Mustika Ratu Case Summary

Mustier Rat's Marketing Strategy Throughout the sass, the company expanded its line traditional cosmetics (facial care & decorative makeup, hair and body care product) and the established itself as the uncontested market leader – by 1998, four out of very 10 cosmetic products sold in Indonesia were Mustier Rata brands. Positioned as competitively priced, quality products formulated specifically for Indonesian skin. Company literature reinforced that its products were natural and integrated timeless Indonesian beliefs of the health and beauty properties of local plants and herbs.Mustier Rat's Jambs appealed to several market segments. Segment : Men, women, adults, and teenagers. Target : Predominantly middle- to upper-middle-income cue insurers. Positioning : Products were natural and integrated timeless Indonesian levels of the health and beauty properties of local plants and herbs. Condition of competition in the jam segment was becoming fierce in the next following years. Ma ny roadside stalls selling jambs to cure headaches, boost sexual drive or to reduce weight were common. These jambs were targeted at the middle- to lower-income market segment.So, Mustier Rata also competed in these market segments with their flank brand â€Å"Garage Jambs†. According to the company's 1 997 annual report, this line â€Å"contributed to overall profitability and had great potential for future growth. † Exhibit low are Mustier Rat's product differentiation based on market segment. Each segment has each marketing strategy that suitable to applied to their market. Based on reading text, Mustier Rat's core value that become major quality of Mustier Rat's product was high quality of their natural ingredients.It become a competitive factor for Mustier Rata differentiation to another brands. This competitive factor that Mustier Rata tried to sell from their marketing campaign. This became a major focus in the company's marketing communications. An average of o ver 25 percent of annual net sales was spent n marketing campaigns which promoted value-priced, natural alternatives to imported cosmetics. Another key promotion activity that increased the company's profile was sponsorship of several major beauty events, including the Miss Indonesia pageant.B. R. A. Immorality's high profile as an owner of Mustier Rata, who granted meritorious achievement in the promotion of Indonesian culture and traditions and the Asian Institute's Marketing Management Award (in 1992 and 1 995) also increased Mustier Rat's profile in domestic area. Mustier Rat's Distribution Strategy Over the years, Mustier Rata had developed its own well-established and highly organized distribution system, controlled through a recently installed information technology (IT) control system.The application of improved IT control systems ensured a higher level of service and more efficient delivery schedules as well as more accurate and timely consumer information. IT system was al so installed due to the the challenges posed by Indonesian geography, which is Indonesian area is so vast. Another significant challenge in distribution in Indonesia was the highly fragmented nature of the retail industry – thousands of small outlets and roadside stalls accounted for a significant percentage of Indonesian retail activity.Mustier Rata used all of kind distribution channel to market their extensive product lines. Mustier Rata Brand's Distribution Channel ‘ Lower- and middle- income brand : ubiquitous stalls, wet markets, conventional retail shop, supermarket, direct sales channel Upper- income brand : Department stores, company-owned stores, direct sales force Since 1 992, Mustier Rata had concentrated on intensifying their department store distribution channel.Another key strategy was to increase of distribution channels previously managed by third parties in their most densely populated and lucrative markets. The establishment of Mustier Rata-owned and operated distribution systems resulted in an average of two and one-half percent increase in Mustier Rat's operating margins. Delivery time was also shortened, and quality of service provided to retail outlets was enhanced. Company also changed its accounts receivable policy, shortening the due period from 90 days to 30 days.Namely it addressed lead times and resulted to smaller order lots. According to Essayist on the reading text, the company's distributors were his â€Å"eyes and ears† monitoring customer opinion and relaying vital market information to the corporate marketing department. Mustier Rat's International Market In international markets, Mustier Rata used a combination of in-house owned operated distribution channels, as well as contracted distributors.Malaysia The company's most significant international market, accounting for 70% of international revenue. 1 995, Mustier Rata established several â€Å"House of Mustier Rata† treatment centers, which resul ted in doubling sales. Target Market : Indigenous Malay (properly target), Chinese (lasted catered), Middle market products. Philippines : Demographics in Philippines market were relatively similar with domestic product lines. Target Market : Health and beauty products for teenage girls was one of the least crowded market segments.Next step in penetrating the Filipino market was to capitalize on the established third-party distribution channels used for the body splash and to introduce other product within the Putter line as well as Mustier Rat's slimming Tea. The Middle East : Mustier Rata had opened 14 â€Å"House of Mustier Rata† outlets in United Arab Emirates, Saudi Arabia, and Egypt. Target Market : Brand with in developing natural products that adhered to the Muslim ‘Hall' standards -? products made with no animal fat and that had never been tested on animals.Other Countries : The another countries was : Hong Kong and Holland (Mail order distribution channel) Sou th Africa, Canada, Australia, China, Japan, Korea, Vietnam Taiwan, and Thailand (Investigating Market) Successfully Navigating Through A Chaotic External Environment Mustier Rata had averted the misfortune in 1 998 that had befallen many of heir competitors through cautious investment of the proceeds of their PIP (much of which had not been used as originally planned), mostly in short term deposits at foreign-owned banks.

