Influenza Vaccination for Pregnant Health Care Workers

Influenza Vaccination for Pregnant Health Care Workers Jee Hae Kim Introduction A certain pregnant nurse was fired because of refusing to get a flu shot in Pennsylvania in December, 2013 (Murphy, 2013). Getting a flu shot is the one of the biggest issues for health care professionals who are especially pregnant health care workers. However, vaccination still remains the most effective way for preventing severe influenza illness. According Center for Disease Control and Prevention (CDC) and American College of Obstetricians and Gynecologists (ACOG), seasonal flu vaccination is recommended for all pregnant women (Goldfarb, Panda, Wylie Riley, 2011). But, why do they hesitate to get a flu shot? Current vaccination rate Flu vaccination rate for pregnant women is still low in the US. In 2005, the US achieved just 16% influenza vaccination coverage of pregnant women, and it is estimated that less than 10% of pregnant women who are at highest risk of influenza receive the vaccine (Broughton, Beigi, Switzer, Raker Anderson, 2009). Even with increased morbidity during pregnancy from seasonal influenza, only 11% of pregnant women were vaccinated during the 2008 through 2009 flu season (Dlugacz, Fleischer, Carney, Copperman, Ahmed, Ross Silverman, 2012). In addition, influenza vaccination rates have remained substantially below 50% for Health Care Personnel (HCP). Within the population of HCP, nurses have been shown to have lower influenza vaccination rates than physicians (Clark, Cowan Wortley, 2009). Although the rate is getting increase little by little, it is still low compared to physicians’ vaccination rate. Barriers for vaccination According to a certain survey, 58.3% of patients reported feeling scared about seasonal flu infection during their pregnancy (Goldfarb, et al., 2011). What are the main causes they are afraid of getting a flu shot? One of those reasons is that they have a fear uncertainly because they do not know specifically how safe flu vaccine is while they are pregnant. In addition, they do not know as well about how dangerous unvaccinated status is during pregnancy. Vaccinated nurses demonstrated greater knowledge about influenza and risk factors for influenza, while unvaccinated nurses believed they were not at risk (Clark, et al., 2009). These facts show that knowledge about safety of vaccine is one of the most important keys to decide whether they get a flu shot or not. Vaccine declination was associated with less knowledge about influenza, lower perceived susceptibility, and beliefs that the vaccine is not efficacious of safe (Eppes, Cameron, Gracia Grobman, 2013). Furthermore, health care workers in the obstetric field also have limited knowledge about the epidemiology of influenza infection and most of them do not consider influenza as a potentially serious disease (Broughton, et al., 2009). Political, social and economic backgrounds The states role is to reduce morbidity and mortality by nosocomial inflammation of influenza and maintenance of a reasonable health care workforce and to show that mandatory influenza vaccination is sensibly related to reducing the flu budget (Ottenberg, Poland, Jacobson, Koenig Tilburt, 2011). It can be one of the political reasons for getting a flu shot for health care workers and government forces them to vaccinate. In addition, we can concern about economic aspect. The commerce legislation can make the federal government regulate activity essentially that affects inter-state commerce, including parts of the health care industry which is related to the management infectious disease and prevention. With the public health service act, health and human services department in the US has organized the national vaccine plan, the national vaccine advisory committee, and the national vaccine injury compensation program (Ottenberg, et al., 2011). Through these mechanisms, the commerce legislation permitted the federal government to control, strengthen, or potentially obligate the vaccination of health care workers against influenza and ensure fair movement to arbitrate complaints related to vaccination (Ottenberg, et al., 2011). It shows that mandatory vaccination can lead saving budget for government because they do not have to pay for the treatment of the secondary infection for people due to influenza . Ethical concerns There are also possible ethical arguments underlying mandatory vaccination. Hospitals are enforcing health care workers to vaccinate for two primary reasons. The one is for supporting of the professional duty of health care workers to benefit for patients individually and to ‘Do No Harm’ and another is for meeting the shared obligations of hospitals and health care workers to protect the public health with infectious disease which is preventable (Ottenberg, et al., 2011). In these situations, we can think about the important questions such as â€Å"What are the obligations of health care workers to their patients?† or â€Å"Is it proper for patients to expect health care workers to get a flu shot because of influenza?† Possible solutions I suggest some solutions to promote vaccination for pregnant health care workers. First of all, the convenience of influenza vaccination is strongly needed such as using mobile vaccination carts. Instead of fixed date or time for vaccination, health care workers can have it depending on their schedules. Secondly, provision of free vaccination and peer vaccination is another good method for promoting vaccination. For example, some pregnant nurses who are already vaccinated could be a good model for other pregnant nurses who are not vaccinated yet. Thirdly, incentive programs also can be a great way for health care workers. If they can get extra pay, the rate of vaccination can be raised. Lastly, education about safety of vaccination for pregnant health care workers is the most effective method. Indeed, I had concerned about wearing a mask while they are working without vaccination, but this could be not a perfect prevention of pandemic influenza. Instead of this, it would be better to persuade them who refuse vaccination and to emphasize again about the safety of vaccination during pregnancy. Safety of vaccination during pregnancy There are already several studies to prove safety of vaccination during pregnancy. According to CDC, studies of a lot of pregnant women in scientific view have checked the safety of vaccination during pregnancy. These studies did not show any evidence of danger to pregnant women, even to the unborn fetus and to newborns of vaccinated women (CDC, 2013). In addition, the Food and Drug Administration’s (FDA) and CDC’s periodic monitoring of side effects’ occurrence has not raised safety concerns (CDC, 2013). Rumors and fears should not be an obstacle to promoting patient safety and public health. The implementation of mandatory vaccination should solve the ambiguous concerns and misconceptions of vaccine safety as well. Rates of serious side effects’ occurrence following vaccination, such as Guillain-Barrà © syndrome, are vanishingly low as no higher than 1 in 1,000,000 (CDC, 2013). Conclusion Among several solutions as I mentioned above, I guess the best way to promote the flu-vaccination rate for pregnant health care providers is education. An effective educational strategy should focus on known misconceptions and knowledge gaps. Furthermore, the influence of health care workers on patient vaccination coverage should not be underestimated. It has been shown that health care workers’ recommendations have positive effects on the likelihood of patients to be vaccinated (Broughton, et al., 2009). According to an article, women whose maternity care provider has recommended the vaccine are much more likely to receive it than those whose providers did not (Broughton, et al., 2009). It shows that how critical education affect not only pregnant health care workers, but also pregnant patients. I insist that health care workers should be vaccinated because reducing the transmission of preventable diseases cannot prevent any harm in the clinical care area. Health care worker vaccination of influenza is consistent with a collective professional accountability to treat all patients moderately and to use appropriate precautions against preventable harms. With mandatory health care worker vaccination, health care organizations should make sure that vaccination is an informed procedure. Health care workers should also get the information clearly about benefits and risks related to influenza vaccination and that vaccines are offered handily. Reference Broughton, D. E., Beigi, R. H., Switzer, G. E., Raker, C. A., Anderson, B. L. (2009). Obstetric health care workers’ attitudes and beliefs regarding influenza vaccination in pregnancy. Obstetrics Gynecology, 114(5), 981-987. Center for Disease Control (2013, September 3). Seasonal Flu Vaccine Safety and Pregnant Women. Retrieved March 17, 2014 from: http://www.cdc.gov/flu/protect/vaccine/qa_vacpregnant.htm Clark, S. J., Cowan, A. E., Wortley, P. M. (2009). Influenza vaccination attitudes and practices among US registered nurses. American Journal of Infection Control, 37(7), 551-556. Danzon, P. M., Pereira, N. S., Tejwani, S. S. (2005). Vaccine supply: a cross-national perspective. Health Affairs, 24(3), 706-717. Dlugacz, Y., Fleischer, A., Carney, M. T., Copperman, N., Ahmed, I., Ross, Z., Silverman, R. A. (2012). 2009 H1N1 vaccination by pregnant women during the 2009-10 H1N1 influenza pandemic. American journal of obstetrics and gynecology, 206(4), 339-e1. Eppes, C., Wu, A., You, W., Cameron, K. A., Garcia, P., Grobman, W. (2013). Barriers to influenza vaccination among pregnant women. Vaccine, 31(27), 2874-2878. Goldfarb, I., Panda, B., Wylie, B., Riley, L. (2011). Uptake of influenza vaccine in pregnant women during the 2009 H1N1 influenza pandemic. American journal of obstetrics and gynecology, 204(6), S112-S115. Murphy Carrie (2013, Dec 23). Pregnant Nurse Wrongfully Fired For Refusing Flu Shot Because Of Miscarriage Concerns. Mommish.com. Retrieved March 21, 2014, from http://www.mommyish.com/2013/12/23/pregnant-nurse-wrongfully-fired-refusing-flu-shot. Ottenberg, A. L., Wu, J. T., Poland, G. A., Jacobson, R. M., Koenig, B. A., Tilburt, J. C. (2011). Vaccinating health care workers against influenza: the ethical and legal rationale for a mandate.American journal of public health,101(2), 212.

