dispensing practices Promote rational use of drug by the public Lower cost of the drugs to the government and public Reduce foreign exchange expenditure 1.3 Yemen Essential Drug List and Drug Policy in Yemen The Concept of Essential Drugs (EDC) developed by World Health Organization (WHO) in 1977 has provided a rational basis, not only for drug procurement at national level but also for establishing drug requirements at various levels within the health care system. The WHOs Action Program on Essential Drugs (DAP) aimed to improve health care. It was established in order to provide operational support in the development of National Drug Policies (NDP), to improve the availability of essential drugs to the whole population and to work towards the rational use of drugs and consequently the patient care. The program seeks to ensure that all people, whenever they may be, are able to obtain the drugs they need at the lowest possible price; that these drugs are safe and effective; and that they are prescribed and used rationally. The first WHO Model List of Essential Drugs was published in 1977 (WHO, 1977). Since that time essential drugs become an important part of health policies in developing countries; but the Essential Drugs Program has been criticized because it emphasis in improving supply of drugs rather than their rational prescribing. The recent revised WHO Model List of Essential Drugs was published the 13th edition in April 2003 (WHO, 2003). Yemen was one of the first countries in the region adapted the EDC in 1984 and implemented this concept in the public sector (Hogerzeil et al., 1989). The first Yemen (National) Essential Drugs List (YEDL) was officially issued in 1987 based on the WHO List of Essential Drugs and other resources. The second edition of the Yemen Drugs list and the Yemen Standard Treatment Guidelines were published in 1996 (MoPHP/NEDL, (1996); MoPHP/NSTG, (1996).Recently the latest edition was published in 2001 with the Standard Treatment Guidelines (STG) in the same booklet (Mo PHP/YSTG and YEDL, 2001). The new edition of the Treatment Guidelines and the Essential Drugs List has been created through a long process of consultation of medical and pharmaceutical professionals in Yemen and abroad. Review workshops were held in Sanaa and Aden and more than 200 representatives of the health workers from different governorates including the major medical specialists participated. Essential drugs are selected to fulfil the real needs of the majority of the population in diagnostic, prophylactic, therapeutic and rehabilitative services using criteria of risk-benefit ratio, cost-effectiveness, quality, practical administration as well as patient compliance and acceptance (Budon-Jakobowiez, 1994). The YEDL was initially used for the rural health units and health centers as well as some public hospitals, but not applied for all levels of health care and the private sector. However, despite the recognition of the essential drug concept by the government of Yemen represented by the Ministry of Public Health and Population (MoPHP), drugs remain in short supply to many of the population and irrationally used. Procurement cost is sometimes needlessly high. Knowledge of appropriate drug use and the adverse health consequences remain unacceptably low. In addition, diminished funding in the public sector resulted in shortage of pharmaceuticals. The 20th century has witnessed an explosion of pharmaceutical discovery, which has widened the therapeutic potential of medical practice. The vast increase in the number of pharmaceutical products marketed in the last decades has not made drug available to all people and neither has resulted in the expected health improvement. While some of the newly invented drugs are significant advance in therapy, the majorities of drugs marketed as â€Å"new† are minor variations of existing drug preparations and do not always represent a significant treatment improvement. In addition, the vast number brand names products for the same drug increases the total number of products of this particular drug resulting in an unjustified large range of drug preparations marketed throughout the world. The regular supply of drugs to treat the most common diseases was a major problem for governments in low-income countries. The WHO recommends that activities to strengthen the pharmaceutical sector be organized under the umbrella of the national drug policy (WHO, 1988). In 1995, over 50 of these countries has formulated National Drug Policies (NDP). The NDP is a guide for action, containing the goals set by the government for the pharmaceutical sector and the main strategies and approaches for attaining them. It provides a framework to co-ordinate activities of patients involved in pharmaceutical sector, the public sector, the private sector, non-governmental organizations (NGOs), donors and other interested parties. A NDP will therefore, indicate the various courses of action to be in relation to medicines within a country. The Yemen National Drug Policy was developed since 1993 with the objectives of ensuring availability of essential drugs through equitable distribution, ensuring drugs efficacy and safety, as well as promoting the rational use of drugs. Unfortunately, it has n Research into Rational Drug Prescribing in Yemen Research into Rational Drug Prescribing in Yemen CHAPTER 1 1.0 Introduction In Yemen as well as in many other developing countries the quality of health services which constitute social indicators of justice and equity is far from being satisfactory. Inappropriate, ineffective, and inefficient use of drugs commonly occurs at different health facilities (Abdo-Rabbo, 1993; Abdo-Rabbo, 1997). Irrational prescribing is a habit, which is difficult to cure. This may lead to ineffective treatment, health risks, patient non-compliance, drug wastage, wasteful of resources and needless expenditure. According to the Yemeni constitution, â€Å"patients have the right to health care and treatment† i.e. appropriate care, consent to treatment and acceptable safety. Therefore, health workers should concentrate on making patients better and patients should concentrate on geting better. Health care in general and particularly the drug situation in any country is influenced by the availability, affordability, and accessibility of drugs as well as the prescribing practices. There are many individuals or factors influence the irrational prescribing such as patients, prescribers, workplace environment, the supply system, including industry influences, governments regulations, drug information and misinformation (Geest S. V. et al, 1991; Hogerzeil H. V., 1995).Improving rational use of drugs (RUD) is a very complex task worldwide because changing behavior is very difficult. The 1985 Nairobi conference on the rational use of drugs marked the start of a global effort to promote rational prescribing (WHO,1987). In 1989, an overview of the subject concluded that very few interventions to promote rational drug use had been properly tested in developing countries (Laing et al., 2001). The selection of drugs to satisfy the health needs of the population is an important component of a national drug policy. The selected drugs are called essential drugs which are the most needed for the health care of the majority of the population in a given locality, and in a proper dosage forms. The national list of essential drugs (NEDL) is based on prevailing health conditions, drug efficacy, safety, and quality, cost- effectiveness and allocated financial resources. WHOs mission in essential drugs and medicines policy is to help save lives and improve health by closing the huge gap between the potential that essential drugs have to offer and the reality that for millions of people particularly the poor and disadvantaged