Mental illness and stigma - Free Essay Example

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Introduction 1.1 Mental illness and stigma Inequalities in health services delivery and utilization for people with mental illness has been widely documented.1 Subsequently this results in poorer outcomes for this population in regard to general health, such as circulatory diseases, mortality from natural causes, and access to interventions .2-4 Several issues have been identified as contributing to these disparities in health service access and delivery, including stigma.5-6Stigma associated with mental illness has been defined as negative attitudes formed on the basis of prejudice or misinformation that are triggered by markers of illness.1-5Illness markers include atypical behaviours, the types of medication prescribed and noticeable medication related adverse effects.5-7These markers allow for the continuation of stigma concerning people with mental illness, but they also allow community pharmacists to identify patients with a broad range of what are often unaddressed health related needs.1 Behavioural and mental disord ers are estimated to account for 12% of the global burden of diseases. Mental health related medications account for 10% of all medications prescribed by general medical practitioners8, therefore, it is an inescapable fact that community pharmacists must interact with patients suffering from mental health problems.9 Mental illness is relevant to practising pharmacists who can play vital roles in the treatment of patients with mental illness.10 Throughout the latter half of the previous century, the diagnosis and pharmacological treatment of mental illness improved radically.9 1990-2000 was proclaimed the à ¯Ã‚ ¿Ã‚ ½Decade of the Brain. Don’t waste time! Our writers will create an original "Mental illness and stigma" essay for you Create order to promote the study of disorders of the brain, including mental illnesses.11 Despite these advances, the stigma associated with mental illness remains a compelling negative feature in society.10 Unfortunately health care professionals, including pharmacists are not invulnerable to such harmful attitudes.9 Pharmacists attitudes toward mental illness and the mentally ill are extremely important because they can affect their professional interactions and clinical decisions.12-13 In addition, they could ultimately affect the delivery of pharmaceutical care which has been defined as the pharmacist assuming the responsibility for positive patient outcomes.14 Activities like medication counselling and monitoring of therapy have been documented to improve both satisfaction and adherence to drug therapy in patients with mental illness.15 It has been pointed out that pharmacists must become more involved in such activities for patients with mental illness.9 1.2 Optimising the use of medications for mental illness Community care offers many advantages over institutional care; however, it can place extra demands on family, friends and primary health care practitioners.16 Health professionals have identified people with mental illness as the most challenging patients to manage.8 The quality and accessibility of community care for people with mental illness needs to be improved.17 The appropriate use of medicines plays an imperative role in the effective management of mental illness, nonetheless, there is evidence that psychotropic medicines are often used inappropriately.18-19 Elderly people are especially susceptible to the effects of psychotropic medicines, and may experience adverse effects such as cardio toxicity, confusion and unwanted sedation .8 Contributing factors to the high rates of non-compliance to psychotropic medicines include, psychosocial problems, the emergence of side effects, and the delayed onset of action of anti-depressant medication.20-21 Medical co-morbidity is also co mmon, and polypharmacy increases the risk of medication misuse and drug-drug interactions.22 The World Health Organisation (WHO) has indicated that the inclusion of pharmacists as active members of the health care team can improve psychotropic medication use.23 The benefits of dynamically engaging mental health service users in their own management is supported by both clinical experience and research evidence.24 A systemic review of the role of pharmacists in mental health care, published in 2003, concluded that pharmacists can bring about improvements in the safe and effective use of psychiatric medicines.23 The wide range of pharmaceutical services provided by community pharmacists are potentially well suited to assisting patients and prescribers optimise the use of medications for mental illness.8 2. Method 2.1 Literature search strategy Pubmed (1965-March 2010), International Pharmaceutical Abstracts (1970-March 2010), Embase (1974-March 2010), Cinahl (1981-March 2010) and Psychinfo (1972-March 2010) were searched using text words and MeSH headings including: community pharmacist.s, pharmacist.s, pharmaceutical care, pharmaceutical services, mental illness, mental disorders, stigma and mental illness, mentally ill persons, depression, schizophrenia, bipolar disorder, psychotic disorders, psychotropic drugs, antidepressive agents, benzodiazepines, anxiety agents and antipsychotic agents. ~550 abstracts were read. Reference lists of retrieved articles were checked for any additional relevant published material. Exclusion criteria included articles not published in English, no service provided by pharmacists, not relevant to mental illness, and studies and surveys that were carried out to evaluate pharmacist.s services in hospital inpatient or acute care settings. The literature search identified 88 papers that repor ted or discussed community pharmacist.s involvement in the care of patients with mental illness. 2.2 Inclusion criteria and review procedure For section 3.1 of the discussion, studies and surveys conducted into the attitudes of community pharmacists toward mental illness and the impact of stigma were considered. The literature review procedure for section 3.2 of the discussion, which deals with optimising the use of medication for mental illness, differed from that of 3.1, as studies without control groups, results of postal surveys and qualitative interviews were excluded. Studies with a parallel control group that reported the provision of services by community pharmacists in community and residential aged care facilities were considered. This included trials specifically conducted for individuals with a mental illness, and studies of medication reviews and education initiatives to optimise the use of medication for mental illness. Papers that reported pharmacist.s interventions in nursing homes were included, because community pharmacists frequently provide services to nursing homes. Studies of pharmacist.s activitie s as part of multi-disciplinary teams were also included. The literature search identified 57 papers that reported or discussed community pharmacy services to optimise the use of medications for mental illness. 3. Discussion 3.1 Mental illness and stigma While the views of the public9 and of certain health care professionals25 and health care students26-28 toward mental illness have been well documented over the years, there are limited numbers of investigations accessing community pharmacists and pharmacy student.s attitudes. Crimson et al.12 examined the attitudes of 250 baccalaureate pharmacy students toward mental illness, Phokeo et al.29 studied the outlook of 283 community pharmacists toward users of psychiatric medication, Cates et al.9 detailed the attitudes of community pharmacists toward both mental illness and the provision of pharmaceutical care to patients with mental illness, and Black et al.1 studied the satisfaction that patients with mental illness have with services provided by community pharmacists. 