De Stijl

De Stijl in Dutch means â€Å" The Style†, also known as neoplasticism, was a Dutch artistic movement founded in 1917. The movement was mainly about creating geometric abstract paintings. In a narrower sense, De Stijl was a term used refers to a body of work from 1917 to 1931 founded in Netherlands. De Stijl was also the name of the journal, which published by the Dutch painter, designer, writer, and critic Theo van Doesburg (1883 ­Ã¢â‚¬â€œ1931), propagating the group’s theories.Besides him, the principal members of De Stijl group include painters Piet Mondrian (1872–1944), Vilmos Huszar (1884–1960), and Bart van der leck (1876-1958), and the architects Gerrit Rietveld (1888–1964), Robert van’t Hoff (1887–1979), and J. J. P. Oud (1890–1963). The basic artistic philosophy of the group’s work was known as neoplasticism — â€Å"the new plastic art (or Nieuwe Beelding in Dutch). †In general, De Stijl used only straight horizontal and vertical lines and rectangular forms to proposed both in architecture and painring , the ultimate simplicity and abstraction. For example,the Red and Blue Chair designed by Gerrit Rietveld in 1917. They used limited colors like red, yellow, and blue as their formal vocabulary. And they had three primary values, black, white, and grey. Their works used opposition to avoid symmetry and attained aesthetic balance. This element of the movement embodies the second meaning of stijl: a post, jamb or support†. It was the best example of the constructive crossing joints, most commonly seen in carpentry. De Stijl was influenced by Cubist painting as well as by the mysticism and the ideas about â€Å"ideal† geometric forms in the neoplatonic philosophy of mathematician M. H. J. Schoenmaekers. This movement also influenced the Bauhaus style and the international style of architecture as well as clothing and interior design.However, different from Bauhaus, D e Stijl didn’t follow the general guidelines of an â€Å"ism† (Cubism, Futurism, Surrealism), nor did it held the principles of art schools like the Bauhaus. It was a collection of artworks and a joint enterprise. De Stijl completely rejected to use any concrete element. They advocated the use of pure geometric abstraction to express the pure spirit. They thought only to put aside specific description and details to avoid the individuality and specificity of an artwork, and then art could obtain the common human sense.

Advantages And Disadvantages Of Online Accounting Systems Information Technology Essay

Advantages And Disadvantages Of Online Accounting Systems Information Technology Essay When a diminutive company desires to apply accounting software then they have to stick to the conventional method of accounting as the price of any certified accounting software is quite high and relatively unfamiliar to many. This concept has received a big blow as these small businesses now have a choice. Accounting software can be procured and mounted on your computer. However, with the presence of ever developing internet a consumer can locate the identical packaged application on the web and doesn’t have to download or purchase anything. I don’t matter if your company is local, or national, or international any business can at present employ internet based accounting software. It doesn’t depend on the size of the business you uphold, there are certain aspects of considerable importance when it comes working online especially with company’s accounts. Security is a major concern and one of the primary steps a large amount of network based merchandises think for users. Web based financial account software handle its personal database hub and all the records are accumulated on huge network servers. Supplementary queries can be raised to internet based companies on the support of their infrastructure. Take a note of the number of web data servers are preserved for backups, involuntarily or manually, backup strength must be taken as the primary factor after security. Everything will appear simple when consumers don’t have to consider or worry about backups any longer. Think of the amount of times every year somebody has to volunteer and preserve your server, format it and your system or else you have to worry about it. How overwhelming that charge sounds as the accounting application and database for the company is stored on a Personal computer or the business’s server. With everything available on the web, you can easily overlook any troubleshooting mishap. IT is addressing certain issues as they come up for the accoun ting software used on the Web. As a matter of fact, a number of web based sellers have forged a plan which will give sufficient time on the maintenance of the entire system and that to on weekly basis. Usually, reviving or modification is done twice or thrice a year where users are informed before hand. Usability is marginally equivalent to 100% both day and night, daily, from any internet accessible tool restricted by a user security system and log on necessities. You will have a lot of capital saving chances while choosing a web based system to have your data. Advisors are no more required to keep the financial accounts and every inescapable timely security update that happen in every application. An unforeseen power reserves arises when small and large businesses toggle to web based application. Reportedly, it was observed that a company saved around millions of dollars from power savings. Additional savings piles up with the exclusion of investment on resources to get the entire system equipped to go. Typically it takes around six months for a large business to mount, switch information, examine and other tedious problems which leads to the build up. This entire process of setting up the infrastructure is quite quick for small companies when they switch to the web based application. The start up time includes the conversation which happens to make the decision.