medicines are unavailable, unaffordable, unsafe or improperly used. The organization works to fulfill its mission in essential drugs and medicines policy by providing global guidance on essential drugs and medicines, and working with countries to implement national drug policies to ensure equity of access to essential drugs, drug quality and safety, and rational use of drugs. Development and implementation of national drug policies are carried out within the overall national health policy context, with care taken to ensure that their goals are consistent with broader health objectives. All these activities ultimately contribute to all four WHO strategic directions to: reduce the excess mortality of poor and marginalized populations reduce the leading risk factors to human health develop sustainable health systems,and develop an enabling policy and institutional environment for securing health gains. The greatest impact of WHO medicines activities is, and will continue to be, on reducing excess mortality and morbidity from diseases of poverty, and on developing sustainable health systems. The people of our world do not need to bear the present burden of illness. Most of the severe illness that affects the health and well-being of the poorer people of our world could be prevented. But first, those at risk need to be able to access health care — including essential medicines, vaccines and technologies. Millions cannot — they cannot get the help they need, when they need it. As a result they suffer unnecessarily, become poorer and may die young. A countrys health service cannot respond to peoples needs unless it enables people to access essential drugs of assured quality. Indeed, this access represents a very important measure of the quality of the health service. It is one of the key indicators of equity and social justice. (Dr Gro Harlem Brundtland, Director-General, World Health Organization Opening remarks, Parliamentary Commission on Investigation of Medicines, Brasilia, 4 April 2000). 1.1 Background 1.1.1 Brief history of antibiotics According to the original definition by Waksman, antibiotics substances which are produced by microorganisms and which exhibit either an inhibitory or destructive effect on other microorganisms. In a wider, though not universally accepted definition; antibiotics are substances of biological origin, which without possessing enzyme character, in low concentrations inhibit cell growth processes (Reiner, 1982). Up to now, more than 4,000 antibiotics have been isolated from microbial sources and reported in the literature, and more than 30000 semi-synthetic antibiotics have been prepared. Of these, only about 100 are used clinically as the therapeutic utility not only depends on a high antibiotic activity but also on other important properties such as good tolerance, favorable pharmacokinetics etc. These antibiotics are today among the most efficient weapons in the armoury of the physician in his fight against infectious diseases. They are therefore used a large extent and constitute the largest class of medicaments with respect to turnover value. Today, antibiotics are also used in veterinary medicine and as additives to animal feed. In the past they were used addition, as plant protection agents and as food preservatives. In this review we have confined ourselves to a brief description clinicallyuseful antibiotics. These belong to various classes of chemical compounds, differ in origin, mechanism of action and spectrum activity, and are thus important and representative examples of known antibiotics. 1.1.2 Problem Statement This study examines drug use in Yemen and factors leading to inappropriate use of medicines particularly antibiotics and the prescribing pattern. It defines rational drug use and describes policy developments, which aim to encourage appropriate use. In Yemen, as well as in many developing countries, the quality of health services is far from being achieved. Therefore, doctors should concentrate on making patients better and patients should concentrate on getting better. The rational use of drugs requires that patients received medications in appropriate to their clinical needs, in doses that meets their own requirements for an adequate period of time and at the lowest cost to them and their community (Bapna et al, 1994). This means deciding on the correct treatment for an individual patient based on good scientific reasons. It involves making an accurate diagnosis, selecting the most appropriate drug from these available, prescribing this drug in adequate doses for a sufficient length of time according to standard treatment. Furthermore, it involves monitoring the effect of the drug both on the patient and on the illness. There is plentiful evidence of the inappropriate use of drugs, not through self-medication or unauthorized prescribing, but inadequate medical prescribing and dispensing. Normally, patients in Yemen enter health facilities with a set of symmetrical complaints, and with expectations about the care they typically receive; they typically leave with a package of drugs or with a prescription to obtain them in a private market. In previous study in Yemen (misuse of antibiotics in Yemen, a pilot study in Aden) (Abdo-Rabbo, 1997) showed that imported quantity and total consumption of antibiotics is increasing. There is a lack of information about the problems created from antibiotics among the community and about the proper efficacy, safety, and rational use of antibiotics among health authority and workers. No supervision or strict rules are applied in the use of antibiotics. They are easily obtained without prescription and available in some shops. The percentage of prescriptions containing antibiotics was more than a quarter of the total prescriptions contained antibiotics, also antibiotics constituted about 25% of all prescribed drugs. 1.1.2.1 Inappropriate Drug Use Increasing use of medicines may lead to an increase in the problems associated with medication use. The use of medicines, as well as improving health, can lead to undesirable medical, social, economic and environmental consequences. Aspects of drug use, which lead to such undesirable consequences, have been called inappropriate drug use (DHHCS, 1992; WHO, 1988). Inappropriate drug use may include under-use, over-use, over-supply, non-compliance, adverse drug reactions and accidental and therapeutic poisoning (DHHCS, 1992). It also includes medicating where there is no need for drug use, the use of newer, more expensive drugs when lower cost, equally effective drugs are available (WHO, 1988) and drug use for problems which are essentially social or personal (Frauenfelder and Bungey, 1985). 1.1.2.2 Quality Use of Medicines In an attempt to encourage the appropriate use of medicinal drugs and to reduce the level of inappropriate use in Yemen, a policy was developed on the quality use of medicines. The stated aim of the policy is: to optimise medicinal drug use (both prescription and OTC) to improve healthoutcomes for all Yemenis. The policy endorses the definition of quality drug use as stated by the World Health Organisation, Drugs are often required for prevention, control and treatment of illness†. When a drug is required, the rational use of drugs demands that the appropriate drug be prescribed, that it be available at the right time at a price people can afford, that it be dispensed correctly, and that it be taken in the right dose at the right intervals and for the right length of time. The appropriate drug must be effective, and of acceptable quality and safety. The formulation and implementation by governments of a national drug policy are fundamental to ensure rational drug use (WHO, 1987 ; DHHCS, 1992). The rational use of drugs can be impeded by the inappropriate selection of management options, the inappropriate selection of a drug when a drug is required, the inappropriate dosage and duration of drug therapy and the inadequate review of drug therapy once it has been initiated. 