Customer Relationship Management Business Dilemma Marketing Essay

Customer Relationship Management Business Dilemma Marketing Essay The most influential person in cafà © or in any business are the customers, since without customers, one does not have a business. Everything in a business environment revolves round customers. Similarly, in case of our cafà ©, customers are a key to a successful business at the end of the day. Knowing your customers and providing satisfaction to those customers would gain customer loyalty. Grandfather gave priority to customers thats why he knew all his customers. However, just knowing your customers is not enough; one needs to keep a record of its customers so that its easy to analyze. Since customers are really influential towards a business, business (in our case, cafe) should treat each and every customer as if they were the only customer. While serving each customer, one must keep in mind the needs of that particular customer only and should serve in such a way that the service exceeds their expectation. Giving most priority towards customers would enhance customer loyalty an d keep that customer attached to a particular business. Through customers, a business can improve its business as said by Bill Gates Your most unhappy customers are your greatest source of learning. Customer complains in fact is a key to improve the service, for instance, if a customer complains that the way coffee served was not pleasant and did not met the expectation, that complain can be used as a tool to improve the coffee serving process through further training workshops for employees in that area. Thus, customers complain can be seen as a challenge to be met in future to make him/her (customer) happy and attracted to the cafe. If you treat your customers well, your customers will go out of their way to return to you. Therefore, customer feedback and suggestion can help improve a service. However, the cafà © may not have answers or response for all of customer questions and suggestions. Customers could help or hurt the cafe through viral marketing. Word of mouth marketing is the largest determining factor for a service business image, which can be either online chatting or physical talk. If the service in cafà © is up to the expectation of the customer, it would help the cafà © to attract more customers through viral marketing and gain market share. However, if the products and service in cafà © is very poor which made the customer unhappy can spread negative impression on other customers, hurting the company through losing its current and potential customers. Moreover, online comment or complain on the cafes website can be injurious such as comment on You Tube. Literally, the customer does not intend to harm or hurt the company; they just want their needs to be fulfilled and service is up to their expectation. As already mentioned customer complains can provide an opportunity, thereby, helping the cafà © to improve its service. My employees will agree that customers are the most important part of cafe since thats the reason they are in cafe. If there wouldnt be any customer, there wouldnt be need for employees. Thus, customers determine or secure the period of employment of the employee. If there are fewer customers, employees may be laid off to cut down costs. However, some employees may feel that they are the most important part in a business. Employees are the most important asset of any business. If cafà © doesnt value its staff, it would demoralize them which can impact their performance in service. And as a result, their poor performance can hinder customer growth of cafà ©. Thus, some employees value themselves as the most valuable person in a business when compared to customers. MAKING BUSINESS DECISION I Virtual world is a 3D, electronically-generated environment where users can interact, create and communicate just as they would in the real world for example, second life (http://ictwm.org/news/virtual-worlds-help-real-businesses). Virtual world provides people with experiences rather than processing transaction. Once people get attached to virtual experience, they would be excited about experiencing it in real life. This would only be possible through going to the real cafà © which would help the business in transaction processing. It also aids in mass customization as customers design or suggest what they exactly want. Virtual world encourage interaction, collaboration and communication. It can be accessed from anywhere in the world, thus, keeping people and cafà © connected. If cafà © provides continuous updates in virtual world, people nearby the cafà © would go for new and innovative products in that cafà © just because of that cafes presence in virtual world which would enhance the business/cafà © operations. It could also be a marketing tool for the cafe to promote its menus for the day through frequently changing attractive ads in the virtual world. Customer relationship in virtual world is very delicate matters since one does not physically meet to create impression. Virtual world should be designed in such a way that it is appealing and attractive to a customer. In virtual world, cafe business would be better able to meet customer satisfaction with minimum or no cost by changing designs to strengthen virtual customer relationship. Customer wont need to wait in long lines to be served, one can just go to the cafes website and get the taste of coffee or of service in that cafà ©. Virtual world does not restrict the access to any person; any person can access to the website to have a taste. In other words, there is a greater reach and contact to maintain strong customer relationship. Cafà © can be always available to its customer through virtual world without any disruption. Customers would be in a position to demand what they want based on their own specification. This makes the customer feel like king through providing their customized products and enhancing better customer relationship. In traditional customer relationship management strategies, there has been lack of customer experience, co-creation, co-production and collaboration with customers. Thus, our strategy to manage customer in new virtual world is through co-creation and co-production with customers. Co-creation and co-production with customers is different than traditional customer-centric approaches in that the focus is not to learn as much as possible about customers but instead consider them as equal problem solvers (http://findarticles.com/p/articles/mi_hb5858/is_200711/ai_n32252899/pg_2/). Giving customers an important role in the value chain can affect customer satisfaction. Value in co-creation derived by customers purposeful interaction cannot be obtained merely from asking the customers to answer questions and leave comments. Virtual worlds may provide an experience space that supports experience networks which go beyond the domain of a single company and its suppliers to one that is experience -centric to the customers. (http://findarticles.com/p/articles/mi_hb5858/is_200711/ai_n32252899/pg_3) Moreover, since there is a growing use of internet, it would be easier for company to collaborate with its customers through electronic CRM. Electronic CRM has a wider scope for managing customer relationship in a variety of ways and not just collaboration ranging from designing and pricing of digital products to loyalty programs. Supporting Second Life customers differs from supporting website customers as well as traditional customers. In second life, cafà © can design and create those products and services that a particular customer wants. It allows basically for customization as well as reaching out to customers for ideas, prototyping and feedback in a particular area giving cafà © a better competitive advantage. This means that customer support in second life would need to be met in real time especially to a customers demand. Second life is basically everything being electronic whereas traditional revolves around physical presence. Moreover, collaboration between customers and company is a major support in second life unlike traditional customers. Website supports customers with visitor information and product review. It does not allow a customer to get the feeling of being in cafà ©. However, second life gives a customer a virtual feel of being part of that cafà © in addition to visitor information. To make the experience of a virtual world customer great, second life location should offer free virtual coff ee, music, and chairs with tables for customers to hang out. In the traditional (physical) environment, the cafà © needed to be closed off at a particular time, even though customers were involved in deep discussion. This does not happen in second life. Second life supports customers to continue with whatever they are doing in the virtual cafà © without any time limit and can chat as late as they want. Furthermore, upcoming events, artwork and music should be available to customers visiting second life so that it becomes interesting and encourages them to explore the site. Another difference