What is wrong with the idea that human visual perception is achieved Essay

What is wrong with the idea that human visual perception is achieved by a single area of the brain that simply reflects the cisual information coming from the e - Essay Example the optic nerves which consist of about a million nerve fibers and contain axons arising from the inner, ganglion-cell layer of the retina (Guyton & Hall, 1996; Waxman, 2000). The arrangement at the optic chiasm allows the left hemisphere to receive visual information about the contralateral half of the visual world and vice-versa (Guyton & Hall, 1996; Waxman, 2000). Moreover, the fibers of each optic tract synapse in the dorsal lateral geniculate nucleus and from here, the geniculocalcarine fibers pass by way of the optic radiation to the primary visual cortex in the calcarine area of the occipital lobe (Guyton & Hall, 1996). The most important cortical region for visual processing is Area V1 in the occipital lobe because it is the first stop in the cortex and almost all of the signals that the other cortical regions get must pass through it which is why Area V1 is often referred to as the primary visual cortex or striate cortex (Coren, Ward, & Enns, 1999). Hubel and Wiesel found cells in the cortex with receptive fields that have excitatory and inhibitory areas and are arranged side-by-side rather than in a center-surround configuration (Goldstein, 2007). Simple cortical cells are cells which have these side-by-side receptive fields mentioned previously and these cells respond best to bars of a particular orientation (Goldstein, 2007). Other kinds of cells in Area V1 are even tuned to more complicated pattern properties of the stimulus such as complex cortical cells which respond best to movement of a correctly oriented bar across the receptive field, and at an even more complicated level of analysis than the complex cells are hypercomplex or end-stopped cortical cells that respond not only to the orientation and direction of movement of the stimulus but also to the length, width, or other features of shapes, such as the presence of corners (Coren, Ward, & Enns, 1999; Goldstein, 2007). Simple, complex, and hypercomplex cells are refer red to as feature

Contemporary vampire saga, twilight Essay Example | Topics and Well Written Essays - 1000 words

Contemporary vampire saga, twilight - Essay Example tive of the vampire as one that went for what it desired, contrary to the modern vampire who exhibits better reasoning capabilities towards relationships and has human values. The vampire series gives the perception of love and relationships as being indiscriminate and binding in that Bella and Edward fall deep in love despite their different natures. On matters of gender, the contemporary vampire does not portray the woman as inferior and as only a target for vampires; Bella and Edward’s intense love relationship proves this. The ancient/gothic depiction of the vampire painted it as ruthless, bloodthirsty, and horrific, only driven by its desires, and portraying minute (insignificant) humanity in it. This is most evident in that it was seen mostly attacking women and children after destroying their protectors (men), and has to kill in order to live. However, the contemporary vampire is portrayed as being attractive and reasonable, with few [necessary] killings. Another aspect is that in the new form of the vampire, it possesses emotion and even falls in love with real humans, exhibiting acts of romance and chivalry, all of which are admirable. This is so unlike the gothic vampire who only perceives of women as targets to kill. Finally, and with regard to social relationships and values, the contemporary vampire constructs, rather than destroy. In the ancient ones’ portrayal, the vampire would invade relationships thus destroy them; however, the contemporary one actually takes part in constructing and maintaining them, as it is seen relating closely with people. All of these support that indeed, what we now have is a reformed-for –the-better vampire, who leans more to their human than animal nature. In Polidori’s Vampyre, there is the contrary perception of the vampire as a creature that lives underground, only coming into the world to attack its prey, and drag them into the dark ages. In the short narration, the â€Å"new† vampire, Lord Ruthven, lives