3.1.1 Community pharmacist.s attitudes toward patients with mental illness In general, pharmacists express positive, unprejudiced attitudes toward mental illness,1, 9, 29, 30 and overall they show encouraging attitudes toward the provision of pharmaceutical care.9 Phokeo et al.29 reported that pharmacists feel uncomfortable inquiring about a patient.s use of psychiatric medication and discussing symptoms of mental illness compared to the medication and symptoms associated with cardiovascular problems. Pharmacists also monitor patients with mental disorders for compliance and adverse effects less frequently than patients with cardiovascular problems. Crimson et al.12 found an association between a personal or family history of mental illness and attitudes of pharmacists toward mental illness. Age and years in practice are also connected with attitudes toward providing pharmaceutical care to patients with mental illness. The older and more experienced pharmacists have more encouraging responses than their counterparts.9Pharmacists are of the opinion, howeve r, that patients with mental illness do not receive adequate information about their medication from their physicians. These patients may also receive less attention from pharmacists compared to medically ill patients, which raises concerns that their drug-related needs are not being met.29 3.1.2 Patient.s attitudes toward community pharmacists Consumers of mental health services generally have a positive perception of community pharmacists and their services, however, expectations are limited to standard pharmacy services, like providing patients with information about their medication and resolving prescription issues when dispensing medications.29 The majority of patients feel at ease while discussing their psychotropic medication and related illnesses with pharmacists.31 Clinically orientated services like working collaboratively with other health care providers, making dosing or treatment recommendations, monitoring response to treatment, and addressing the individuals physical and mental health needs have been found to be unavailable to patients.32 Patients with mental health problems, expectations of community pharmacists are low, and do not match the services that they can provide.33 Although stigma has been perceived to be similar with other health care professional, Black et al.1 revealed that 25% of patients wi th mental illness have experienced stigma at community pharmacies. 3.1.3 Substance misuse The prevalence of coexisting substance misuse and mental illness (dual diagnosis) has increased over the past decade, and the indications are that it will continue to do so.15 A patient with both a mental illness and a substance misuse problem can face prejudice and stigma from health care professionals, who might question the capacity of dually diagnosed individuals to respond to care.34 A Canadian survey into the attitudes of community pharmacist.s toward mental illness showed that only 55% of respondents agreed that substance misuse is a mental health problem. This finding reflects the perception that addiction represents poor self control or is a self inflicted problem.29 Over recent years, the capacity to intervene pharmacologically in substance misuse has increased greatly, pharmacotherapy is now available for opiate, alcohol and nicotine misuse.19 Some psychiatric patients with comorbid substance abuse achieve stabilisation rapidly, furthermore, severe mental illness does no t necessarily predict worse outcomes.35 Socio-economic and emotional aspects are the main challenges to recovery, and case management in the context of integrated community and residential services has been shown to increase medication compliance over time.36 The contribution that community pharmacists have in the management of substance abuse has been well documented.37 Most general psychiatrists are only in the position to give patients 5-10 minutes of brief advise or intervention regarding a substance misuse problem,38 whereas community pharmacist.s are easily accessible to the public and are in a central position to provide specific advice about substance misuse.37 Community pharmacists currently provide dispensing services to drug addicts,38 and they are also the first point of contact for people misusing substances who are not in touch with the substance misuse services.39 3.1.4 Overcoming the barriers created by stigma Studies have indicated that patients prefer to go to the same pharmacy for their medication and other pharmacy needs and a significant number of patients favour to interact with the same pharmacist, which suggests that the relationship they have with their pharmacist plays an imperative role in their health and well being.1 A lack of privacy from failure to use an available private counselling room in the pharmacy contributes to patients feelings of discomfort regarding talking about their medication and their illness.31 Pharmacists are trained to educate and support patients regarding psychotropic medications, including how a drug works, monitoring for treatment response and adverse effects, and guiding patients through the process of stopping treatment, however, there are inconsistencies in the provision of these services.29 The potential for discrimination and stigma in community pharmacies has been well documented and initiatives to improve exposure of pharmacists to persons wi th mental illnesses in practice and in training has been suggested.23, 29 Pharmacists experience an increased level of discomfort in this therapeutic area as they receive inadequate undergraduate training in mental health.9 Adequate training in mental health is needed to improve the professional interactions of community pharmacists toward users of psychiatric medication.1 3.2 Optimising the use of medications for mental illness Community pharmacists are one of the primary health care providers in the community and have the opportunity to influence patient.s perception of their mental illness. Patients are far less likely to adhere to medications for mental health problems outside the hospital setting. Community pharmacists can significantly contribute to optimising medication use in mental illness through counselling, 40-42 patient education and treatment monitoring, 43-36 medication review services, 30, 47-49 pharmacotherapy meetings with general medical practitioners, 50-54 delivering services to community mental health centres and outpatient clinics,55-57 improving the transfer of information between health care settings,58-60 and being active members of community mental health teams.61-63 3.2.1 Counselling services In the Netherlands, three studies were carried out to highlight the impact of community pharmacist.s medication counselling sessions for people commencing non-tricyclic antidepressant therapy.40, 42 Intervention patients participated in three consecutive counselling sessions which lasted between 10 and 20 minutes each. They also received a take-home video that reiterated the importance of adherence. Throughout the counselling session, pharmacists informed patients about the appropriate use of their medications, which included, providing information about the benefits of taking the medication, informing patients about potential side effects, informing patients about the onset of action for antidepressant medication and explaining the crucial importance of taking their medication on a daily basis. Medication compliance was measured using an electronic pill container that recorded the time and frequency that the cover was opened.41 At the three month follow up the intervention patient s had significantly more positive attitudes compared to the controls.40 At six months greater medication compliance was observed with the intervention patients that remained in the study25 55, also apparent improvements in symptoms were noted.41 Research on adherence shows that the patient.s knowledge and beliefs about the benefits of adhering to their medication regime plays a critical role in compliance.64 Non-adherence is not an irrational act but rather a product of poor communication.65 Patient compliance to health care recommendations is more likely when communication is optimal.66 The results of these studies indicated improvements in depressive symptoms,41 more positive attitudes,40 and better compliance to their medication.42 A limitation of this method was that the same pharmacist provided counselling services to both the intervention and the control group. As the intervention studied was multifactorial, it is inconclusive whether the three face-to-face counselling sess ions or the take