between traditional and second life customer support is in terms of advertising. In past, business would use advertising agency to promote their products but now the cafà © can do in house advertising in virtual world attracting wider range of customers all round the world. Second life does not provide authentication of a persons identity. There is no access control and anyone can easily get into the second life and if there is any confidential information for customers only, that can be easily leaked and used to the disadvantage of the business, that is, the cafà ©. Moreover, phishing can easily take place whereby an intruder who is against the cafà © business can create a website similar to the cafà © site and trick the customers into inputting confidential data. This confidential information can be used as a tool to harm the image of the cafà © through missing the customers information which would tremendously impact on the cafà © business. Similarly, misrepresentation can be another issue just like phishing, whereby someone designs an avatar that looks just like the avatar of a customer service representative. Other issue involves the obsolesce of real life location. Since people get attached to second life, they dont go or visit the real life cafà ©. Second life cafà © can be visited by anyone but real world cafà © may not be. People in a region would only be visiting the cafà © and if those limited people get attached to second life cafà ©, there wont be much importance of real life cafà ©. Thus, issue arises that second life should be positioned and designed in such a way that real life cafà © does not get obsolete and people remain attracted to it as well to have real currency flow in business. Due to lack of authentication, privacy concerns arise. Maintaining customer confidentiality becomes an ethical issue and a challenge for businesses. MAKING BUSINESS DECISION II You Tube can be an important vehicle to communicate with the cafes customers. It is a popular free video sharing website where people can also comment on a particular video. We would design and create video clips of the cafes products and the way service is provided in cafà © and then share it on You Tube, using cartoon characters and other imaginary characters making the clip funny, interesting and informative. Through these clips, we can conveniently show our customers how we have minimized the problem of long wait lines. Firstly, we would make clips showing more counters for serving as well as drive in windows. Long wait lines are basically because of few or only one counter, thus showing a clip with more counters can be seen as a reasonable rectification to the problem. Moreover, for travelers who want to be served instantly while in their vehicle, drive in windows would be a solution to avoid waiting in lines when in rush as in case of McDonalds in Fiji. Clip can show a custome r ordering and being served in just few seconds through drive in windows. Furthermore, online ordering and tele-ordering can also be a rectification to long waiting lines. Through virtual world or cafes website, customers can order online as well as through phone calls before actually going to cafà © so that on their arrival, their order is prepared and no waiting is required. These solutions can be depicted on You Tube through videos using animated characters. You Tube as a communication vehicle, is free and easy to use. Unlike advertising over television, which is associated with costs, You Tube provides this for free whereby anyone can watch the videos and pass comments about how they feel about that particular video. As already said, it saves money on marketing since advertising can be done through clips to promote the cafà ©. You Tube has a wider reach in terms of customers and markets. It is not restricted to a particular geographical region or location. Customers all around the world and in different market can get access to You Tube and learn about the cafà ©. Also through You Tube, cafà © can get a great deal of information to many people in a short amount of time just through one clip. These benefits show that You Tube can be an efficient communication vehicle for any business whether it be cafà © or a car dealer. However, there are various disadvantages for You Tube as well. Since it can be viewed by anyone in the world, it may capture unwanted attention, for instance, is a person does not love coffee, he/she may not like the clip based on coffee and would comment negatively which would create bad impression to other customers. You Tube also in some cases compresses the content of clips and other files, making it unappealing to customers as its not presented in the right way intended and information can be chopped in that compression. Products may not be clear to customers, thus, proper communication of that product such as coffee maybe hindered. Also due to missing information or half information, it could become difficult to understand what the file tries to reveal to customers. Issues of privacy concern and copyright infringement can be cons of You Tube. Privacy can be made vulnerable as amount of information on video can be dangerous such as unintentionally showing where an employee lives or showing someones bio-data while promoting the product or service. Therefore, before starting to use You Tube as a medium of communication vehicle, one must clearly study the pros and cons of it to see whether benefits are there or not. Other new technologies that can be used as a customer communication vehicle that would be more effective than You Tube are social networking sites such as twitter and facebook. It allows more than just posting video. One can post comments, pictures, update information and create events on it. Twitter and facebook help bringing customers together. With help of twitter, cafe can send an alert about new deals or offers in the cafà ©. Blogging can also be a publishing medium. If a customer complements the cafes service or the products and food in cafà © in his blog, it would be a free advertising for the cafà ©. But can also harm the image if blogger comments in a negative way. APPLY YOUR KNOWLEDGE To obtain high quality data, systems in the cafà © must be integrated, since quality information does make a difference in any business. Major importance of quality information is that it induces enhanced, accurate and appropriate decision making. The quality of information used to make business decision determines the quality of decision made. Having real time system in cafà © would provide real time information in response to decision makers queries and requests. High quality decisions can significantly impact the cafes bottom line, thus, profitability. For instance, having integrated and real time system, cafà © can provide what customer wants in an instance which would meet customer satisfaction, thus, improve profitability. Moreover, high quality information enables any business to track valuable customers who generate most revenues. Having proper information about a particular customer visiting cafà © frequently can help cafà © identify the loyal customer and could reward him or her so that they keep coming in future. Uses can place confidence on information of high quality since it is reliable. For instance, if cafà © post on its website information generated from its systems, customers could be easily in a position to rely on it. On the other hand, low quality information results in various business effects. Low quality information are those which has missing information example no first name of customer, incomplete information example no street or missing area code, probable duplicate information such as similar name, same address or phone number and potentially wrong information. The effects of this on cafes business would be its inability to accurately track customers, difficulty identifying valuable customers, inability to identify selling opportunities of cafes product, marketing to non-existent customers, difficulty tracking revenue and inability to build strong customer relationship (net: slides). Low quality information would hinder cafà © to follow up with its profitable customers who frequently such as daily visit cafà © since there may be name confusion. Also if systems are not integrated, it becomes difficult to provide accurately what customer wants and may lead to providing wrong products. Thi s will affect the demand and supply of a particular product which would not be reliable. Also cafà © may be marketing and promoting its cafà © and product to a non-existent customer online due to fake or same names who are not cafes usual customers. Overall, low quality information vigorously degrades the decision making quality in managing a customer and the cafà ©. The examples of information that can be used by The Broadway Cafà © to gain better understanding of its customers are customers taste and preferences. If the cafà © gets a picture of what their current and potential customers would like to consume, cafà © can be prepared for the product and provide the customer that product when they actually came and