1.1.2.3 The Requirement of Drug Information for Quality Use of Medicines A medicine has been described as an active substance plus information. (WHO, 1994). Education, together with, objective and appropriate drug information have been two of the factors consistently identified as necessary for rational drug use (Naismith, 1988; Soumerai, 1988; Carson et al, 1991; Dowden, 1991; Henry and Bochner, 1991; Tomson and Diwan, 1991). The WHO guidelines for developing national drug policies also identify the importance of information provision for facilitating drug use: Information on and promotion of drugs may greatly influence their supply and use. Monitoring and control of both activities are essential parts of any national drug policy (WHO, 1988). Objective and appropriate drug information is a necessary factor for quality drug use. It is the basis for appropriate prescribing decisions by medical practitioners. Medical practitioners require objective product, specific drug information and comparative prescribing information. Objective drug information is avai lable to medical practitioners through continuing education programs co-ordinated by professional bodies, medical and scientific journal articles, drug information services and drug formularies and guidelines. 1.1.2.4 Problem with antibiotic use The concerns regarding inappropriate antibiotic use can be divided into four areas: efficacy, toxicity, cost, and resistance. Inappropriate use of antibiotic can be due to: Antibiotic use where no infection is present, e.g. continuation of peri-operative prophylaxis for more than 24 hours after clean surgery. Infection, which is not amenable to antibiotic therapy, e.g. antibiotics prescribed for viral upper respiratory infection. The wrong drug for the causative organism, e.g. the use of broad anti-Gram negative agents for community acquired pneumonia. The wrong dose or duration of therapy. Such inappropriate use has a measurable effect on therapeutic efficacy. For example, one study showed that mortality in gram-negative septicemia is doubled when inappropriate empiric agents were used (Kreger et al., 1980). Since most initial antibiotic therapy is empiric, any attempt at improving use must tackle prescribing habits, with particular emphasis on guidelines for therapy based on clinical criteria. Inappropriate antibiotic use exposes patients to the risk of drug toxicity, while giving little or no therapeutic advantage, antibiotics are often considered relatively safe drugs and yet direct and indirect side effects of their use are frequent and may be life-threatening, allergic reactions, particularly to beta-lactam agents are well recognized and have been described in reaction to antibiotic residues in food (Barragry, 1994). Life threatening side effects may be occur from the use of antibiotics for apparently simple infections, it is estimated, for example, that eight people per year in UK die from side effects of co-trimoxazole usage in the community (Robert and Edmond, 1998). Indirect side effects are often overlooked: especially as may occur sometime after the antibiotic has been given. These include drug interactions (such as interference of antibiotic with anti-coagulant therapy and erythromycin with antihistamine) (BNF, 1998), side effects associated with the administration of antibiotics (such as intravenous cannula infection) and super-infection (such as candidiasis and pseudomembranous colitis). Each of these may have a greater morbidity, and indeed mortality, than the initial infection for which the antibiotic was prescribed (Kunin et al., 1993). The medical benefit of antibiotics does not come cheap. In the hospital setting, up to fifty percent of population receive one antibiotic during their hospital stay, with surgical prophylaxis accounting for thirty percent of this (Robert and Edmond, 1998). The first penicillin resistant isolate of Staphylococcus aureus was described only two years after the introduction of penicillin. Within a decade, 90% of isolates were penicillin resistant. This pattern of antibiotic discovery and introduction, followedby exuberant use and rapid emergence of resistance has subsequently been repeated witheach new class of antibiotics introduced. Bacteria can so rapidly develop resistance due to two major evolutionary advantages. Firstly, bacteria have been in existence for some 3.8 billion years and resistance mechanisms have evolved over this time as a protective mechanism against naturally occurring compounds produced by other microorganisms. In addition, they have an extremely rapid generation time and can freely exchange genetic material encoding resistance, not only between other species but also between genera. The vast quantities of antibiotics used in both human and veterinary medicine, as a result present in the environment, have lead to eme rgence of infection due to virtually untreatable bacteria. Multiply drug resistant tuberculosis is already widespread in parts of Southern Europe and has recently caused outbreaks in hospitals in London (Hiramatsu et al., 1997). Anti-infective are vital drugs, but they are over prescribed and overused in treatment of minor disorder such as simple diarrhea, coughs, and colds. When antibiotics are too often used in sub-optimal dosages, bacteria become resistant to them. The result is treatment failure where patient continue to suffer from serious infections despite taking the medication (Mohamed, 1999). Drugs prescribed are in no way beneficial to the patient s management if there are some negative interactions among the various agent prescribed, over prescribed, under prescribed or prescribed in the wrong dosage schedule. How does one ensure that good drug are not badly used, misused, or even abused? How can drugs be used rationally as intended? What is rational use of drugs? What does rational mean? 1.1.3 Rational Use of Drug Rational use of drugs requires that patients receive medications appropriate to their clinical needs, in doses that meet their own individual requirements for an adequate period of time, and the lowest cost to them and their community (Bapna et al., 1994). These requirements will be fulfilled if the process of prescribing is appropriately followed. This will include steps in defining patients problems (or diagnosis); in defining effective and safe treatments (drugs and non-drugs); in selecting appropriate drugs, dosage, and duration; in writing a prescription; in giving patients adequate information; and in planning to evaluate treatment responses. The definition implies that rational use of drugs; especially rational prescribing should meet certain criteria as follows (Ross et al., 1992): Appropriate indication. The decision to prescribe drug(s) is entirely based on medical rationale and that drug therapy is an effective and safe treatment. Appropriate drug.The selection of drugs is based on efficacy, safety, suitability, and considerations. Appropriate patient. No contraindications exist and the likelihood of adverse reactions is minimal, and the drug is acceptable to the patient. Appropriate information. Patients should be provided with relevant, accurate, important, and clear information regarding his or her condition and the medication(s) that are prescribed. Appropriate monitoring. The anticipated and unexpected effects of medications should be: appropriately monitored (Vance and Millington, 1986). Unfortunately, in the real world, prescribing patterns do not always conform to these criteria and can be classified as inappropriate or irrational prescribing. Irrational prescribing may be regarded as pathological prescribing, where