home video were primarily responsible for changes in drug attitude, adherence and the symptom scores.40-42 3.2.2 Patient education and treatment monitoring Four studies have reported results from pharmacist conducted patient education and treatment monitoring services for people prescribed antidepressant medications in the United States.43-46 These services involved the pharmacist taking a medication history, providing information about the prescribed antidepressant medications, and conducting telephone and face-to-face follow-ups. In two of the investigations, one of which was controled43 and the other randomised controlled, 62 medication adherence was calculated by reviewing prescription dispensing data, and reported using an intention-to-treat analysis. Both studies also demonstrated that involvement of the pharmacist was associated with a decrease in the number of visits to other primary health care providers; however, statistical significance was only achieved in one of the studies. Improved adherence to antidepressant medication was reported in both studies, 43-44 although patient satisfaction was only evident in one.44 The othe r two studies were randomised controlled.45-46 One of the studies was conducted using a self administered health survey,45 while in the other study antidepressant adherence was measured by asking patients how many times a day they took their medication in the past month. The results obtained from these investigations45-46 showed that patients who were taking their medication at the six month follow-up exhibited better antidepressant compliance and improved symptoms. However, antidepressant adherence and depression symptoms scores were similar for both the intervention and control group.46 Given the high rates of antidepressant discontinuation during the first three months of treatment, pharmacists have a potentially crucial role in providing medicines information and conducting treatment monitoring for those patients at high risk of non-compliance. Studies need to be conducted to compare outcomes of pharmacist.s treatment monitoring of people commencing antidepressant medication and other health professionals monitoring.8 An investigation into the impact of nurses treatment monitoring, also demonstrated improved medication adherence.67 3.2.3 Medication management reviews Pharmacist conducted medication management reviews are crucial in identifying potential medication related problems among people taking medications for mental illness.8 Medication review services provided by pharmacists comprise of comprehensive medication history taking, patient home interviews, medication regimen reviews, and patient education.68 A randomised controlled study of pharmacist conducted domiciliary medication reviews was carried out in the United States. The patients involved in the study were individuals living independently in the community that were identified to be at high risk of medication misadventure. The results showed a significant decline in the in the overall numbers and monthly costs of medication, however, there was no major difference in cognitive or affective functioning between the intervention and control group. The majority of patients were unwilling to follow the pharmacist.s recommendations to discontinue benzodiazepines and narcotic analgesics.4 7 The great potential of pharmacist conducted medication reviews for people with mental illness may not be limited to optimising the use of mental health medication.8 Physical health care for people with mental illness is generally less than adequate. This is caused by the tendency among health professionals to focus solely on the management of the mental illness among people with both mental and physical illnesses. Pharmacist conducted medication reviews may be a comprehensive strategy to improve medication use for both mental and physical illness.68 3.2.4 Medication management reviews in nursing homes Older people who are cared for in nursing homes are arguably the most vulnerable patient group, and the useful contribution that pharmacists can make to the care of these patients has been documented.30 Older people are particularly sensitive to the effects of medication,69 regular use of psychotropic medication is associated with an increased risk of recurrent falls,70 and also long term usage is linked with tardive dyskinesia.71 Psychotropic medication use may also be connected with an increased rate of cognitive decline in dementia.72 The beneficial effects of psychotropic medication must be balanced against extrapyramidal and other side effects.73 In 1995 it was reported that psychotropic drug use in Australian nursing homes was 59%, although this figure has fallen in recent years.74 In Ireland, 19% of older people in nursing homes were reported to be taking phenothiazines,75 however, this figure is lower now following a tightening of the licensing indications of thiordazine . In the England, a study showed that 30% of residents in nursing homes were taking antipsychotics.76 Two studies have looked at the appropriateness of psychotropic medication prescribing in the United Kingdom. In Scotland antipsychotic medication use in nursing homes is 24%, it was found that 88% of these prescriptions were inappropriate if the United States criteria for use were applied. In England, 54% of prescriptions were found to be inappropriate according to the United States criteria.77 A study conducted in Denmark suggested that behavioural problems were a determinant for the use of antipsychotics and benzodiazepines, irrespective of the psychiatric diagnosis of the resident.78 A randomised controlled study of pharmacist-led multidisciplinary initiative to optimise prescribing in 15 Swedish nursing homes was carried out. The study involved pharmacists participating in multidisciplinary team meetings with nurses and physicians at regular intervals within a 12 month period . A significant decline in the use of antipsychotics, benzodiazepines and antidepressants by 19%, 37% and 59%, respectively was observed in the intervention facilities.79 A follow-up investigation of the same intervention and control facilities three years later indicated that the intervention facilities maintained a significantly higher quality of drug use, with far fewer residents being prescribed more than three drugs that could lead to confusion, not-recommended hypnotics and combinations of interacting drugs.48 An additional randomised controlled study showed that pharmacist.s medication reviews in residential care facilities demonstrated significant reductions in the number and cost of medications prescribed. 10.2% fewer residents were administered psychoactive medications and 21.3% fewer hypnotic medications. The impact of medication reviews on mortality was also measured and a noteworthy reduction was observed.49 One study indicated that one hour per week of a pharmacist.s t ime can make a significant contribution to patient care in nursing homes. It was found that this input was well received by nursing staff and prescribers and that general medical practitioners accepted the pharmacist.s advice in 78% of cases.30 Physician.s recognition was 91% in south Manchester, where 55% of interventions resulted in treatment modifications. Community pharmacist.s in Northamptonshire analysed prescriptions of nursing home residents and provided prescribing advice to general medical practitioners. The advice was accepted in 73% of cases and it was estimated that pharmacist involvement could give a 14% reduction in the cost of prescribing.69 A randomised controlled trial in 14 nursing homes in England showed that a brief medication review reduced the quantity of medication overall with no detriment to the mental and physical functioning of the patients.58 A reduction in the use of primary and secondary care resources by pharmacist medication review services has also been shown.80 The recommendations provided by pharmacists included stopping and starting medicines, generic substitution, switching to another medicine, dose modification, changes in administration frequency, formulation change and requests for laboratory tests or nurse monitoring.30 Almost 50% of the recommendations were to stop medication and 66% of these were due to the fact