demand. Moreover, having a brief idea about the customers disposable income would help understand the affordability of prices by customers. This would give the cafà © a view as to what prices customers would be willing to pay for the cafes products such as coffee. Changes in environment and weather would also help in getting to know the customers and their wants, for instance, coffee would be largely demanded during colder seasons in Fiji. Some of the data quality issues are as follows. Firstly, dirty data issues due to data errors which can be attributed to human errors or an application error due to legacy systems. Since theres a large quantity of data to be fed in the system, humans are prone to make errors. Missing and duplicate data are other two issues (Turban, E., and Volonino, L., 2009). The cafà © lacks in proper management of its data which can lead the data to be easily lost as well as to be entered twice. This could really affect the output results thus affecting decision making. Moreover, data can be non-standardized and massed up due to lack of standards. The strategies the company can use to avoid such data quality issues are to implement Master Data Management system. It is comprises a set of processes and tools that consistently defines and manages the non-transactional data entities of an organization. MDM has the objective of providing processes for collecting, aggregating, matching, consolidating, quality-assuring, persisting and distributing such data throughout an organization to ensure consistency and control in the ongoing maintenance and application use of this information. (http://en.wikipedia.org/wiki/Master_data_management) MDM would reduce or eliminate the data quality issues, giving a unified view of enterprise data. It can also use automated data entry, Web forms for individual entering data with data integrity checks and drop down menus and radio buttons. (Turban, E., and Volonino, L., 2009) having frequent data audits in the system can also aid in preventing the above mentioned issues since data would be continuously reviewed and any errors would be detected and corrected appropriately without further problems in future. CAFES BEST CUSTOMERS** Customer ID Total Sales Amount ($) 3548 18,261.86 4438 26,474.28 5657 11,342.98 6891 10,585.94 13801 33,555.50 13959 19,593.65 270177 14,355.99 294896 11,348.40 305668 49,647.45 540135 16,338.02 1309948 11,401.60 ** We have assumed that the cafes best customers are the ones that bring in sales amount dollars of more than $10000. Listed above are the cafes best customers. The cafà © should offer to its valuable customers loyalty marketing programs such as point programs whereby a customer would get points for every purchase they make and when they reach a certain level and collected enough points, will get a special reward such as Jacks of Fiji which is using this marketing system to keep their loyal customers attached. Moreover, the cafà © can give its valuable customers loyalty cards as MH in Fiji is dong with its flash and gain card. Providing customers with promotional vouchers would also give them a feeling of appreciation for their service. Keeping in touch strategy can also be a way of marketing campaign towards valuable customers. Giving personal attention towards the profitable customers is a way to build relationship and keep them in your business. This can be done by sending them promotional messages personally through email or calls frequently and asking for their feedbacks as to what they would like in future and their expectation from cafà ©. Broadway Cafe Question Name Total What is the best selling product? Music CD $776,813.17 What is the worst selling product? Kids CD $96 What is the best sales month? 3 $569,339.10 What is the worst sales month? 5 $58,501.06 What is the best selling product during the best month? Music CD $235,054.45 What is the worst selling product during the best month? Kids CD $64 What is the best selling product during the worst month? Music CD $33,684.43 What is the worst selling product during the worst month? Food $63.2 * For answering the above questions, we have taken our base as sales amount values to reach an answer. SUPPLY CHAIN MANAGEMENT BUSINESS DILEMMA Broadway Cafà © can reinvent the cafà © by making use of demand planning software. This software would enable the cafà © to be prepared in peak hours of business since it would capture and give information as and when a customer enters either the cafà © or the car park of the cafà ©. For instance, as part of software set, a camera can be attached at the roof of the cafà © to capture information on people entering the car park and determine what they would normally order at that particular time of the day. Also, it would allow the cafà © to keep track of its regular customers and their demands, thus, have the items available for them without having them wait in lines. This can be done before a customer enters the cafà ©. The software would also enable in ensuring whether the cafà © has enough of the products that that would be demanded by the customer such as a particular type of coffee. Although the implementation of such a software would be costly at its initial stage, it w ould be beneficial for cafà © in future as it is located in Suva, to obtain customer satisfaction and where people are always in rush. Thus, demand planning software would be a great benefit for the cafà ©. Like Netflix, we would not see cafà © becoming a supplier in another business supply such as hotel industry since our cafà © itself is very small at this stage. First, it needs to widen its customer base with the help of demand planning software and online ordering system (electronic ordering). Since our cafà © has a website, we could include in that a feature where customers order online, paying through credit cards or paying subscription fee for being in that account. The cafà © can based on customers order deliver the items to the customer within the Suva area if large quantities are ordered such as Pizza King which delivers pizza to people living in urban and suburban areas. Moreover, a customer would also order online so that before their arrival in cafà ©, the items are prepared for them before hand such as coffee. Thus, innovating ordering system would also attract more customers in the cafà ©. With the help of these supply chain technologies, the cafà © can expand its customer base and from there on can think bigger and better options such as becoming supplier of coffee/coffee beans to hotels or other businesses such as MacDonald. MAKING BUSINESS DECISION I The success of any business depends on its ability of short and long term planning. As a concerned business operator, I would always maintain some inventory in my warehouse for such unexpected events especially coffee beans which are in demand. Since not being able to meet customer demand would lead to losing out customers. Thus, our cafà © would keep with its operation regardless of disruption in supply chain du to dockworkers strike and would run on warehouse inventory (Brazil Beans, China Tea and custom Coffee press machines). Moreover, based on available inventory analysis in the warehouse, we would determine how long supply would last. Is our warehouse inventory wouldnt be able to meet up with the disruption period, we would resort to redundant suppliers since all suppliers wont be affected at once with the same problem. We would consider our temporary local suppliers such as Nestle to supply us with similar products as long as we are able to operate efficiently, although the cost in emergency need may be higher than usual price paid to our fixed suppliers. Since the cafà © has been going towards demand-driven manufacturing, Radio Frequency Identification Technologies (RFIT) would be the newest and most efficient solution to supply chain problems. RFIT is the most valuable technology to track inventory. If inventory level in any case would be low, it would trigger automatic alert to our suppliers. It is an important device in global transportation both land and sea. It ensures that inventory level are checked and replenished on need by need basis. Although this strategy would be bit costly for the cafà © in the initial stage at present, it would provide benefits in the future. Another strategy I would recommend is to create a position as freight specialist whose job would be to enable transportation of products in whatever the situation maybe and at any cost. The freight specialist would guarantee that products would reach the cafà © on time to meet customer demand and if not than they would be responsible for the loss. MAKING BUSINESS DECISION II Broadway cafà © No move Broadway Cafà © Units sold per month: 20,000 Unit variable costs: $0.50 Average unit sales price: $2.20 Current fixed costs: $5,000 Added lease payment, new offices: $2,500 Projected fixed costs: $7,500 Sales month Units Sales Fixed Costs Variable Costs EBIT January 6,582 $14,480 $5,000 $3,291 $6,189 February 11,121 $24,466 $5,000 $5,561 $13,906 March 14,178 $31,192 $5,000 $7,089 $19,103 April 13,692 $30,122 $5,000 $6,846 $18,276 May 11,597 $25,513 $5,000 $5,799 $14,715 June 9,599 $21,118 $5,000 $4,800 $11,318 July 9,913 $21,809 $5,000 $4,957 $11,852 August 10,926 $24,037 $5,000 $5,463 $13,574 September 14,349 $31,568 $5,000 $7,175 $19,393 October 12,965 $28,523 $5,000 $6,483 $17,041 November 6,972 $15,338 $5,000 $3,486 $6,852 December 2,455 $5,401 $5,000 $1,228 ($827) Sum $151,393 Broadway cafà © Move Broadway Cafà © Units sold per month: 20,000 Unit variable costs: $0.30 Average unit sales price: $2.20 Projected fixed costs: $7,500 Sales month Units Sales Fixed Costs Variable Costs EBIT January 6,582 $14,480 $7,500 $1,975 $5,006 February 11,121 $24,466 $7,500 $3,336 $13,630 March 14,178 $31,192 $7,500 $4,253 $19,438 April 13,692 $30,122 $7,500 $4,108 $18,515 May 11,597 $25,513 $7,500 $3,479 $14,534 June 9,599 $21,118 $7,500 $2,880 $10,738 July 9,913 $21,809 $7,500 $2,974 $11,335 August 10,926 $24,037 $7,500 $3,278 $13,259 September 14,349 $31,568 $7,500 $4,305 $19,763 October 12,965 $28,523 $7,500 $3,890 $17,134 November 6,972 $15,338 $7,500 $2,092 $5,747 December 2,455 $5,401 $7,500 $737 ($2,836) Sum: $146,263 APPLY YOUR KNOWLEDGE Broadway Cafà © Shipping Analysis Number to ship from DC to Roasting Plants: DCs Total Salt Lake Chicago Albeq <