the above- mentioned criteria are not fulfilled. Common patterns of irrational prescribing, may, therefore be manifested in the following forms: The use of drugs when no drug therapy is indicated, e.g., antibiotics for viral upper respiratory infections, The use of the wrong drug for a specific condition requiring drug therapy, e.g., tetracycline in childhood diarrhea requiring ORS, The use of drugs with doubtful/unproven efficacy, e.g., the use of antimotility agents in acute diarrhea, The use of drugs of uncertain safety status, e.g., use of dipyrone, Failure to provide available, safe, and effective drugs, e.g., failure to vaccinate against measles or tetanus, failure to prescribe ORS for acute diarrhea, The use of correct drugs with incorrect administration, dosages, and duration, e.g., the use of IV metronidazole when suppositories or oral formulations would be appropriate. The use of unnecessarily expensive drugs, e.g., the use of a third generation, broad spectrum antimicrobial when a first-line, narrow spectrum, agent is indicated. Some examples of commonly encountered inappropriate prescribing practices in many health care settings include: (Avorn et al., 1982). Overuse of antibiotics and antidiarrheals for non-specific childhood diarrhea, Multiple drug prescriptions, prescribe unnecessary drugs to counteract or augment, Drugs already prescribed, and Excessive use of antibiotics in treating minor respiratory tract infection. The drug use system is complex and varies from country to country. Drugs may be imported or manufactured locally. The drugs may be used in hospitals or health centers, by private practitioners and often in a pharmacy or drug shop where OTC preparations are sold. In some countries, all drugs are available over the counter. Another problem among the public includes a very wide range of people with differing knowledge, beliefs and attitudes about medicines. 1.1.3.1 Factors Underlying Irrational Use of Drugs There are many different factors that affect the irrational use of drugs. In addition, different cultures view drugs in different ways, and this can affect the way drugs are used. The major forces can be categorized as those deriving from patients, prescribers, the workplace, the supply system including industry influences, regulation, druginformation and misinformation, and combinations of these factors (Table 1.1) (Ross et al., 1992). Table 1.1: Factors affecting irrational use of drug Impact of Inappropriate Use of Drugs The impact of this irrational use of drugs can be seen in many ways: (Avorn et al., 1982). Reduction in the quality of drug therapy leading to increased morbidity and mortality, Waste of resources leading to reduced availability of other vital drugs and increased costs, Increased risk of unwanted effects such as adverse drug reactions and the emergence of drug resistance, e.g., malaria or multiple drugs resistant tuberculosis, Psychosocial impacts, such as when patients come to believe that there is a pill for every ill. This may cause an apparent increased demand for drugs. 1.1.3.2 The Rational Prescription (i.e. the right to prescribe) The rights to prescription writing must be ensuring the patients five rights: the right drug, the right dose, by the right route, to the right patient, at the right time. Illegible handwriting and misinterpretation of prescriptions and medication orders are widely recognized causes of prescription error. The medicines should be prescribed only when they are necessary, should be written legibly in ink or, other wise, should be led, and should be signed in ink by the prescriber, The patients full name and address, diagnosis should be written clearly, the name of drugs and formulations should be written clearly and not abbreviated, using approved titles only. Dose and dose frequency should be stated; in the cases of formulations to be taken as required, a minimum dose should be specified (British National Formulary, 1998). 1.2 Overview on Essential Drug Concept (EDC) Essential drugs relate to an international concept proposed by the World Health Organization (WHO) in 1977. WHO in that year published the first model list of essential drug and WHO has put in enormous resources into the campaign to promote the concept of essential drugs (EDL). Essential drugs were defined as a limited number of drugs that should be available at any time to the majority of population in appropriate dosage forms and at affordable prices. In other words, it meets the criteria generally abbreviated as SANE [that mean safety , availability, need efficacy] (John, 1997). The essential drug concept is important in ensuring that the vast majority of the population is accessible to drugs of high quality, safety and efficacy relevant to their health care needs, and at reasonable cost (New Straits Times, 1997a). In support of this concept, the WHOissued a model drug list that provided examples of essential drugs. The list is drawn up by a group of experts based on clinical scientific merits, and provides an economical basis of drug use. This list is regularly, revised and, since 1997, eight editions have been published. This ensures that the need for essential drugs is always kept up-to-date with additions and deletions. Despite such rigorous revision, the number of drugs in the list remains at about 300, although the initial list comprised less. Most of the drugs are no longer protected by patents and can therefore be produced in quantity at a lower cost without comprising standards (WHO, 1995). This is indeed important for countries like Yemen not only because health care are rapidly escalating, but also because the country is still very dependent on imports of strategic commodities like drugs. The EDC will enable Yemen to focus on becoming self-reliant where generic equivalents of essenti al drugs can be manufactured and popularized to meet the health needs of the majority of the people. The limited number of drugs regarded as essential on the list offers a useful guide for practitioners as well as consumers. It underscores the general principle thata majority of diseases can be treated by similar drugs regardless of national boundaries and geographical locations (New Straits Times, 2000) Moreover, certain self-limiting diseases may not need drug treatment as such. For example, in the case of diarrhea, certain so-called potent anti-diarrhoeal drugs (including antibiotics) are not generally recommended. The more preferred treatment is oral rehydration salt that could easily be obtained or prepared at a fraction of the cost while giving the most optimum outcome. The goal of the Yemen Drug Policy was to: Prepare a list of essential drugs to meet the health of needs of the people. Assure that the essential drugs made available to the public are of good quality Improve prescribing and dispensing practices Promote rational use of drug by the public Lower cost of the drugs to the government and public Reduce foreign exchange expenditure 1.3 Yemen Essential Drug List and Drug Policy in Yemen The Concept of Essential Drugs (EDC) developed by World Health Organization (WHO) in 1977 has provided a rational basis, not only for drug procurement at national level but also for establishing drug requirements at various levels within the health care system. The WHOs Action Program on Essential Drugs (DAP) aimed to improve health care. It was established in order to provide operational support in the development of National Drug Policies (NDP), to improve the availability of essential drugs to the whole population and to work towards the rational use of drugs and consequently the patient care. The program seeks to ensure that all people, whenever they may be, are able to obtain the drugs they need at the lowest possible price; that these drugs are safe and effective; and that