that there was no indication for the drug prescribed. This suggested that medication regimes were not reviewed. Conversely, initiation of a new drug made up 8% of recommendations, which implied that indications were present but not always treated76. Pharmacists have an important part to play in multi-disciplinary health teams and they must be integrated into any proposed models of care. Nursing home residents are a vulnerable group of patients who deserve the same high-quality clinical care as people of any age living at home.30 3.2.4 Pharmacotherapy interventions to optimise prescribing Pharmacist.s educational visits to general medical practitioners have been shown to modify prescribing behaviour.54 Four studies have evaluated the impact of pharmacists educational visits to general medical practitioners to optimise the prescribing of benzodiazepines and other psychotropic medications prescribed for mental illness,50-53 two of which showed positive results.52-53 A cluster randomised controlled study carried out in the United States found that pharmacists educational visits to general medical practitioners were associated with a significant decline in the prescribing of potentially inappropriate psychotropic medications in intervention facilities.53 An Australian study of educational visits to general medical practitioners, conducted by three physicians and one pharmacist resulted in a noteworthy decline in the prescribing of benzodiazepines.52 In the Netherlands, groups of local pharmacists and general medical practitioners conduct inter-professional meetings t o optimise prescribing. These pharmacotherapy meetings are undertaken as part of routine clinical practice. A cluster randomised study of pharmacotherapy meetings to discuss prescribing of antidepressant medications resulted in a 40% reduction in the prescribing of highly anticholinergic antidepressants, compared to a control group of practitioners that did not partake in these meetings39. The possible awareness of prescribing related issues generated by asking general medical practitioners to conduct a self-audit of their prescribing caused this overall reduction.52-53 Additionally, pharmacist.s initiatives to improve prescribing are most effective when both pharmacists and general medical practitioners have an opportunity to build rapport.39 3.2.5 Community mental health centres and outpatients clinics Two studies were carried out to investigate the effect of pharmacist delivered services to community mental health centres and outpatient.s clinics.56-57 In a controlled trial, pharmacists managed patient cases in a community mental health centre in the United States. Significantly better personal adjustment scores were observed from patients receiving case management from a pharmacist in comparison to those receiving it from a nurse, social worker or psychologist.56The patients also rated themselves as healthier and were considerably less likely to seek help from other health care providers. The medication service provided allowed the pharmacist to adjust medication doses and dose timing, and prescribe or discontinue medications under supervision. The cost effectiveness of incorporating a pharmacist as part of the health care team was also measured. It was estimated that a 60% cost reduction can be achieved when medication monitoring is conducted by a pharmacists instead of a clin ic psychiatrist. The pharmacist also performed more medication monitoring of patients per month than the clinic psychiatrist and had more contact with each individual patient .56 In Malaysia, a study of patients discharged from hospital after admission for relapse of schizophrenia, who were identified as having poor medication adherence were allocated to receive pharmacist medication counselling or standard care.57 The importance of compliance to medication was also reinforced by the patient.s psychiatrists at follow up visits. At the 12 month follow-up, patients receiving counselling from a pharmacist and who were exposed to daily or twice daily medication treatments, had significantly fewer relapses that required hospitalisation than patients receiving standard care.57 3.2.6 Integrated mental health services The needs of people with recurrent, severe mental illness fluctuate over time and services must be coordinated, and be able to anticipate, prevent and respond to crisis. Integrated mental health services across primary and specialist services should promote early interaction and allow the provision of continuous care to meet patients needs.58 Prescribed medication is an important component in the successful management of mental illness. Accurate information should be transferred seamlessly between primary and secondary sectors to ensure the optimum care of these patients.59 The simple delivery of information to community pharmacists regarding drugs prescribed at discharge enables comparison with general medical practitioners prescriptions and any discrepancies can be followed up and resolved.82 Discrepancies that may occur can be described as any changes observed between supplies of prescribed drugs, including a wide spectrum of observed events.83 These can range from simple cha nges between supplies of prescribed drugs to more complex errors that might result in adverse reactions.60 This information transfer enables a cost-effective reduction in all unintentional discrepancies, including those judged to have significant adverse effects on patient care.58 An investigation that evaluated the impact of providing mental health patients with a pharmacist generated medication care plan at the time of discharge found that patients with care plans were less likely to be readmitted to hospital than those without. Information contained in the care plan included lists of discharge medications, a summary of the patient education that was provided, and the potential adverse effects that need to be assessed. Community pharmacists who received copies of the care plan were also more likely to identify medication related problems for the discharged mental health patients than those pharmacists who were not provided with copies of the care plan, however, the results from th is study are not significantly significant.57Other methods of transferring information such as electronic transfer have the potential to be of value in this patient population.84 People with mental illness have complex needs which are not recognised by organised boundaries.58When discussing discharge and after-care in the community, medication management must be prioritised.85Mentally ill patients are vulnerable and medication is a vital part of their well being. It is therefore essential that an accurate transfer of information between care settings minimises the potentially harmful discrepancies that can occur. Community pharmacist.s interaction in this area could prevent such incidents.58 3.2.7 Community mental health teams Most people with bipolar mood disorders and psychotic illnesses in the United Kingdom and Australia are managed by interdisciplinary community mental health teams (CMHTs).86 The potential benefits of greater involvement by pharmacists in CMHTs have been documented and debated for over 30 years.87-90 The majority of clinical team meetings conducted by CMHTs do not involve a pharmacist. A review of CMHTs in New South Wales found that just 1 in 5 had a designated pharmacist.91 Pharmaceutical care programs provided by pharmacists working as members of CMHTs can fulfil an important public need.32 Psychotropic medications are frequently used for unapproved indications,92-94 outside recommended dosages,95-96 and are prescribed concurrently.97-99 Adverse drug reactions to psychiatric medications include extrapyramidal side effects, weight gain, sedation, orthostatic hypotension and antcholinergic effects.32 Patients taking psychotropic medications may have higher rates of mortality, hospit alisation, and experience more adverse drug reactions.100-101 Routine monitoring for potential metabolic and cardiovascular complications of antipsychotic treatment is suboptimal.102-103 In addition, patients with mental illnesses have reported their dissatisfaction with the quantity and quality of drug information provided by their health professionals.104 