Income Distribution and Economic Growth in LDCs Essay -- essays paper

Income Distribution and Economic Growth in LDC's INTRODUCTION In recent years, one of the major concerns of economic development is the study of poverty, the income distribution and growth in the less developed countries (LDC’s) or Third World countries. Economists from all over the world have been doing researches and studies on how to induce a growth in those underdeveloped countries. However, countries differentiate in historical backgrounds, cultural believes and natural resources. As a result, the government would implement different strategies to attain a much fairer distribution of income among the society. The relationship between the income distribution and growth in the LDC’s is a significant factor that would affect government policies. Also, the study of the strategies, promoted from the government, would show us how the government can enable economic growth with a more equal income distribution. INCOME DISTRIBUTION AND ECONOMIC GROWTH For years, most of the more developed countries have been helping the less developed countries. Most of them believed that the only solution to the problem of poverty is to make the GDP grow. However, some other questions may arise as to who would make it grow, and should they be the few or the many. If it is the many who need to make it grow, then the GDP may be shared more equally. On the other hand, in order to make the GDP rise, we need to make decisions in production. The Production Possibility curve can show us the maximum amounts an economy can produce, but it doesn’t tell us which decision would be made. A country makes the decision on what to produce is accordance to the income distribution. The most ideal case is to have perfect income equality (Gini Coefficient equal to 0) in one society. However, studies tell us that this can never be reached. In most of the more developed countries, a Gini Coefficient (G.C.) of 0.2 to 0.35 is considered to be in relative equa lity. One may wonder what is the G.C. in the less developed countries? The answer is assumed to be a number in the higher rank. In fact, in most LCD’s, the G.C. is about 0.5 to 0.7 or even higher. This shows us that the problem of income inequality is very seriously in those countries. â€Å"We were taught to take care of our GNP as this will take care of poverty. Let us reverse this and take care of poverty as this will take care of po... ...ad to many positive notes such as increase in productions, employments, and indirectly increase the local investments. Increase in productions, employments and capitals in the country thus enable a growth in the economy and therefore, the government should make careful decisions keeping in mind that of the impact these factors have on the societies. Bibliography: Judith Randel and Tony German., The Reality of Aid 1998/1999, UK:Earthscan Publications Ltd., 1998 Adelman and Morris: Economic Growth & Social Equity in Developing Countries, California: Stanford University Press.,1973 David Dembo, Clarence Dias, Ward Morehouse, James Paul: The International context of Rural Poverty in the Third World, Newyouk: Council on International and Public Affairs, Inc., 1986 Jacques Lecaillon, Felix Paukert, Christian Morrisson, Dimitri Germidis. Income Distribution and economic development,French:International Labour Organisation., 1984 Gary S. Fields. Poverty, Inequality, and Development, New York: Cambridge University Press.,1980 Michael P. Todaro. Economic Development, New York: Longman.,1994 Simon Kuznets. Population Capital & Growth, New York: W.W. Norton & Company. Inc.,1973

The Articles of Confederation Essay -- articles of confederation, cent

A few hundred years ago, the United States first Constitution, the Articles of Confederation, was created. This Constitution created a weak central government in order to give the people the rights that they deserve. This plan of government, however, proved to be too weak and it could not control the people or pay the debts that the country had acquired from the Revolutionary War. One of the many problems of the Articles of Confederation was that it had no power to collect taxes(wikipedia.org). This made the new nation go in huge debt because it had no way of paying the army for their services in the Revolutionary War. The United States did receive some money from neighboring countries in order to pay of the debt and they had also gotten a few pence from the states, but this was insufficient and they still could not pay their debt. Another problem of the Articles of Confederation was that it could not enforce its laws and make the states pay the money that they promised the government. One of the many effects that this problem made was Shays' Rebellion. This rebellion was caused by the taxes that the government made. It stated that everybody must pay for the taxes or they would have their land taken away from them and be sent to jail. This angered the farmers since they could not pay the taxes, and so, this rebellion was formed. In order to prevent any further outbreaks from occurring, our Founding Fathers got together to form a convention, which was called the Constitutional Convention. This convention was to be held to fix the government and stop other occurrences, such as Shays' Rebellion, from ever happening again. When the Founding Fathers went to Philladelphia, they quickly decided that their gov... ...ticles of Confederation was the first constitution of the United States. A few years later, the Founding Fathers found out that the Articles weren't working as they had in mind and they then went to Philladelphia to revise it. When they go there, there were many disagreements about slavery and representation. To stop these arguments, the Connecticut and the Three-fifths Compromise was made. Then, all but Virginia and Washington agreed to ratify the Constitution because it had no Bill of Rights. To fix this problem, James Madison then promised to create a Bill of Rights to protect the people and ensure that there new government would never again turn into one like Great Britain's. Works Cited The Articles of Confederation, https://en.wikipedia.org/wiki/Articles_of_Confederation The U.S. Constitution, https://en.wikipedia.org/wiki/United_States_Constitution

Sigmund Freuds Ego Defense Mechanisms Essay -- denial displacement pr

Sigmund Freud is perhaps one of the most well-known theorists in regards to the study of the human psyche. Freud’s model of the human psyche is comprised of three core elements: the Id, or the unconscious mind; things out of our awareness. The Superego, or the subconscious mind, and finally the Ego, which lies between the unconscious and subconscious. Freud proposes that there are nine ego defense mechanisms that act the ego uses in its job as the mediator between the id and the superego. In psychoanalysis, an ego defense mechanism is an unconscious personality reaction that the ego uses to protect our conscious mind from threatening feelings or perceptions. The ego defense mechanisms are as follows: denial, displacement, projection, rationalization, reaction formation, regression, repression, sublimation, and suppression. Ego defense seems to occur subconsciously – we are often not aware that we are becoming â€Å"defensive†. I believe that we use a complex of many, if not all of Freud’s ego defense mechanisms.   Ã‚  Ã‚  Ã‚  Ã‚  Personally, I believe regression and rationalization may be the two defense mechanisms I use most. Regression is defined as â€Å"returning to a previous stage of development†. For example, if things do not go my way and continue to do so, it might be followed by bouts of temper tantrums and mood swings.   Ã‚  Ã‚  Ã‚  Ã‚  Rationalization is supplying a rational or logical reason as opposed to the real reason. I have found that I use this â€Å"tactic† a lot, and was not aware of i...