Humerous essay Example | Topics and Well Written Essays - 250 words

Humerous - Essay Example I waited for the Colonel to go on his walk and then telephoned him. You answered the phone. I kept on talking asking irrelevant questions. Of course you did not know it was me. Your voice, I swear, was sweet. Seeing that you visited the temple, I started visiting too. I developed devotion and started praying devoutly to God almighty to join us in holy wedlock. Whenever you saw me, your eyes used to light up with recognition and respect. I knew you loved me. I was sure. I had no doubt of it whatsoever. I belong to a well-to-do house and we were eight children. I was the eldest, and the others were girls. So I was too busy settling their marriages to think about my own. I was sacrificing my life for them. But I am not sorry about it. My sorrow is that those sisters do not care for me. I am not bothered about that, either. For, now I have you. And you are equal to a thousand sisters. I retired from government service last month. I get a handsome pension and this will be there for my wife too till her death. I am sixty years old. But what of that? I am hale and healthy. I used to play hockey and tennis. And badminton too. They say badminton is the game for pregnant women. So when you are in the family way, you won’t have to look for other pregnant women to play with. You can play with me. You are about 55 unless my eyes deceive me. I had a cataract operation last year, and they generally don’t. You are beautiful. Your strands of white hair, your dark complexion and the mole on your chin add to your beauty. But the thing that clinched the issue was the dimple on your left cheek. Whoever heard of a single dimple? And that dimple I am sure contains the whole universe and will show me everything that Yasoda saw in the Lord’s

Self-Evaluation Paper Essay Example | Topics and Well Written Essays - 500 words

Self-Evaluation Paper - Essay Example Having learned all the above, I can confidently say that I have attained my educational goals for this course. My goals in this course were not as deep and wide as what we have already covered in this course. The course being about Academic Reading and Study Skills, I never anticipated that we would go as deep as to studying topics such as analyzing an annotation and Academic vocabularies. One of my prime goals was to formulate a plan on how I can understand written materials in a shorter time period than I was before the course. I have achieved this goal. The skills acquired in ESL 23 come in handy in academics writing and in professional work. I expect to use note-taking skills in writing core information dictated by lectures in classes. Reading skills are also vital in understanding day to day material that we read such as newspapers and comprehensively understanding questions asked during examinations. Skills acquired in this course can be effectively applied in professional work such as research writing, journalism and report writing. Here, one needs to know how to write good summaries by separation the main and minor points in writings. There were lots of things to enjoy in this course. This is directly as a result of the professionalism and friendly learning environment created by the lecturer. Students also made the lessons interactive capturing my attention during the entire class period. The efficient course system was quite good since it ensured that vital knowledge in the course content was excellently passed to students throughout the semester. The least impressive situation regarding this course was the unanticipated urgency of the time line near the end of the semester. Having learned and increased my knowledge regarding vast skills in reading and writing, there are some strategies that I need to acquit myself to more. One of these is the SQ3R strategy. This is because it needs a lot of practice

Strategic Human Resource Management Essay Example | Topics and Well Written Essays - 1500 words