Potential roles for community pharmacist.s in CMHTs in the United Kingdom have been investigated, with 7 possible pharmaceutical care roles being identified, they included, patient facilitating, instalment dispensing, domiciliary visiting, provision of medication education and advice, adherence monitoring, medication reviews, and inter-professional liaison.61 A survey of pharmacist.s interventions at 12 mental health trusts in the United Kingdom reported the detection of 579 cases of less than ideal prescribing of which 60% were clinical in nature.105 Between 35% and 81% of pharmacists recommendations for patients of CMHTs hav e been judged clinically significant by expert panels.62-63 Pharmacists participation in CMHTs could be facilitated by the formation of collaborative working relationships with community pharmacists working in the same locality as CMHTs. An Australian study into the impact of community pharmacists being active members of CMHTs was carried out, in one case the study pharmacist was also the local community pharmacist, this was perceived as a factor that contributed to the success of the collaboration. New models of pharmaceutical care proposed from focus groups comprising of psychiatrists, indicated the new level of awareness and recognition of the potential of community pharmacy services. Most of the studies conducted in this area raised the important issue of whether pharmacists should be considered as essential and legitimate members of interdisciplinary CMHTs.32 4. Conclusion Herein, I have discussed the contribution that community pharmacist.s can make to the care of patients with mental illness. The provision of community pharmacist.s services are limited by a lack of specific training to counsel this patient population, and pharmacist.s attitudes toward people with mental illness. Community pharmacist.s need to examine an address factors that can predispose, enable, and reinforce activities and behaviours associated with stigma toward people with mental illnesses in their practice setting. I believe that the wide range of pharmaceutical services provided by community pharmacist.s are potentially well suited to assisting patients and prescribers optimise the use of medications for mental illness. The review of the international literature highlights that medication counselling and treatment monitoring conducted by community pharmacist.s can improve medication adherence. Community pharmacist.s performed medication reviews and resulting recommendations to optimise medication regimens may reduce the numbers of potentially inappropriate medications for mental illness prescribed to elderly people. This review of the available published evidence supports the continued expansion of pharmaceutical service delivery to people with mental illness. I am of the opinion that, community pharmacist.s services are seriously under utilised in the mental health sector of the health system. Community pharmacists should be considered as essential and legitimate members of multi-disciplinary health and social services teams, and they must be integrated into any proposed model of care. References 1. Black, E.; Murphy, A. L.; Gardner, D. M. à ¯Ã‚ ¿Ã‚ ½Community pharmacist.s services for people with mental illnesses: preferences, satisfaction, and stigmaà ¯Ã‚ ¿Ã‚ ½. Psychiatric Services 60, (2009): 1123-1127 2. Kisley, S.; Smith, M.; Lawrence, D. à ¯Ã‚ ¿Ã‚ ½Inequitable access for mentally ill patients to some necessary proceduresà ¯Ã‚ ¿Ã‚ ½. Canadian Medical Association Journal 176, (2007): 779-784 3. Hiroech, U.; Kapur, N.; Webb, R. à ¯Ã‚ ¿Ã‚ ½Deaths from natural causes in people with mental illness: a cohort studyà ¯Ã‚ ¿Ã‚ ½. Journal of Psychosomatic Research 64, (2008): 275-283 4. 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G. à ¯Ã‚ ¿Ã‚ ½Under recognised and under treatment of depression: what is the pharmacist.s culpability?à ¯Ã‚ ¿Ã‚ ½ Pharmacotherapy 19, (1999): 1237-1239 15. Bultman, D. C.; Svarstad, B. L. à ¯Ã‚ ¿Ã‚ ½Effects of pharmacist monitoring on patient satisfaction with antidepressant medication therapyà ¯Ã‚ ¿Ã‚ ½. Journal of the American Pharmaceutical Association 42, (2 002): 36-43 16. Meadows, G. N. à ¯Ã‚ ¿Ã‚ ½Overcoming barriers to reintegration of patients with schizophrenia: developing a best-practice model for discharge from specialist careà ¯Ã‚ ¿Ã‚ ½. Medical Journal of Australia 178 (2003): 53-56 17. Chang, E.; Daly, J.; Bell, P.; Brown, T.; Allan, J.; Hancock, K. à ¯Ã‚ ¿Ã‚ ½A continuing educational initiative to develop nurse.s mental health knowledge and skills in rural and remote areasà ¯Ã‚ ¿Ã‚ ½. Nursing Education Today 22, (2002): 542-551 18. à ¯Ã‚ ¿Ã‚ ½Improving access and use of psychotropic medicinesà ¯Ã‚ ¿Ã‚ ½. Geneva, World Health Organisation (2004) 19. Mort, J. R.; Aparasu, R. R. à ¯Ã‚ ¿Ã‚ ½Prescribing of psychotropic.s in the elderly: Why is it so often inappropriate?à ¯Ã‚ ¿Ã‚ ½ CNS Drugs 16, (2002): 99-109 20. Lambert, M.; Conus, P.; Elde, P.; Mass, R.; Karrow, A.; Moritz, S.; Golks, D.; Naber, D. à ¯Ã‚ ¿Ã‚ ½Impact of present and past antipsychotic side effects on attitude toward typ ical antipsychotic treatment and adherenceà ¯Ã‚ ¿Ã‚ ½. European Psychiatry 19, (2004): 415-422 21. Rettenbacher, M. A.; Holder, A.; Eder, U.; Hummer, M.; Kemmier, G.; Weiss, E. M.; Fleischhacker, W. W. à ¯Ã‚ ¿Ã‚ ½Compliance in schizophrenia: psychopathology, side-effects, and patients attitudes toward the illness and medicationà ¯Ã‚ ¿Ã‚ ½. Journal of Clinical Psychiatry 65, (2004): 1211-1218 22. Lambert, T. J. R.; Velakoulis, D.; Pantelis, C. à ¯Ã‚ ¿Ã‚ ½Medical comorbidity in schizophreniaà ¯Ã‚ ¿Ã‚ ½. Medical Journal of Australia 178, (2003): 67-70 23. Finley, P. R.; Crimson, M. L.; Rush, A. 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Community Mental Health 29, (1993): 223-234 29. Phokeo, V.; Sproule, B.; Raman-Wilms, L. à ¯Ã‚ ¿Ã‚ ½Community pharmacist.s attitudes toward and professional interaction with users of psychiatric medicationà ¯Ã‚ ¿Ã‚ ½. Psychiatric Services 55, (2004): 1434-1436 30. Furniss, L. à ¯Ã‚ ¿Ã‚ ½Use of medicines in nursing homes for older peopleà ¯Ã‚ ¿Ã‚ ½. Advances in Psychiatric Treatment 8, (2002): 198-204 31. Bell, J. S.; Aaltonen, S. E.; Bronstein, E. à ¯Ã‚ ¿Ã‚ ½Attitudes of pharmacy students toward people with mental disorders, a six country studyà ¯Ã‚ ¿Ã‚ ½. Pharmacy World and Science 30, (2008): 595-599 32. Bell, J. S.; Rosen, A.; Aslani, P. à ¯Ã‚ ¿Ã‚ ½Developing the roles of pharmacists as members of community mental health teams: perspectives of pharmacists and mental health professionalà ¯Ã‚ ¿Ã‚ ½. Research in Social and Administrative Pharmacy 3, (2007): 392-409 33. Bell, J. 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J.; Stalman, W.; Nieuwenhuysea, H.; Bakker, B.; Heerdink, E.; De Haan, M. à ¯Ã‚ ¿Ã‚ ½A pharmacy based coaching programto improve adherence to antidepressant treatment among primary care patientsà ¯Ã‚ ¿Ã‚ ½. Psychiatric Services 56, (2005): 487-489 43. Finley, P. R.; Rens, H. R.; Pont, J. T.; Gess, S. L.; Louie, C.; Bull, S. A.; Bero, L. A. à ¯Ã‚ ¿Ã‚ ½Impact of collaborative pharmacy practice model on the treatment of depression in primary careà ¯Ã‚ ¿Ã‚ ½. American Journal of Health-System Pharmacy 59, (2002): 1518-1526 44. Finley, P. R.; Rens, H. R.; Pont, J. T.; Gess, S. L.; Louie, C.; Bull, S. A.; Lee, J. Y.; Bero, L. A. à ¯Ã‚ ¿Ã‚ ½Impact of collaborative care model on depression in a primary care setting: a randomised controlled trialà ¯Ã‚ ¿Ã‚ ½. Pharmacotherapy 23, (2003): 1175-1185 45. Adler, D. A.; Bungay, K. M.; Wilson, I. B.; Pei, Y.; Supran, S.; Peckham, E.; Cynn, D. J.; Rogers, W. 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Childhood Obesity The United States - 1202 Words