they are prescribed and used rationally. The first WHO Model List of Essential Drugs was published in 1977 (WHO, 1977). Since that time essential drugs become an important part of health policies in developing countries; but the Essential Drugs Program has been criticized because it emphasis in improving supply of drugs rather than their rational prescribing. The recent revised WHO Model List of Essential Drugs was published the 13th edition in April 2003 (WHO, 2003). Yemen was one of the first countries in the region adapted the EDC in 1984 and implemented this concept in the public sector (Hogerzeil et al., 1989). The first Yemen (National) Essential Drugs List (YEDL) was officially issued in 1987 based on the WHO List of Essential Drugs and other resources. The second edition of the Yemen Drugs list and the Yemen Standard Treatment Guidelines were published in 1996 (MoPHP/NEDL, (1996); MoPHP/NSTG, (1996).Recently the latest edition was published in 2001 with the Standard Treatment Guidelines (STG) in the same booklet (Mo PHP/YSTG and YEDL, 2001). The new edition of the Treatment Guidelines and the Essential Drugs List has been created through a long process of consultation of medical and pharmaceutical professionals in Yemen and abroad. Review workshops were held in Sanaa and Aden and more than 200 representatives of the health workers from different governorates including the major medical specialists participated. Essential drugs are selected to fulfil the real needs of the majority of the population in diagnostic, prophylactic, therapeutic and rehabilitative services using criteria of risk-benefit ratio, cost-effectiveness, quality, practical administration as well as patient compliance and acceptance (Budon-Jakobowiez, 1994). The YEDL was initially used for the rural health units and health centers as well as some public hospitals, but not applied for all levels of health care and the private sector. However, despite the recognition of the essential drug concept by the government of Yemen represented by the Ministry of Public Health and Population (MoPHP), drugs remain in short supply to many of the population and irrationally used. Procurement cost is sometimes needlessly high. Knowledge of appropriate drug use and the adverse health consequences remain unacceptably low. In addition, diminished funding in the public sector resulted in shortage of pharmaceuticals. The 20th century has witnessed an explosion of pharmaceutical discovery, which has widened the therapeutic potential of medical practice. The vast increase in the number of pharmaceutical products marketed in the last decades has not made drug available to all people and neither has resulted in the expected health improvement. While some of the newly invented drugs are significant advance in therapy, the majorities of drugs marketed as â€Å"new† are minor variations of existing drug preparations and do not always represent a significant treatment improvement. In addition, the vast number brand names products for the same drug increases the total number of products of this particular drug resulting in an unjustified large range of drug preparations marketed throughout the world. The regular supply of drugs to treat the most common diseases was a major problem for governments in low-income countries. The WHO recommends that activities to strengthen the pharmaceutical sector be organized under the umbrella of the national drug policy (WHO, 1988). In 1995, over 50 of these countries has formulated National Drug Policies (NDP). The NDP is a guide for action, containing the goals set by the government for the pharmaceutical sector and the main strategies and approaches for attaining them. It provides a framework to co-ordinate activities of patients involved in pharmaceutical sector, the public sector, the private sector, non-governmental organizations (NGOs), donors and other interested parties. A NDP will therefore, indicate the various courses of action to be in relation to medicines within a country. The Yemen National Drug Policy was developed since 1993 with the objectives of ensuring availability of essential drugs through equitable distribution, ensuring drugs efficacy and safety, as well as promoting the rational use of drugs. Unfortunately, it has n

Different Cultural Practices in the Philippines

Christille Lindy Joyce D. Caluyo BMLS II-A 1) Different cultural practices in the Philippines which could affect our health. Herbalaryo/Arbolaryo/Witch-Doctors †¢ Filipinos believe that some illnesses are caused by evil spirits that enter the body which are cast by â€Å"Manga ga mud†. †¢ â€Å"Manga ga mud† casts spells on people if they are jealous or disliked. They take personal items such as, clothing, a brush (to obtain a piece of hair), pictures, jewelry, etc. It is also done by food poisoning. †¢ These people who became sick / cursed ask help from herbalaryo/arbolaryo. They are also called witch-doctors. The herbalaryo may treat â€Å"Manga ga mud† by gathering unmarried individuals, and a bag of rice. †¢ This treatment involves a night of ritual sprinkling of rice, dining and dancing to Filipino music. †¢ After the night of festivities, everyone will say a Filipino prayer for the person who has been cursed. They believed that this treatment would remove the curse from the affected person. Halaman (Medicinal Herbs & Plants) †¢ Filipinos also believe in the healing effects of nature. †¢ Medicinal herbs & plants like ginger, garlic, and chives are used to treat different sickness. Religion †¢ Filipinos believe that religion is closely tied to health.Younger Filipino gives importance to prayer. †¢Filipinos are religious people that they entrust their health to their faith. †¢Prayer also has a role in the understanding of health. Regardless of how religious each age category, there is a consistent belief that God is present at work in times of illness. †¢In the case of terminal or serious illness, Filipino accepts the situation in a sense that â€Å"it is God’s will. Superstitious Beliefs †¢Many of Filipino’s believe on superstitious things such as if you comb your hair at the night, someone will die or eating twin bananas will helmyou conceive a twin. These belie fs are not scientifically proven and can only be supported by the word of our ancestors. †¢Maybe these things occur because of coincidence, just like when someone died because he is ill then they blame it for combing their hair and the word spread all over the nation. 2) Different religious practices that can affect our health. †¢Religious beliefs cause patients to forego needed medical care, refuse life-saving procedures, and stop necessary medication—choosing faith instead of medicine. Religion can cause people to be judgmental and lead to alienation or exclusion of those not playing â€Å"by the rules. † †¢If physical healing does not come immediately, the person may be disappointed and disheartened and claims that the prayer was not answered and that God does not care, and worse that the illness was sent by an angry, vengeful God as a punishment. †¢Religion may become so rigid and inflexible that it becomes excessively restricting and limiting. †¢Religion may encourage magical thinking as people pray for and expect physical healing. Jehovah's Witnesses may refuse life-saving blood products, and some Christian Scientists may avoid seeing Healthcare Provider because they rely on prayer instead. †¢Patients may stop their medications after attending a healing service in order to â€Å"demonstrate their faith†. †¢People believe that being spiritually healthy could lead you to a healthy body. †¢People would pray always and avoid being problematic. Sources: http://www. hawcc. hawaii. edu/nursing/tradfil2. htm http://www. spirit-health. org/resources_detail. asp? q=12 http://www. esipa. org/happening/documents/Culture_Health_Report. pdf