Inta Omri by Oum Kalsoum Essay

Enta Omri is Egyptian singer and songwriter Oum Kalsoum’s best known work. The song Enta Omri has been revived and reinterpreted many times over the past few decades. Even then, no one can compare to the original recordings of Oum Kalsoum, who was the best singer to come from the Middle East. Many contemporary Western artists and musicians have been significantly influenced by her work. Famous artist known to be admirers of her body of work range from such stars as painter Salvador Dali to rock star Bono. Today, her popularity has not faded and the recordings of her songs continue to sell very well in the Middle East, with about one million records sold each year. The song Enta Omri has significantly influenced Oum Kalsoum as an artist. The lyrics of her subsequent songs followed the theme of Enta Omri, centered on the topics of love, longing for someone, or the loss of a loved one, much like the topics prevalent on country music today. Her musical performances are also very long by today’s standards. While the official recording of the song Enta Omri is about an hour, her live performances could last for several hours. The people listening to her songs are mesmerized by Oum Kalsoum’s vocal range, who had one of the deepest singing voice for females. References: 1. Shira. Inte Omri: You Are My Life. Retreived on November 28, 2008. 2. You Tube. Omm Kalthoum-Inta Omri.Retreived on November 28, 2008. 3. Imeem. Inta Omri by Yahel. Retreived on November 28, 2008. 4. Egypt State Information Service. Umm Kolthoum. Retreived on November 28, 2008. 5. Al-Ahram Weekly. The Voice of Authority. Retreived on November 28, 2008. 6. Al-Ahram. Umm Kuthoum Superstar. Retreived on November 28, 2008. 7. OumKalthoum. org. Oum Kalthoum. Retreived on November 28, 2008. 8. Al-Masriq. Umm Kulthum. Retreived on November 28, 2008.

An Analysis of the Urban Issue of Tuberculosisin the Bourough of Newham

1.Introduction Tuberculosis is a very serious infectious disease that primarily affects the lungs, causing cough and breathing difficulties. The infection also causes systemic effects including fever, night sweats and weight loss (Ellner, 2011). In some cases, the infection can spread beyond the lungs and affect the bone/joints, lymph nodes, abdomen and blood stream (Ormerod, 2003). The disease is caused by the bacteria mycobacterium tuberculosis (WHO, 2014), which is spread through respiratory droplets. These droplets are passed when an infected individual coughs or sneezes and the droplets become inhaled by another person (NHS, 2014). Despite this easy method of transmission, tuberculosis is not readily transmitted, and therefore is most likely to affect those in close contact such as family or household members (Castillo-Chavez & Feng). Tuberculosis represents a significant risk of morbidity and mortality and represents a significant cost to society to treat and manage. Tuberculosis has particul arly shown to be a problem in cities, whereby the rates of increase are greater than those of rural areas (Anderson et al. 2006). This essay will address the reasons as to why tuberculosis affects urban areas (the sick city hypothesis), and look in to why tuberculosis contributes to this urban health penalty. As an exemplar of an urban environment suffering from the burden of tuberculosis, this essay will focus on the London borough of Newham. Newham has a tuberculosis rate 8 times higher than the national average and 3 times that of London. This essay aims to investigate the aetiology behind the incidence, and to find ways of reducing the rates of tuberculosis among individuals in the London borough of Newham. The paper will include the intervention strategies and how they should be implemented in order to reduce the rates of new infections and encourage men to get tested and get early treatment before the spread of infection. 2.Tuberculosis in an Urban Environment Tuberculosis tends to be regarded as a problem of the past, and was responsible for 20-30% of all mortality in 17th-19th century Europe (Dye & Williams, 2010). The incidence of tuberculosis declined throughout the 20th century (Watson & Maguire, 1997), however, the disease has been slowly returning to London since the 1980’s (Great Britain 2008, p. 19). The problem seems to be worsening in urban areas. This is illustrated by the example of London, where 3,302 new cases of tuberculosis (TB) were reported in 2010 (Fullman & Strachan 2013, p. 25), a figure that has more than doubled since 1992 (Anderson et al 2006). In 2006, the incidence of tuberculosis in London was 41.5 people in 100,000, a figure that represented the highest number of new cases in any major city in Western Europe (Anderson et al, 2006). Dyer (2010, p. 34) claims that the London borough of Newham is the most affected with some people already referring to it as the TB capital of the affluent western world. In f act, the rates of tuberculosis in Newham are currently higher than that in some impoverished countries. Vassall (2009, p. 48) suggest that Newham has 108 cases per 100,000 and Anderson et al suggest a 2001 figure of 116/100,000, figures that are more than half that in India (174 cases per 100,000) (Public Health England, 2012). Newham has a population of 308,000 with a population density of 85.1 per hectare as compared to 31 in central London (UK Census, 2012). These figures suggest that even in the populated city of London, Newham is an area of urbanisation, with a large number of people concentrated into a relatively small area. The increase of tuberculosis has been described as a ‘penalty for high density urban living’ (Dye 2010, p.859), likely due to the increased potential for transmission in overcrowding, and the increased rates of immigration to inner-city areas. Bhunu and Mushavabasa (2012) propose that tuberculosis thrives in conditions of overcrowding and poverty, issues that are common in urban areas. The high rates of tuberculosis in cities such as London, and areas of urbanization such as Newham, suggest that the incidence of tuberculosis is indeed an urban issue. Newham fulfills the criteria of high immigration rates and being an area of deprivation.. Newham has a diverse ethnic population, with 61% of the people being non-white (Farrar & Manson 2013, p. 54). The population of ethnic minorities continues to grow along with the increasing numbers of refugees and asylum seekers in greater London. Another aspect of urbanisation illustrated in the borough of Newham is that of deprivation and overcrowding. Farrar & Manson (2013, p. 16) claim that Newham ranks as the third most deprived borough in inner London. Most of the people here live in tower housing and overcrowded conditions that are the perfect condition for the spread of tuberculosis. There is a positive correlation between poor housing and poverty and the prevalence of tuberculosis, which is very clear in Newham as evidenced by the findings of 108 and 116 cases per 100,000 people (Vassal, 2009; Anderson et al., 2001). The aetiology of the issue of tuberculosis is highlighted when considering the distribution of the disease across Newham. The occurrence of disease is not evenly spread across the borough, with 70% of cases coming from Manor Park, Green Street and East Ham. These boroughs represent areas of population increase, overcrowding and higher levels of those living in poverty. Manor Park and Green Street also sho w differing dynamics of tuberculosis incidence, representing an overall increase of 40% since 2006 whilst all other areas of Newham either remained static or showed slight decrease (Malone et al 2009, p. 23). It can be seen that tuberculosis presents a significant urban issue, especially when comparing incidence in an urban area such as Newham to those less urbanised areas. Bromley has a population of 309,000 and a population density of 20 per hectare, in comparison to Newham’s population density of 80 per hectare (UK Census, 2012). Tuberculosis incidence in Bromley is between 0-19 per 100,000 compared to that of Newham, which is five times greater at 80-100 per 100,000 (Anderson et al., 2006). It is for this reason that necessary intervention strategies need to be formulated and implemented to help reduce the rates of tuberculosis among individuals living in Newham. 