Childhood obesity is becoming one of the top public health concerns in the United States. â€Å"Over the past three decades, childhood obesity rates have tripled in the U.S., and today, the country has some of the highest obesity rates in the world: one out of six children is obese, and one out of three children is overweight or obese† (World Health Organization, 2015). With the drastic increase in obese children over the last 30 years and the huge healthcare associated costs many programs and incentives have been implemented to fight this epidemic. Although any child can become obese â€Å"racial and ethnic inequities persist among children; 22.5 percent of Latino children and 20.2 percent of Black children are obese, compared to 14.1 percent of†¦show more content†¦The program provides in home eduction about the importance of nutrition and exercise in the life of the mother and infant. ECHO aims to teach mothers the benefits of breastfeeding and when to introdu ce solids and what foods to feed babies. The program also emphasizes the harm that giving babies juices and sugar-sweetened beverages can have. â€Å"Feeding infants energy-dense, high-fat, high-sugar and high-salt foods is a key contributor to childhood obesity† (WHO, 2015). Helping mothers make healthy choices in their infants life and teaching them the harm of certain choices and foods is a preventive action and can have a lasting impact on a child’s life. The aim of ECHO is to prove that interventions and behavior modification in mothers and infants lives can help prevent obesity in the child’s future. ECHO hopes to bring the program into many homes and provide a healthy beginning to infants in low-income areas. When a parent is educated about healthy life style choices they often will teach their children how to lifestyle. Diet is one of the main factors that contributes to childhood obesity. Access to healthy food key factor of childhood obesity prevention. Reaching minority and low income populations and providing access to affordable health food choices can help in the fight against childhood obesity. Eating well and making health food choices is often expensive and a lot of families are not able to afford these kind of foods. People

To Investigate Importance Of Physical Architecture Essay Free Essays

string(134) " treatment one may feel that there something more than physical dimension, which makes public infinite socially sustainable infinite\." The essay aims to look into importance of physical and non spacial facets and their interrelatedness thru series of geographic expeditions and apprehension by instance surveies ( Old market square Nottingham and St John churchyard Hackney ) with theoretical statements.At the terminal paper would happen out cogency of selected theoretical statements about the physical and non physical facets. Further the interrelatedness of the of these facets will research. We will write a custom essay sample on To Investigate Importance Of Physical Architecture Essay or any similar topic only for you Order Now The selected cased surveies are Market square Nottingham and St John God’s acre, Hackney, London. ‘Many interior decorators and designers regard public infinite as the publically owned empty spots between edifices. Many of these infinites are useless or unsafe and abandoned, with the consequence that ‘this renders their definition as public infinite nothing and nothingness ( Worpole and Greenhalgh, 1996 ) This essay besides opposes the generic manner of thought of planning and designing of the unfastened infinites sing merely physical properties of design. This essay besides advocates wholly different position for sing the unfastened infinite and non the stereotype impression of aesthetic, beautification, take a breathing infinite, or lungs infinite. ‘The Parkss are volatile infinites and tend to runs to the extremes of popularity and unpopularity ‘ ( Jane Jacob 1960 ) . Open infinite is unstable entity and quiet unpredictable in many ways, and have much more significance than mere take a breathing infinite or lung infinite or merely to fulfill the unfastened infinite norm set by the town planning or development control ordinance. ‘There are far excessively many unfertile place and windswept corners that are infinites left over from another map ( such as traffic circulation or natural lighting demands for tall edifices ) .This phenomenon is Sometimes referred to as ‘SLOAP ‘ – infinite left over after be aftering ‘ . ( Henry Shaftoe 2008 ) Open infinite planning and planing inherently critical compared to other edifice or land uses this has lowest grade of the spacial excitations but can be highly vulnerable if non decently thought. This essay arranged to flux from the theoretical to practical. Attempts to bring out the facets that constitute public infinites. 1.2 Defining and understanding Open infinite Open infinite has different reading for interior decorator and designer and the end-users. The town and state planning act defines it as ‘land laid out as a public garden, or used for the intents of public diversion, or land which is a obsolete entombment land ‘ . This definition is consequence of academic or what town contriver A ; architect feels about the public infinite as public garden or infinite for diversion can non specify holistically. Conversely Gehl defined the unfastened infinite on the footing of the activity forms and more users centric. ‘An sphere allows for different types of activities embracing necessary, optional, and societal actives ‘ ( Gehl 1987 ) . However Walzer ‘s definition is more inclusive and holding societal dimension, he says Public infinite is infinite where we portion with aliens, Peoples who are n’t our relations, friends or work associates. It is infinite for political relations, faith, commercialism, athletics ; infinite for peaceable coexistence and impersonal brush. Its character expresses and besides conditions our public life, civic civilization, mundane discourse Walzer ( 1986 ) The above reading gives different virtuousnesss of the unfastened infinite and establishes importance of it. Chapter 2. Discussion of Theories and Principles This chapter would cover about statements of the spacial and non spacial facets of the public infinite. Kavin lynch ‘s theory about the ocular facets of the ocular facets of the cityscapes easiness with which its parts can be recognized and can be arranged in to coherent form ( Lynch 1960 ) . However Henry Shaftoe argues ‘People want coherency and a sense of safety in public infinites, but they do n’t desire blandness ‘ ( Kaplan and Kaplan 1989, Marsh 1990 ) . I would state topographic point devising should see both facets as they are every bit contribute for doing the topographic point societal sustainable. I would wish to confirm with Rasmussen statement who says ‘It is non adequate to see architecture ; you must see it ‘ ( Rasmussen 1959 ) ‘Sensuous demands may co-occur or conflict with other demands but can non be separated from them in planing or judgment, nor are they ‘impractical ‘ or simply cosmetic, or even nobler than other concerns. Feeling is indispensable to being alive ‘ . ( Lynch 1971p189 ) Lynch statements are pro aesthetic or pro physical development but harmonizing to him the physical scene is strong plenty to make the sense of the topographic point. Other observer differs with Lynch ‘If our apprehension is limited to a ocular apprehension, we merely concentrate on forms. If, nevertheless, we go beyond visual aspects, we start a spacial apprehension, a three dimensional experience. We can come in this infinite, instead than merely see it. The same applies to the design of infinites. We do non make mere visual aspects but infinites that we can utilize for different intents ‘ . ( Madanipour 1996 p99 ) . The undertaking for public infinite has put frontward Ten Principles for Creating Successful Squares. However it would be hard to use this rule universally as said earlier Open infinite is unstable entity and is affected by socio- economic system, political relations, and human ecology and other societal ailments or good qualities. Generalised attack for planning and planing unfastened infinite may non work as the unfastened infinite is alone in many ways. Further Ali Midanapour expressed concern over planing without understanding the world. ‘This position of design, as an elitist, artistic endeavor which has no relationship to the existent, day-to-day jobs of big subdivisions of urban societies, has led to the decrease of urban design to a ocular activity ‘ ( Ali Midanapour 1997 ) . Similar to above statement Henry Shaftoe emphasis on the psychological dimension /non spacial dimension of the unfastened infinite ‘Public infinites serve a figure of practical maps, being topographic points for trading, meeting, conversing, resting and so on. Yet