Personal life and sports Essay

Sportsmanship is the character, practice, or skill of a person involved in sports. This includes the participant, the parents, the coaches, and all spectators. Sportsmanlike conduct includes fairness, courtesy, learning to be a good loser, being competitive without rude behavior, or experiencing any ill feelings toward the opponent. Too often in any sporting event, the purpose of the sport is forgotten. Winning has become overwhelmingly important to the adults involved. This attitude is inflicted on the youth. People of all ages should be allowed to fully embrace the challenge and fun of playing sports. Teaching, coaching, motivating, and winning are fine as long as the reason for the sport or activity is prioritized. The attitudes of athletes are instilled in them at a very young age. They reflect the motivation and goals of their parents, who sometimes push them into sports they would not normally choose for themselves. Play is essential in growth and develop- ment. Children who play sports with other children tend to socialize and adjust better as adults. Healthy competition provides a natural, emotional outlet for children, but should not be forced or overemphasized. Competition should be kept friendly with the emphasis on participation rather than the outcome of the event. Parents should not pressure the child to excel, regardless of his abilities, because this takes away the fun of the sport, adds undo pressure on the participant, and produces unsportsmanlike conduct. Sportsmanship is participating in a sport, rather than performing, and realizing how you play the game is more important than winning. Too many coaches and parents tend to forget the reason for sports for children. They get caught up in the excitement and competitiveness. Winning is the ultimate goal, at all costs. The cost is the effect this attitude has on the children. I have witnessed this behavior from coaches and parents, where they have actually embarrassed and humiliated young players in front of their peers. The negative effect this has on the athletes is obvious. They become aggressive, sometimes withdrawn and angry, rude, and inconsiderate. Sports are not just an activity. They form a stepping stone toward the future. Sportsmanship teaches children how to interact with peers, how to relate and interact with others. Sports can teach cooperation, sharing, and compassion. At a young age participation in sports introduces players to rules, and how to incorporate them into other aspects of life. A child must realize that losing has absolutely nothing to do with self-worth, that their personal value is not measured by winning or losing, but doing the best that they can in sports and life. It is important that children and adults be part of a group to feel acceptance, without the emphasis on winning. Self-confidence does not come from winning or losing, but how the outcome is handled. If you perform to your best ability, then you have won the only  important game. Sportsmanship is what the activity should be about. Coaches and parents should relax, enjoy the fact that their children are active and adjusting socially, have fun, and allow their children to have fun. They will produce healthier, happier, more secure, self-confident, and less angry, frustrated children. Sportsmanship carries into every aspect of daily life. Winning and losing is part of every day life at every age and every stage. We should learn and be taught through praise and example how to win and lose with dignity, humility, and self-respect.

child poverty - 999 Words

Child poverty in the U.K Introduction Child poverty is becoming more of a big issue now more than ever in the U.K, with so many people unemployed and living on benefits. Children across the country are being deprived of basic living standards. The price of living is going up and it’s no wonder people are struggling to make ends meet. In my essay, I will talk about all aspects of how child poverty impacts greatly on children’s lives. I will talk about the effects poverty has on a child’s health, housing, education and social exclusion. I will also talk about how child poverty can be tackled, and the causes of child poverty with in the United Kingdom. Firstly, I would like to talk about what causes child poverty. An important factor†¦show more content†¦And the government’s aim is to completely eradicate child poverty by the end of 2020, (end child poverty, 2013). To completely get rid of child poverty by 2020, the aim will be to; increase minimum wage, get more people back in to work, help more disadvantaged people to progress back to work, ensure education works for all children, and provide access to high quality of early years for every child who is from low income families. Conclusion Throughout my essay I found a lot of information on causes and effects that child poverty has on family lives. Although there are help for families who are living in poverty, such as; child tax credits, child benefit and housing benefit, they are still struggling to make ends meet and are living below basic standards of living. I have found out that not only living in poverty can affect a child socially but can also affect their health. To think that children from different areas are more likely to die earlier than children from more affluent parts of the country is completely mad. Socially children living in poverty are also being let down educationally. Possibly, the reason that children are struggling at school, is because they are stressed with home life, and the struggles of having no money. I think that all the charities and organisations out there to help raise awareness of child poverty is a great way to eventually end it by 2020. People shouldShow MoreRelatedChild Poverty101 42 Words   |  41 PagesPrinceton University Child Poverty Can Be Reduced Author(s): Robert D. Plotnick Source: The Future of Children, Vol. 7, No. 2, Children and Poverty (Summer - Autumn, 1997), pp. 72-87 Published by: Princeton University Stable URL: http://www.jstor.org/stable/1602388 . Accessed: 16/05/2013 10:19 Your use of the JSTOR archive indicates your acceptance of the Terms Conditions of Use, available at . http://www.jstor.org/page/info/about/policies/terms.jsp . 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Self Defense Laws State - 1542 Words

We’ve all seen Laura Croft of the Tomb Raider series adorned in her signature costume: tank top, cargo shorts, and a utility belt with two pistols. Besides the exhilaration of onscreen combat, what would prompt a woman to carry a firearm? Some may assume that an armed woman must be living in constant fear and therefore imagined the only solution to the problem to be gun ownership or in universal language an â€Å"equalizer†. However balancing the term equalizer is intended, it carries the negative connotation of an existing inequality; perhaps in gender, which a firearm would somehow resolve. Studies show that women, like men, carry their firearms in the event the need arises. In the doctrine of self-defense laws state â€Å"it’s a man’s prerogative to carry a legal firearm† and â€Å"man has the right to protect his castle†. Each an example of the need for updated policy in a society that continues to correlate gun culture with men. The purpose of this paper is to introduce my artifact and examine my findings to reveal who, what, where, when and how. I will provide a brief discussion of women and gun ownership with respect to gender stereotypes, and gun politics. Finally, I will discuss gun violence as it relates to gender and its association to women as victims. Who, What, Where, When, and How Gun ownership is overall a male phenomenon sometimes used as a means to validate manhood, particularly amongst young men (xxxxx). In the article that I selectedShow MoreRelatedThe Theory Of Self Defense962 Words   |  4 PagesSelf-defense is described in the dictionary as; â€Å"the act of defending one s person when physically attacked, as by countering blows or overcoming an assailant† (â€Å"self-defense,† n.d.). The concept of self-defense appears well-defined; however, the tactics allowed to protect oneself have evolved just as America has. 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Graphic Causes A Great Impact On The Consumers Mind