3. The Influence of Urbanisation on Tuberculosis Incidence While the global rates of tuberculosis are declining, the disease is showing steady increase in the United Kingdom. In 2012, 8751 new cases of the disease were identified in the country with 39% coming from London (Fullman and Strachan 2013, p. 43). Indeed London has the highest rates of the disease in Western Europe with Newham borough having the highest rates in the UK. Jindal (2011, p. 55) claims that the rate of tuberculosis in some London boroughs is more than twice higher than the threshold used by the world health organisation to define high rates. These higher incidences support the notion of a sick city hypothesis where there are greater levels of ill health than in rural areas, and may be due to the presence of factors in an urban environment that contribute to ill health (an urban health penalty). One factor that may contribute to the urban health penalty is that of immigration. Cities are easier to access than rural areas, provide areas of congregation and provide more fa cilities for immigrating families and individuals. The majority of individuals suffering from tuberculosis are people born outside the United Kingdom, with 75% of cases in 2003 being born abroad (Anderson et al., 2006). A reason for the high incidence in those born abroad but now living in the UK is exacerbated by the nature of tuberculosis. On initial infection, tuberculosis is confined by the immune system with only around 5% of cases experiencing symptoms within the first two years of infection (Narasimhan et al., 2013). The remainder of cases harbour a latent infection which may reactivate later in life, with about 10-15% of those infected going on to develop an active disease (Narasimhan et al., 2013). This insidious nature combined with the later activation of the disease explains why many people do not get the disease until later in life. It is likely that it is contracted in their country of birth, however then manifests much later once they have moved to the UK. Statistics indicate that over 90% of the residents in Newham diagnosed with the disease in 2011 were born outside the United Kingdom (Fullman and Strachan, 2013, p. 33). Among these, 50% arrived in the country in the last five years. In the same year tuberculosis diagnosis increased by 25% compared to 2010 (Fullman and Strachan, 2013), possibly as a reflection of the increased immigration. Additionally to a high immigrant population bringing significant disease burden from their countries of birth, London and Newham both represent many of the other issues of urbanisation and urban health penalty that can contribute to the high incidence of tuberculosis. Studies have shown that low vitamin D levels are associated with an increased risk of developing tuberculosis (Campbell and Spector, 2012; Chan, 1999). This is an important association in urban populations, as the living and working conditions foster less access to sunlight (the major source of vitamin D). Additionally, Asian immigrants present a problem of low vitamin D due to vegetarian diets, and a tendency to cover up their skin, not allowing to take advantage of the small amount of sunlight available (Chan, 1999). As previously mentioned, Newham is an area of both high urbanisation and with a large immigrant population, and 38.6% of the population being of Asian descent (London Borough of Newham, 2010). The immigrant population of urban areas such as Newham also present a non-vaccinated proportion of society. Whilst the BCG vaccine against tuberculosis was introduced in the UK in the 1950s and was shown to provide a reduction in risk of contracting tuberculosis (Colditz et al., 1994), those immigrating were less likely to receive this vaccination on moving to the UK. London also represents cases of tuberculosis that are socially and medically complex. As a hugely populated area, London includes those with HIV infection and presents other risk factors such as onward transmission and poor treatment. HIV is one of the m ost powerful risk factors for tuberculosis, with a incidence rate of 20 times higher in those that are HIV positive (Dye and Williams, 2010). People’s attitudes towards and access to healthcare also present a complex mix of factors which contribute to an increased incidence of many health problems, including that of tuberculosis. Those in impoverished areas have reduced access to healthcare, which may stem from many reasons such as complex needs, chaotic lifestyles, location of services, user ignorance, and language and literacy barriers (Szczepura, 2005). These can affect the disease process of tuberculosis from prevention, treatment of active disease, adherence to treatment and prevention of the health consequences. Especially problematic are misconceptions and a lack of understanding of the disease, leading to late presentation and delayed access to treatment (Figuera-Munoz and Ramon-Pardo, 2008) With the close living quarters in areas such as Newham, the spread of tubercu losis is facilitated. With poverty, poor housing and overcrowding, these areas concentrate several risk factors and lead to a greater spread of tuberculosis (Bates et al., 2004). These determinants therefore suggest that the incidence of tuberculosis in urban areas is a complex issue. Controlling and preventing tuberculosis in London requires effective social and economic tools that must be incorporated in the development of policies of control in treatment initiation. 4. Consequences and implications of tuberculosis on the general population Tuberculosis ranks with HIV/ AIDS and Malaria as one of the three main health challenges currently facing the world. The Commonwealth Health Ministers Update 2009 (2009, p. 41) indicates that 8 million new cases are reported globally each year. As previously mentioned, when combined with HIV, tuberculosis can prove lethal as the two diseases enhance the progress of each other. It is for this reason that tuberculosis is the major cause of death among HIV patients with the rate standing at 11% globally. The World Health Organization (2009, p. 27) indicates that tuberculosis is responsible for more deaths today than ever before, with approximately 2 million lives claimed by the disease annually. As well as the significant mortality contributed by tuberculosis, the morbidity of the disease can be extremely detrimental both socially and economically. Those with the active disease that are not receiving treatment have been shown to go on to infect 10-15 others every year (WHO, 1998). Those who do receive treatment face a long (up to six months) and complex treatment regime involving several medication side effects. This can affect adherence to the treatment regime, and lead to the disease developing a resistance to the treatment, with this drug resistant tuberculosis contributing to greater mortality and increased expense to treat (Ahlburg, 2000). As well as the significant morbidity and mortality, it is important to consider the economic impact of tuberculosis. The World Health Organisation estimated the cost to treat tuberculosis in 2000 as $250,000 US dollars (?150,000) in developed countries (Ahlburg, 2000). This presents a significant burden to the UK NHS, not to mention the time lost through not working which can dent the economy. London is a global world trade centre whose economy is shaped by global forces, particularly in terms of trade, labour and capital. As a gateway to both the UK and other parts of Europe and the rest of the world, London records a very large number of tourists and immigrant populations. This high number of people accelerates the spread of the disease as people carry it to the country from other parts of the world is indicated by the new infection patterns and is highlighted by the prevalence in immigrant populations. 5. Strategies and intervention for addressing tuberculosis Current UK guidelines for tuberculosis intervention were made by NICE in 2006 (updated 2011). The recommendations propose strategies for identifying those with latent (non-active) tuberculosis to prevent spread or reactivation and also specify criteria for treatment (NICE, 2011). Those recommended for screening for latent tuberculosis include close contacts of infected individuals, immigrants from high incidence countries, immunocompromised individuals, and healthcare workers. Whilst this strategy targets prevention of the spread of tuberculosis, they are only targeting specific groups, and it is likely in high incidence areas such as Newham, people will slip through the net. These guidelines have only changed minimally since 2006, and since then tuberculosis incidence has been on the increase in areas such as Newham, suggesting that changes may need to be made. High incidence areas of the UK such as Newham could learn from New York experience and copy the strategy it used in dealing with the disease. With the implementation of broadened initial treatment regimes, direct observed therapy, and improved guidelines for hospital control and disease prevention, the city managed to halt the progression of an epidemic (Frieden et al., 1995). As mentioned in the previous chapter, adherence to the lengthy treatment regime as well as a lack of understanding may contribute to the spread of tuberculosis. Directly observed therapy (DOT) involves observing the patient take each dose of their medication, with outreach workers travelling to their homes. Evidence from New York showed that through DOT, only 3% of patients in therapy were infectious, compared to a proposed 20% if not receiving DOT (Frieden et al., 1995). Current UK guidelines (NICE, 2006) do not recommend