Strategic Human Resource Management - Essay Example Recently, the strategic role of the HR field and linkages between business and Hr strategy have been the subject of extensive discussion. Jim walker (1980), with his classic book on Human resource planning, was the first writer to suggest considering the corporate business strategy while developing and executing HR plans. Since then, in just over a greater of a century, a plethora of research, theory and cases examining research on aligning HR policies and practices with business strategies has become the focus of management studies (Wright et al 2005). Strategic HRM: The field of HRM has under gone significant changes in scope, functions and activities over the years, with the rise in professional maturity in the field; Personnel management has become HRM, which in recent years has become strategic HRM. Strategic HRM is the explicit link HRM has with the strategic management process of the organization. Strategic HRM is viewed as strategic as it involves the managerial personnel of the organization and regards: People as the single most important asset of the organization" (Poole & Jenkins, 1990). It is proactive in its approach to people. It seeks to enhance organizational performance, employee needs and societal well being. The key difference therefore between traditional and strategic concepts with extent to which management of HR is integrated into the strategic decision making processes that direct organizational efforts towards coping with the environment (Guest, 1990). Strategic HRM practitioners are now considering human r esources to be a major source of competitive advantage and a growing body of research supports this view (Arthur 1994; Guest, 1997; Tyson, 1997; Wright et al. 2005; Youndt et al. 1996). SHRM theory is based upon the recognition that organizations can become more effective, if their human resources are managed with HR policies and practices, which can help the right number of people, acquire the appropriate behaviors, the needed HR competencies and the feasible levels of work motivation. The relevant external and internal environment or components of the organizations and the relevant stakeholders are thus important to the practice of strategic HRM (Schuler & Jackson 1999). The 1980's and the 1990's have witnessed a great deal of emphasis being placed on a strategic implementation of the HRM policies and practices all over the world. Shift in strategic HRM perspective have changes the orientation of HR managers world over. The last two decades saw major shift in people management approaches and practices as SHRM becomes more proactive in approach, people oriented, and people as investment, key player in competitive advantage and integrated role in company's goals and planning. The fields of HRM, HRD and organizational development (OD) have converged into the new strategic HRM. As Ruona and Gibson (2004) remarked "Twenty-first-century strategic HRM lay more emphasis on increased centrality of people for organizational success, importance of whole systems and integrated solutions in strategic alignment and impact and lastly, has a tremendous capacity for change". The concept of HRM has generated a lot of attention from researchers since it first emerged in the 1980's. The

The collapse of HIH (Australian Insurance company) Essay

The collapse of HIH (Australian Insurance company) - Essay Example Moreover, analysts were concerned with the increase in the capital adequacy requirements in favor of the insurers. It was basically a proposal by Australian Prudential Regulatory Authority (APRA) in 2000. (A Chronology of Key Events, n.d) This was followed by selling part of domestic business to German based Allianz at about $500 million. The same year also saw the tumbling of share prices reaching to the lowest ever. Markets blamed the Allianz deal. The following year saw the most heartening part of HIH as it estimated $800 million loss and enters into a position of provisional liquidation. Both Australian Securities & Investments Commission (ASIC) and Royal Commission after analyzing the documents finally forced the company to close down its operations which marked the collapse of one of the biggest corporate ruins in Australia. (Kehl, 2001) Many would opine the fact that the sudden demise of such a huge insurer firm is generally due to its aggressive business strategies. It has moved on to acquire FAI and within a year or two it has again made a move to sell off its part of business to Allianz. Also another most remarkable part of the story is regarding its subsidiaries. The company recorded to have more than 200 subsidiaries world-wide. This extensive creation of subsidiaries has affected the business as a whole. With such expansion policies and an average of 26% a year of growth, the company struggled hard to find its way through as the market was experiencing enough competition especially from its overseas operations in UK and US. (HIH Insurance, 2001) Even one of the prime liquidators of HIH, Mr. McGrath also opined that the FAI Insurances were of no value when HIH bided for $295 million. (Sexton, 2009) The main motive that is to be considered in acquiring FAI Insurance by HIH was to make a significant mark in the Australian insurance industry. Therefore in 1995 the