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Managing Social Enterprise

Question: Explain. Develops the set-up plan for social enterprise. Answer: Aims and Objectives The main purpose of this research paper is to provide relevant domestic market information to social enterprise producers those want to protect women and girls from the Domestic Violence. The main aim of this paper is to develop the setup business plan of Sisters Freedom Association to evaluate the future success of the enterprises. The following are the main objectives of this paper: To identify the social need of Sisters Freedom Association To evaluate the future sales and future success of Sisters Freedom Association Introduction and Background Domestic violenceis a complex issue which affects a lot off woman in the society. With one woman in four physically abused by their partner at some point in their life. Sisters Freedom Association will target all woman in the borough of Croydon my aim is to provide services such as counselling, refuge, trips , money advise, support groups and educational support (WOMEN, 2014). Sisters Freedom Association will target all woman in the borough of Croydon my aim is to provide services such as counselling, refuge, trips , money advise, support groups and educational support. Currently theres only one organisation that helps out women who have been a victim off abuse they are called Family Justice Croydon. Sisters Freedom Association will stand out from other organisations because it will be offering a lot of services such as camping trips and prizes to children and mothers also babies (Refuge, 2015). A good way to stop Domestic Violence is by educating as many women as possible about Domestic Violence. This can be done in collaboration with the local Domestic Violence shelter or womens organisation or police community outreach officers who can work with the community, local schools and local companies to organise and implement talks, town halls meetings and other group sessions to talk about this issue (Weygandt, Kimmel Kieso, 2009). Market Research- Business /Social Need/Market Failure Sisters Freedom Association will target all women because between the ages of 16 till older age 15-76 % of women are targeted for physical or sexual violence in their lifetime, according to the available country data. Most of this violence takes place within intimate relationships, with many women (ranging from 9 to 70%) reporting their husbands or partners as the perpetrator. Across the 28 States of the European Union, a little over one in five woman has experienced physical or sexual violence from a partner (UN WOMEN, 2014). 2 women are killed every week in England and Wales by a current or former partner (Homicide Statistics, 1998) 1 woman killed every 3 days 1 in 4 women experience domestic violence over their lifetimes and between 6-10% of women suffer domestic violence in a given year (Refuge, 2015). These statistics clearly show that women in the community are at higher risk from suffering from domestic abuse thats why they are my target market Sisters Freedom Association believe it can reduce these numbers by educating all women on time making them aware of health and mental issues also how this can affect children. Sisters Freedom Association plan to reach my target audience by: Providing a wide range of services to meet the diverse needs of abused women and children A public awareness programme for children and young people also women A strong response from the police and criminal justice system to show that violence is unacceptable and that abusers will be punished Posters Social network Workshop The market research and social need indicates the Sisters Freedom Association is need to protect the women and girls from the domestic violence over their lifetimes. The enterprise is played major role in educate the women and girl, so they re protected self from domestic violence over their lifetimes (Weygandt, Kimmel Kieso, 2009). Human Resource Sisters Freedom Association is finding volunteer that can advise women those have suffered from domestic abuse or who are likely to suffer educating each individual about the services and information available. Asking the local borough to provide professionals that can help with counselling the women and girls, so they able to protect self from domestic violence (Refuge, 2015). Volunteers and professionals are the main human resources of Sisters Freedom Association because these are mainly contributed into the success of the enterprises. In addition, general public also played role into the success and effectively implement the Sisters Freedom Association programs. Governance, Legal and Management Structure Sisters Freedom Association is a social enterprise, so it will be needed to follow all the laws and government guidelines related to the women and girls to achieve its business objectives. Moreover, for a social enterprises and NGOs, it is necessary to follow government regulations and all laws to maintain their registration and to successful run their businesses or operations for long time (Davis Media, 2015). In a social enterprise and NGO, organizational structure or hierarchy level is very low. Sisters Freedom Association will only have management level and after that staff, volunteers and general public are included in the second level of enterprises. Marketing The below table and graph indicates the Sisters Freedom Association total marketing expenses ($1500) on the different activities. It indicates the enterprise expenses around 50% of marketing on communication to educate the women and girls about the domestic violation. Sisters Freedom Association will spend around 14% of total marketing expenses on the advertising and marketing research (Hughes, 2004). Moreover, it will spend approx 13% of total marketing expenses on events to encourage people to connect with the enterprise. Furthermore, it will spend about 3% on promotion 6% on public relation of marketing expenses to create awareness and attract the women and girls in the target market. SISTERS FREEDOM ASSOCIATION Marketing Budget Forecast Receipts Amount Research 210 Networking 0 Advertising 210 Promotion 45 Public relations 90 Events 195 Communication 750 Total Marketing Expenses à ¢Ã¢â‚¬Å¡Ã‚ ¹ 1,500 (Source: Tracy CPA, 2008) Finance Sales Forecast, Cash-flow, and Budget The below table indicates the cash inflows and cash outflows of Sisters Freedom Association: SISTERS FREEDOM ASSOCIATION First Year Cash Flow Forecast Receipts Amount Cash sales 22100 Collections from credit sales 0 Capital Introduced (owner) 3000 Capital Introduced (investor etc) 0 Loans received 7000 Other Business Income 0 Total Receipts 32100 Payments Cash purchases 0 Payments to creditors 0 Salaries and wages 0 Employee benefits 0 Payroll taxes 0 Rent 7800 Rates 3000 Utilities 1440 Repairs and maintenance 0 Insurance 0 Travel 0 Telephone 0 Postage 0 Office supplies 0 Advertising 0 Marketing/promotion 0 Professional fees 0 Training and development 0 Bank charges 0 Miscellaneous 0 Owner's drawings 0 Loan repayments 3000 Tax payments 0 Capital purchases 0 Other 0 Total Payments 15240 Cash flow Surplus/Deficit (-) à ¢Ã¢â‚¬Å¡Ã‚ ¹ 16,860 (Source: Tracy CPA, 2008) Revenue budget is responsible to indentify the each source that is expected to