DOT, although they do state that it may be used in cases of patients with previous issues with adherence or at high risk. Although an expensive and time consuming process, if DOT can reduce infectious cases, thi s would also work as a preventative measure. There could be one allocated outreach nurse for the borough of Newham and other high-risk areas. Another method implemented in New York was the downsizing of large shelters for the homeless. These were breeding grounds for tuberculosis, and the subsequent reduction in overcrowding led to a decrease in transmission of the disease (Frieden et al., 1995). Whilst it is not possible to split people up from living with their families in crowded homes in terms of Newham, education about keeping those with tuberculosis from interacting with too many others in crowded conditions may be of benefit. The model should also borrow from those used by other cities like Paris and the rest of Europe in controlling tuberculosis with intervention at the level of the agent, individual and community levels. In Paris, Rieder (2002) suggested that prophylactic treatment could be used to prevent the disease occurring in those at risk, for example those in the hou sehold of an identified case of tuberculosis. Additionally, Rieder (2002) proposed that early or neonate vaccination be used especially in those in areas where tuberculosis is frequent, rarely diagnosed, and adequate contact examinations rarely feasible. It may be possible that in cases where lots of people are vaccinated that they may infer herd immunity and thus protect unvaccinated individuals from the disease. Once the populations have been protected and the incidence (number of new cases) of tuberculosis has been reduced, this allows for a reduction in the prevalence of tuberculosis (number of ongoing cases at any one point in time) with preventative chemotherapy that can treat sub-clinical, latent tuberculosis in the population. This preventative chemotherapy is likely to be extremely relevant to Newham due to the large immigrant population likely harbouring latent tuberculosis. On a country- or city-wide scale, these recommendations from New York and Paris provide excellent m odels for preventing the increase of tuberculosis any further. It is also important, however, to consider the individual communities in Newham, and to promote health awareness and an attitude towards taking responsibility for their health. Their needs to be an encouragement at the level of primary care where immigrant populations feel that they can approach healthcare, and education to encourage tuberculosis prevention and adherence to treatment. The strategy should be all-inclusive in order to encourage people to not only go for testing but also start and finish the treatment process. 6. Recommendations and conclusion Tuberculosis presents an important urban issue in the area of Newham. Incidence is greater than other areas of the UK, and is over half that of India. There are several factors contributing to this including a large immigrant population, crowding and overpopulation, access to healthcare and comorbid health problems such as vitamin D deficiency and HIV. The disease has considerable effect on morbidity and is responsible for high levels of mortality. Further consequences of the disease manifest as economic problems such as cost of treatment and loss of work. London and the UK already have policies and structures for controlling tuberculosis in place; however the implementation process is patchy across the city, and often dependent upon budget. In high-risk areas such as Newham, there is poor access of healthcare due to inaccurate beliefs on the disease, language and cultural barriers, and complex needs of the population. In the case of tuberculosis, these contribute to poor disease pre vention, delayed diagnosis and poor treatment adherence. All of which lead to an increase in transmission and health consequences. The area of Newham would benefit greatly from further education into tuberculosis, how to look for signs and how to get treatment. Encouraging good relationship with healthcare professionals and promoting access to healthcare through outreach programmes and targeting pharmacies may be helpful. Additionally, Newham should look to employ techniques used in New York and Paris, including DOT, prophylactic treatment and neonate vaccination to reduce both the prevalence and incidence of tuberculosis. References Ahlburg (2000). The economic impact of TB: ministerial conference Amsterdam, WHO Bates, I., Fenton, C., Gruber, J., Lalloo, D., Lara, A. M., Squire, S. B., †¦ and Tolhurst, R. (2004). ‘Vulnerability to malaria, tuberculosis, and HIV/AIDS infection and disease. Part II: determinants operating at environmental and institutional level’. The Lancet Infectious Diseases, vol. 4(6), pp. 368-375. Bhunu, C. P., and Mushayabasa, S. (2012). ‘Assessing the effects of poverty in tuberculosis transmission dynamics’. Applied Mathematical Modelling, vol. 36(9), pp. 4173-4185. Campbell, G. R., and Spector, S. A. (2012). ‘Vitamin D inhibits human immunodeficiency virus type 1 and Mycobacterium tuberculosis infection in macrophages through the induction of autophagy’. PLoS pathogens, vol. 8(5). Castillo-Chavez, C., and Feng, Z. (1997). ‘To treat or not to treat: the case of tuberculosis. Journal of mathematical biology’, vol. 35(6), pp. 629-656. Colditz, G. A., Brewer, T. F., Berkey, C. S., Wilson, M. E., Burdick, E., Fineberg, H. V., and Mosteller, F. (1994). ‘Efficacy of BCG vaccine in the prevention of tuberculosismeta-analysis of the published literature’. Jama, vol. 271(9), pp. 698-702. Commonwealth Health Ministers Update 2009. (2009). Commonwealth Secretarial. Dye, C., and Williams, B. G. (2010). ‘The population dynamics and control of tuberculosis’. Science, vol 328(5980), pp. 856-861. Dyer, C. A. (2010). Tuberculosis. Santa Barbara, California: Greenwood. Ellner JJ. Tuberculosis. In: Goldman L, Schafer AI, eds. Goldman’s Cecil Medicine. 24th ed. Philadelphia, PA: Elsevier Saunders; 2011: vol332. Farrar, J., & Manson, P. (2013). Manson’s tropical diseases. Hoboken, NJ: Wiley. Figueroa-Munoz, J. I., & Ramon-Pardo, P. (2008). Tuberculosis control in vulnerable groups. Bulletin of the World Health Organization, 86(9), 733-735. Frieden, T. R., Fujiwara, P. I., Washko, R. M., and Hamburg, M. A. (1995). ‘Tuberculosis in New York City—turning the tide’. New England Journal of Medicine, vol. 333(4), pp. 229-233. Fullman, J., & Strachan, D. (2013). Frommer’s London 2013. Hoboken, NJ: Wiley. Great Britain. (2008). Diseases know no frontiers: How effective are intergovernmental organisations in controlling their spread; 1st report of session, 2007-08. London: Stationery Office. Jindal, S. K. (2011). Textbook of pulmonary and critical care medicine. New Delhi: Jaypee Brothers Medical Publishers. London Borough of Newham, (2010). Community Leaders and Engagement, Manor Park Community Forum Profile [Online], Available:http://www.newham.info/research/CFProfiles/ManorPark.pdf [12 April 2014]. Malone, C., Beasley, R. P., Bressler, J., Graviss, E. A., Vernon, S. W., & University of Texas Health Science Center at Houston, School of Public Health. (2009). Trends in anti-tuberculosis drug resistan ce from 2003–2007 at Pham Ngoc Thach Tuberculosis and Lung Disease Hospital, Ho Chi Minh City, Vietnam. (Masters Abstracts International, 47-5.) National Institute for Health and Care Excellence (2006) [Clinical Diagnosis and Management of Tuberculosis, and measures for its prevention and control]. [CG117]. London: National Institute for Health and Care Excellence. Ormerod, L.P. (2003) ‘Nonrespiratory tuberculosis. In Davies PDO (Ed) Clinical Tuberculosis. Third Edition. Arnold: London. pp. 125-153. Public Health England (2012), World Health Organization (WHO) estimates of tuberculosis incidence by rate, 2012 (sorted by rate). [Online] Available at: http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317140584841 [12 April 2014]. Rieder, H. A. (2002). Interventions for Tuberculosis Control, 1st edn. International Union Against Tuberculosis and Lung Disease, Paris, France. Szczepura, A. (2005). ‘Access to health care for ethnic minority populations’. Postgraduate Medical Journal, vol. 81(953), pp. 141-147. Vassall, A., & University of Amsterdam. (2009). The Costs and cost-effectiveness of tuberculosis control. Amsterdam: Amsterdam University Press. Watson, J. M., and Maguire. H.C (1997). ‘PHLS work on the surveillance and epidemiology of tuberculosis.’ Communicable disease report. CDR review 7.8, pp. R110-2. World Health Organization. (2009). Global tuberculosis control: Epidemiology, strategy, financing : WHO report 2009. Geneva: World Health Organization. World Health Organisation (2014). Tuberculosis. [Online], Available: http://www.who.int/topics/tuberculosis/en/ [12 April 2014] UK Census (2012), UK Census Data, [Online]. http://www.ukcensusdata.com/newham-e09000025#sthash.51Phmj6a.dpbs [12 April 2014]