there is an extra dimension to public infinite – it can carry through certain psychological demands every bit good as strictly physical 1s. By ‘psychology ‘ in this context, I mean anything that affects our behavior or feelings. ( Henry Shaftoe 2008 ) From the above treatment one may feel that there something more than physical dimension, which makes public infinite socially sustainable infinite. You read "To Investigate Importance Of Physical Architecture Essay" in category "Essay examples" As infinite is an enclosing component and it encloses the activity. Activity is non needfully being merely physical enclosure centric. Chapter 3. The Research Question ‘Do merely aesthetically fulfilling public infinite can organize the socially sustainable infinites ‘ ? The research inquiry would research the interrelatedness of the non spacial dimension with spacial one in designing of the unfastened infinite. Underpinnings and rules of the doing successful infinites would be tested on the real-time instance surveies to formalize the statements. The testing of the theoretical hypotheses may give us the being of the non design facets and their importance. The inquiry besides explores how intentional public infinites matched to the cross subdivision of the society. 3.1 Framework for probe. Since the research inquiry demands geographic expeditions qualitative and quantitative facets. The of import virtuousness of the instance survey would be ocular study, thru which I would look into the both physical and non physical facet of the instance survey. ‘Only through eternal walking can the interior decorator absorb into his being the true graduated table of urban infinites ‘ ( Edmund Bacon 1975 ) . The recognizance study would be distributed over weekends weekdays and different period of a twenty-four hours. Further the instance survey would look into the qualitative facet of the study through people perception study. The probe of non spacial facets would be done by Reconnaissance study and the Study of tenancy in different period of hebdomad and different period of twenty-four hours. Besides examines the tenancy in gay and non gay season. Non spacial facets would be done by semi structured interviews with end-users to cognize what they feel about public infinite what is missing. What is the factors attractive force or repulsive force to the unfastened infinite? Their aspirations about the unfastened infinite. Due to restriction of the academic paper the sample of size of the instance surveies would be little. However the series of ocular geographic expedition and reconnaissance study would bridge the spread. 3.2 Case surveies The instance surveies for the testing are Nottingham old market square and St. John church viridity. Idea of choosing these instance surveies is they portion similarities in many ways, some of them are postulated below. Surrounded busy commercial country. Cardinal location of the metropolis and country i.e. east London. Heritage structures around like church and St.Augustine tower in footings of Hackney, town hall and Municipal council office. Areas offer Transport connectivity to the remainder of the metropolis or country. Nottingham Old market Square Area of the old market square is 4,400m2, quiet geometrical ( i.e. inner square approximately 100 x44 m ) . The natural topography of the original medieval square is exploited in the design by gradual degrees for wheel chair users and for drainage flow. The council house forms the border of the northern border of the market square Figure 1 The study demoing the solid and null country of the market square The enclosure of the market square is formed by constructing about. Inner Square is bounded by the commercial, constitution ‘s coffeehouse, restaurants and branded supermarkets via Debenhams. Outer ring of the pedestrianised on North and east side portion of the Square. Strategically located in the bosom metropolis commercial country the edifice has utilised about 100 % of the secret plan are. The country around the market square represents all right grained development. 3.3 Case study no-1 The St John Church Yard -Hackney London Area of the public infinite – 3.83 hour angle. The St John Church Yard -Hackney London is outstanding pubic infinite in Hackney cardinal. A mixture of different infinites, the gardens provide a formal scene for the church and Clapton Square to the North. The public infinite is isolated from the from the busy Mare street. From part majorly utilised for the inactive diversion and rear countries constitutes the kids play country. The St. John Church and St. Augustine tower is major landmark of the country helps in voyaging prosaic traffic. 3.4 Discussion of instance surveies illations and theory 3.4.1 Amenities- ‘A square should have comfortss that make it comfy for people to utilize.A bench or waste receptacle in merely the right location can do a large difference in how people choose to utilize a topographic point ‘ ( www.PPs.org 2009 ) . However Urbanist William H. Whyte ‘s suggested more ‘flexible attack ‘ harmonizing to him ‘in public infinites, people prefer movable chairs to repair seating. Peoples like to command their ain infinite, and movable chairs allow them to make merely that. Movable chairs let people face one another and interact in different ways. ‘ ( hypertext transfer protocol: //www.city-journal.org/2009/eon1019am.html ) This suggests that planing the unfastened infinites should be sing mind of larger subdivision of the society and non merely what landscape interior decorator ‘s want. Harmonizing to H. Whyte maintaining the scattered would direct a message of trust that people will non steal them. Conversely, since the unfastened infinite is affected by the society ailments and frailty versa, this besides can non be generalised rule. 3.4.2 Seasonal Strategy – Is programme is overmastering than infinite? ‘Successful Square ca n’t boom with merely one design or direction scheme ‘ . ( PPs.org 2009 ) . This statement is quiet valid in many ways, public needs to alter or accommodate as per the seasons. In absence of the seasonal scheme may ensue underutilisation of the infinite in certain period of twelvemonth. The seasonal scheme is good demonstrated in Old market square Nottingham. Figure 6 Shows the wheel of Nottingham by and large opens from February to stop of April. ( hypertext transfer protocol: //www.wheelofnottingham.co.uk/index4.html ) Figure 5 Shows the ice skating sphere and German market is chief attractive force in the winter. During Christmas the infinite is filled with activities and peoples. The seasonal scheme is programme that is implemented. The seasonal schemes non merely do the best use but besides generate activities throughout the twelvemonth.Further makes infinite more economically sustainable and can be managed good. This rule can be supported with Henry shaftoe ‘s statement, he says ‘As a species we are sociable animate beings who like to garner in groups or battalions. Therefore, when we see people like us lingering in a infinite, we are attracted to it, over and above any physical or environmental attractive forces that the topographic point may hold ‘ . ( Henry Shaftoe 2008 ) On the other manus the Hackney does n’t show as stronger seasonal scheme or programme. Therefore ST.John God’s acre is n’t able generate activities to pull the people. Even if Hackney church pace has appealing landscape gardening, the heritage construction Church and St. Augustine tower, locality to the busy market street and strategic positing. However the scheduling limited for the certain period of clip of twenty-four hours but he country around the market square is chiefly commercial so this country becomes dull and inactive so leads to less perceptual experience of safety. 3.4.3 Flexibility and Adaptability ‘The usage of a square alterations during the class of the twenty-four hours, hebdomad, and twelvemonth. To react to these natural fluctuations, flexibleness demands to be built in. Alternatively of a lasting phase, for illustration, a retractable or impermanent phase could be used. Likewise, it is of import to hold on-site storage for movable chairs, tabular arraies, umbrellas, and games so they can be used at a minute ‘s notice ‘ . ( www.PPs.org 2009 ) . The principal of flexibleness and adaptability can been seen in the old market square. The H2O characteristic of the old market square is 1.8 thousand H2O autumn, rivulets and 53 jets and a scrim, arranged as patios. This H2O characteristic can be turned off and used as phases or impermanent screening countries. Five listed lanterns and two flag poles have besides been refurbished and integrated into the new strategy. 