Accounting and Bookkeeping Services Marketing Plan Essay Example for Free

Accounting and Bookkeeping Services Marketing Plan Essay Marketing Vision Sorcerers Accountant will fit the needs of transitional small businesses, dealing with the growing pains of leaving an owner-operator model to hiring employees and expanding. These clients will see that Sorcerers Accountant is competitively priced, both compared with the market and with the substitute option of hiring their own bookkeepers. Clients will see that Sorcerers Accountant is extremely flexible and scalable in a way that in-house bookkeepers cannot be. To move forward with this new business line, Sorcerers Accountant will make the bookkeeping services the core of its business and a source of leads for its additional accounting services, rather than the other way around. Over time, as this transition happens, the marketing plan will be revisited to see how these clients can be better used as a source for referrals and more business. See more: The Issues Concerning Identity Theft Essay Goals Sorcerers Accountants goals include Personal, Marketing, Business, and Client Satisfaction goals. They are: 1. Personal To reduce the time spent on the business by Max Greenwood to a more sustainable level over a few years and to achieve professional recognition 2. Marketing Generation of large numbers of leads and press mentions 3. Business Expand sales significantly over the next three years 4. Client Satisfaction To achieve a high level of very satisfied clients Purpose Sorcerers Accountant seeks to provide a full suite of tax and management accounting services for small businesses in Chicago, Illinois, allowing business owners to not only save money over in-house accounting and ensure their compliance with tax laws, but to make valuable management decisions from their numbers. Picture When clients come to Sorcerers Accountant, the frustration of dealing with in-house bookkeepers and low-quality providers will recede. Clients will be given the time to have all of their questions answered and valuable accounting and systems advice will be given even in the initial meetings. The client will quickly understand that Sorcerers Accountant will scale their services to meet the clients needs and can add to those services as the clients needs change. They will understand that they are not entering into an onerous contract and that the cost of getting started is low. The client will be delighted the first time they receive a thank you card and small gift when theyve made their budgeted numbers for the quarter. At this point it will truly sink in that Sorcerers Accountant has their bookkeeping and accounting needs covered and that they can put away any worry that this area will be a weak link in their business. Gap Dashboard Weekly measurements of key metrics will be averaged for each month and entered in the Gap Dashboard. Personal goals will be tracked by Max Greenwood directly to make sure he is moving towards both professional recognition and a sustainable work/life balance. Marketing goals will be tracked by the CRM system and business goals will be tracked by QuickBooks. Client satisfaction numbers will be derived from the survey providers database. Whether numbers are met or not, the news will be shared on a monthly basis with the entire staff, with congratulations and discussion as to what is going right as well as a look at what is going wrong and how it can be rectified. These reports will be shared in full with the bookkeeping program manager and partially with the bookkeepers. Ideal Customer The ideal customer for Sorcerers Accountant is an owner of a very small business. Having launched within the last few years, the customer has just hired his first employee. The bookkeeping work (accounts payable and receivable, payroll, bank reconciliations, tax preparation) that the owner did for the first few years is taking more and more time and is holding him back from working on sales, marketing, and strategy for the business. The new employee has been hired to handle more of the technical work of the business, not to do bookkeeping. However, when considering the type of bookkeeping help he can afford, the customer realizes that a ten-hour-a-week employee would most likely be a student or low-skills worker who would require a great deal of training. The customer is put off by the idea of spending a great deal of time training such an individual, who may leave within a year (or even less) due to school schedule changes or finding a full-time job. He realizes that keeping the books correctly is important work, but because he understands his own value to the business, his knows his time is better spent elsewhere. He might then begin to search for professional bookkeeping options that can offer just a low-level of support by doing his own research and asking other business owners he knows. Market Description The small business accounting market consists of virtually every small business in the United States. As businesses grow larger than one person sole proprietorships, they generally require expert help with at least their tax preparation, and often with additional bookkeeping and accounting services. Even many non-employer sole proprietorships will use accounting help at some point. While some small businesses hire bookkeepers or CFOs directly, many successfully outsource these types of services. The market for Sorcerers Accountant is small businesses in the city limits of Chicago. This will represent approximately 85,000 businesses in 2010. This market can be subdivided into three groups: Non-employer firms: Without employees, these firms do not have many of the concerns of larger businesses. However, the owners must be vigilant to protect their own tax liability and sort out how their personal and business tax returns intersect. These firms are generally buyers of QuickBooks services and tax preparation services. As they grow, this group becomes ripe for outsourced bookkeeping services before they can hire a full-time in-house bookkeeper. Very small businesses: Defined for our purposes as businesses with 2-10 employees. Made up of businesses that are designed to stay small and those which are growing through a phase, these businesses require payroll services, bookkeeping, and tax preparation. They are concerned about losing control, but can generally be convinced of using outsourced accounting and bookkeeping with cost analysis. With the stakes higher, these businesses can make greater use of management accounting services, especially as most cannot afford a dedicated CFO. Many do not need a full-time bookkeeper, but can made due with part-time help, which limits their hiring options. Other small businesses: Defined for our purposes as businesses with 11 to 99 employees. Many of these businesses will have some in-house financial management and bookkeeping help. However, they may be able to save money by outsourcing these services as they are not generally core to what the business seeks to do. These businesses may be comfortable with their situation as a cash producer for their owners or intent on g rowing or positioning themselves for sale. Remarkable Difference Sorcerers Accountant offers the flexibility and low rates of an in-house bookkeeping employee, while providing all of the training, oversight, and deep knowledge of a Certified Public Accountant. Differentiators Sorcerers Accountant will achieve a competitive edge among Chicago bookkeeping services due to its combination of CPA oversight with lower-level, inexpensive labor to solve the specific problems of small business owners. Clients will receive the advantage of having a CPA review their books and propose additional advice when appropriate, while not paying much more than they would to hire their own part-time bookkeeper. This is not an inimitable competitive edge, but the market in Chicago is significantly large enough to allow for the success of Sorcerers Accountant with this strategy. Large firms ignore the small business market because they are better positioned to serve larger businesses. They are unlikely to imitate this strategy as they will find it difficult to convince small businesses that they can offer services which are affordable to them.