generate revenue within the budget year. The main purpose of revenue budget is to estimate revenue over a specified future period of time. Revenue budget is also prepared to measure the adequacy of revenue against the expenditure so that effective decision could be taken for the future of business. For example: an organization estimates different revenue sources in a year. By comparing this revenue source from the annual expenditure budget, an organization is enabled to determine the operational efficiency. If the annual revenue budget is counted less than annual expense then company enables to find other sources of revenue on prior basis. In contrast, if the annual expense budget is estimated less from revenue budget then company enables to choose appropriate investment decisions (Rasmussen, Eichorn, Barak Prince, 2003). In both situations, revenue source help organizations for building future. Non production expenses such as marketing, research or development and general administrative costs can contribute in the success of a company. Company can expand money of non-production expenses and service costs to improve its ability to meet demand and survive in market. Marketing and research or development mainly provides result for company in long period that help company to meet long-term goals (Weygandt, Kimmel Kieso, 2009). Budgeting of non production expenses helps firm to control the costs of operations and reduce the production cost that can contribute to the company success. Budgeting of non-production cost is beneficial for firm to reduce expenses and maintain cost-effective production. It can help firm to takes decisions about products prices, production levels and product mix. Company engages in budgeting of non-production expenses to determine the effective and efficient strategies for making money and expanding its assets. Budgeting can help a company to effectively use its limited financial resources and improve its ability to meet long-term goals (Waagen, 2000). Budgeting of marketing expenses plays a greater role in a companys success in market. Without effective budgeting of marketing expenses firm cannot utilize and control its marketing activities. Budgeting of marketing expenses can help firm in the development of long-term marketing strategies to attract the customers. An expenditure that incurs to facilitate the motive of long-term advantage for the business can be defined as capital expenditure. On the other hand, funds that are spent by organization to acquire or upgrade the fixed assets such as buildings, machinery etc. can be termed as capital expenditure. There are basically two ways from which the capital expenditure incurs in an organization. By acquiring an asset or by increasing the capacity of revenue earning, organizations are engaged to incur capital expenditure. It is a creational expenditure and due to this, it is associated with the capital. This type of expenditure is incurred within organizations either for adding value or generating more revenue accordingly. The tax over capital expenditure cannot be deducted in the year in which they are incurred within the organizations (Tracy CPA, 2003). Capital expenditure can be defined as expense that incur due to purchase and upgrade of physical assets such as equipment, property, or industrial buildings etc. In current business environment, organizations operate with an aim to achieve customer satisfaction and profit maximization accordingly. The funds that an organization spends to acquire or upgrade the asset help in improving the business performance at greater extent. The additional assets can help an organization to increase production and to reduce cost simultaneously. It would be beneficial for an organization to provide quality product in less cost comparatively (Crowther). With this, organization would be enabled to increase consumer base and profit accordingly. At the same time, with an appropriate expenditure on capital, organizations are enabled to achieve investment objectives effectively. This type of expenditure is quite significant value in the asset that increases the competency of organizations balance sheet (Hughes, 2004). This can be used by organizations to attract investors and to raise more capital for business. Income Generation/Fundraising Strategy Income generation: The below table indicates the sales, expenses, and profit of Sisters Freedom Association that expressed the income generated by the enterprise in the first financial year: SISTERS FREEDOM ASSOCIATION First Year Income Statement Forecast Sales 22100 Administration Expenses Rent, rates utilities 12240 Depreciation and amortization 0 Marketing expenses 1500 Other operating expenses 0 Operating profit 8360 Financial income 0 Financial expense 3000 Net financial expense 3000 Profit before taxation 5360 Taxes @ 35% 1876 Profit for the financial year à ¢Ã¢â‚¬Å¡Ã‚ ¹ 3,484 (Source: Tracy CPA, 2008) Funding strategy: Embedded model needs to be mentioned to state what this means in practice business model simply means how you intend to generate income clearly state why it is needed. However, Sisters Freedom Association plans to raise money on a daily basis to cover expenses. Sisters Freedom Association will open up a cafe that can be used to generate money and while it will have a counselling room at the back that will be an embedded model. Sisters Freedom Association will need 10000, so it will get a 7000 will be a bank loan and the remaining 3000 savings and money from family and friends (Rasmussen, Eichorn, Barak Prince, 2003). Exit/Sustainability Strategy On the basis of the above sales forecast, profit loss forecast and cash flow forecast, it can be suggested that Sisters Freedom Association would use the sustainable strategy rather than exit strategy from the market. First year profit and cash flow surplus situation indicates the Sisters Freedom Association should sustainable in the market and prepare the long-term sustain strategy of business (Hughes, 2004). Conclusion On the basis of the above discussion, it can be concluded that new social enterprise of Sisters Freedom Association would be appropriate decision of owner to create aware and protect the women and girls from the domestic violence. First year forecasting of the business indicates Sisters Freedom Association would be achieved profit and cash flow surplus in the first year, so it support that the new social enterprise set-up decision would be appropriate decision of owners. References Crowther, D. (n.d.). Managing Finance. UK: Routledge. Davis, S.S. Media, D. (2015).What Is a Charitable Organisation? Available:https://smallbusiness.chron.com/charitable-organization-796.html. Last accessed 23/02/2015. Hughes, V. (2004). Becoming a Director: Learn the Basics and Become an Effective and Successful Director. UK: How To Books Ltd. Rasmussen, N.H., Eichorn, C.J., Barak, C.S. Prince, T. (2003). Process Improvement for Effective Budgeting and Financial Reporting. USA: John Wiley Sons. Refuge. (2015).Get Help now.Available: https://www.refuge.org.uk/get-help-now/what-is-domestic-violence/domestic-violence-the-facts/ Last accessed 22/02/15. Refuge. (2015).Get Help now.Available: https://www.refuge.org.uk/get-help- now/what-is-domestic-violence/how-can-we-end-it/. Last accessed 22/02/15. Tracy, J.A. CPA (2008). Accounting For Dummies (4th ed.). USA: John Wiley Sons. UN WOMEN. (2014).Fast facts: statistics on violence against women and girls.Available: https://www.endvawnow.org/en/articles/299-fast-facts-statistics-on-violence-against-women-and-girls-.html.Last accessed 22/02/15. Waagen, A.K. (2000). How to Budget Training. USA: American Society for Training and Development. Weygandt, J.J., Kimmel, P.D. Kieso, D.K. (2009). Managerial Accounting: Tools for Business Decision Making (5th ed.). USA: John Wiley Sons.