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

Stand By Me :: Drama

Stand By Me Stand by me was the first topic we studied this term we were put into groups of six to create a short play based on the 70s film stand by me based on Stephen King's Short story "The Body", "Stand By Me" tells the tale of Gordie Lachance, a writer who looks back on his preteen days when he and three close friends went on their own adventure to find the body of a kid their age who had gone missing and presumed dead. The stakes are upped when the bad kids in town are closely tailing - and it becomes a race to see who'll be able to recover the body first. We were given 30 minutes to gather an idea in our groups about a group of friends who want to go on an adventure. We all were hot seated in our groups as our characters. We created a still image of the characters before the adventure and our play was based on a series of 6 still images. We all put our ideas in and produced a 10minute production. In our productions we used a number of dramatic devices such as monologues, still images, dramatic irony and split scenes. Character Profiles Paul- Is 12 he lives at home with his mum and dad and 5 siblings. Paul is the loud member of the group who always wants to fight and show off he is really looking forward to the adventure. Scott- ====== Is 11 he lives at home with his mum and dad and 5 siblings one of which is Paul. Scott is quietest boy in the group Scott doesn’t want to go on the adventure he is very nervous but tries to act brave in front of the rest of the group. Lauren- ======= Is 11 she lives with her mum and dad and is an only child. Lauren is the girly girl of the group she likes to be centre of attention and wants everyone to like her. She is looking at the adventure more like a holiday and planning how many outfits she should take. Amy- ==== Is 13 and in foster care she is the Tomboy in the group she is very boisterous and always wants to be with the boys she doesn’t get on very well with Lauren. She is excited about going on the adventure. Jack- Is 12 he lives with his grandma and granddad he is the leader of the

Women’s Self-Discovery During Late American Romanticism / Early Realism

When we think of women writers today we see successful, gifted and talented women. Although these women writers have been established for sometime their status of contributions to society has only been recognized way too late. During the late romantic/early realism period numerous women found success in writing despite the fact that they may have encountered numerous obstacles in their path. The characters these women wrote about almost have a kinship with themselves bringing out certain personality traits not seen written about women before. From these traits a voice emerges in literature that has been hidden from the public view. This new true voice of female self-discovery finally comes out for the public to see in numerous works of that day. Courage, independence and emotional portrayal are the pivotal key traits that make up their self-discovery in the works of numerous female writers such as Gilman, Freeman, Woolson, and Chopin. These women writers were writing in the day where women were taught to maintain their place in society and family. After the Civil War â€Å"the homosocial world of women’s culture began to dissolve as women demanded entrance to higher education, the professions, and the political world† (Showalter 67). The roles of housewife and society maiden that were created by society did not allow for any room of expression by these women. The lack of women who at this time were seeking a higher education or pursuing the arts was very small. If they did not come from a family who supported them in their quest than most likely they did not get the chance to pursue their dreams. If a woman did want to extend their learning most of the time they did it in secrecy. A woman artist... ...kins. â€Å"The Yellow Wallpaper.† The Norton Anthology of American Literature, Shorter Sixth Edition. Ed. Nina Baym. Kahane, Claire. Passions of the Voice. Baltimore: The John Hopkins University Press, 1995. Leitch, Vincent B., ed. The Norton Anthology, Theory and Criticism. New York: W. W. Norton & Company, 2001. Showalter, Elaine. Sister’s Choice. New York: Oxford University Press, 1991. Toth, Emily. Introduction. A Vocation and a Voice. By Kate Chopin. New York: Penguin Book, 1991. vii-xxvi. Toth, Emily. Unveiling Kate Chopin. Jackson, Mississippi: University Press of Mississippi, 1999. Treichler, Paula A. â€Å"Language and Ambiguity.† The Awakening, A Norton Critical Edition. Ed. Margo Culley. Woolsen, Constance Fenimore. â€Å"Miss Grief.† The Norton Anthology of American Literature, Shorter Sixth Edition. Ed. Nina Baym.