3.4.4 Peoples pulling people or steering physical properties of public infinite ‘Any great square has a assortment of smaller â€Å" topographic points † within it to appeal to assorted people. These can include out-of-door caf A ; eacute ; s, fountains, and sculpture, †¦ ( www.pps.org ) However Henry shaftoe argues ‘As a species we are sociable animate beings who like to garner in groups or battalions. Therefore, when we see people like us lingering in a infinite, we are attracted to it, over and above any physical or environmental attractive forces that the Topographic point may hold. ( Sahftoe Henry ) . If we test above the statements on St. John God’s acre, Hackney, Henry Shaftoe ‘s statement is holds cogency. Because St. John God’s acre has quiet pulling physical properties such as St John church, Saint Augustine tower but still fails to pull peoples. Similarly in study one of the interviewee said, he follows the crowd for utilizing the infinite. This may because more figure of people gives perceptual experience of safety and for many users sense community is much more of import than the physical visual aspect of the scene. 3.4.5 Interrelation of the Inner Square, Outer Square, and Series of Small Squares ‘Visionary park contriver Frederick Law Olmsted ‘s thought of the â€Å" interior park † and the â€Å" outer park † is merely as relevant today as it was over 100 old ages ago. The streets and pavements around a square greatly affect its handiness and usage, as do the edifices that surround it ‘ . ( www.pps.org 2009 ) This rule is quiet right and can be seen in the Old market square as the street on the northern and eastern side are wholly pedestranised with active frontage facing towards the square. It provides surveillance and besides increases its tenancy. Further Henry Shaftoe adds new dimension of series of squares. ‘Some of the most gratifying public infinites are those that consist of a series of squares connected by short prosaic paths, so that one can roll through a series of Unfurling tableaux. ‘ ( Henry Shaftoe 2008 page figure 80 ) This hypothesis is valid in footings of market square as shown in program the Old market square is surrounded by series of smaller squares of the size ( mention fig no xxxxxx ) . Figure 6 the study demoing little public infinites around the Old market squares shown in blue. the smaller public infinites around the market squares makes people to flux into the old market square Further the grounds of interrelatedness of spacial character, graduated table and proportion are derived from how human perceive it. Kavin lynch has put frontward some dimension of the outdoor squares based on how we experience the out-of-door infinite. â€Å" We can observe human being from the distance of 1200 m, recognize him at 25 m see his facial look at 14 m, and experience him in direct relation to us -present or intrusive -at 1-3 metre. † ( kavin lynch 1 Gary Hack2 1971 ) further he says the dimension 12 are confidant and up to 25 metre is still an easy for human graduated table This hypotheses are valid in the in the smaller squares near to the Market squares viz near to the express vacation in western side. ( 17 Wide ) And 2nd square ( as shown in phtoxxx in ) northern side 9 near to the, pizza hut etc which is 28 metre ( measured from www.googlemaps.co.uk ) . 3.4.6 Natural elements The natural component are besides important subscriber in the in heightening the experience of the infinite. ‘The feel of the warm zephyr, or a sudden iciness Draft, the sound of air current through the trees, or blasts of blown fall leaves waken the passer-by to the present minute. These intense experiences of alteration or difference in nature – particularly those that are peculiarly gratifying – may arouse shared looks of delectation and pleasance ‘ . ( Lennard and Lennard 1995 p39 ) In reconnaissance study and the semi structured interview uncovers the natural elements such as the visible radiation and shadiness of trees, thick green grass, sound of H2O adds up to the experience of infinite, so the park is non stay mere physical entity it turns in to see. And experience of the infinite makes users to see once more and once more. 1.1 Summary of findings, decisions In visible radiation of the instance surveies and the statements of different writers it points out towards our experience of the topographic point is combination of all senses non merely ocular. This hypothesis forms the lineation of the aesthetic and environmental psychological science. There are many factors such as right graduated table enclosures sense of machination, easiness of apprehension, neither claustrophobic nor agoraphobic etc many of these factors interact in really harmonious mode. The aesthetics dominates desires believing in many ways for the simple ground it is they are visually appealing, therefore interior decorators approach is aesthetic centric and tends to overlook the non spacial facets such the noise, odor, touch, sense of topographic point The unfastened infinite phenomenon in the typically urban context is truly unstable and dynamic. In my sentiment handling the unfastened infinite more carefully and non merely left over or take a breathing or lungs infinite or merely attractive unfastened infinite, it much more than that. As designer we should non enforce individualized thought on the unfastened infinite as terminal users are one who makes it successful. The physical enclosure of public infinite is one that starts the interaction and non design facets are besides moving as accelerator to organize socially sustainable infinite. The essay restriction being academic survey and research more by increasing sample size and besides clip restriction. Reconnaissance study and user ‘s perceptual experience study with bigger sample size and including representative of cross subdivision of society i.e. based on age group ethnicity, physically handicapped etc distributed over the twelvemonth. We may non get at definite solutions or exact constellation of what unfastened infinite should or should non hold but planing of unfastened infinite maintaining users psyche in foreground would decidedly give the hints for planing the socially sustainable unfastened infinites Safety and Regulation of use of infinite Puting things together after every chapter Mentions The winning design – ‘The Defender of the City ‘ hypertext transfer protocol: //www.nottinghamcity.gov.uk/www/marketsquare/design.asp ( 2 -1-2010 4.30 autopsy ) Gustafson Porter. ( 2008 ) . ‘the Guardian of the City ‘ . Available: hypertext transfer protocol: //www.gustafson-porter.com/intro.htm. Last accessed 3 Jan 2010 4.30am. Hackney Council. ( Mar 09 ) . Draft Interim Hackney Central Area Action Plan. Avilable: hypertext transfer protocol: //www.hackney.gov.uk/draft-hackney-central-masterplan-p102-mar09.pdf. Last accessed 3 Jan 2010 p114 ) Andrew M. Manshel. ( 2009 ) . A Topographic point Is Better Than a Plan. Available: hypertext transfer protocol: //www.city-journal.org/2009/eon1019am.html. Last accessed 1 January 2010. Shaftoe. H ( 2008 ) . Convivial Urban Spaces: Making Effective Public Places. London: Earthscan.p. 51 Lynch. K ( 1960 ) . The Image of the City. 15th erectile dysfunction. Cambridge: MIT Press. p2, 49,81. Lynch.K, Hack K ( 1984 ) . Site Planning. 3rd erectile dysfunction. Cambridge: MIT Press. P.157, 158 Bacon E ( 1975 ) Design of Cities. Thames A ; Hudson, London Worpole K and Greenhalgh L ( 1996 ) . The Freedom of the City. Demos: London. p14. Jacobs. J ( 1961 ) . The Death and Life of Great American Cities: The failure of town planning. 3rd Ed. New York: Random House. p88 Gehl, J. ( 1987 ) Life between Buildings: Using public infinites, New York: Van Nostrand Reinhold p. 2, 3, 85 Walzer, M. ( 1986 ) ‘Public Space: Pleasures and Costss of Urbanity ‘ , Dissent 33, 4: 470-475. Rasmussen S.E ( 1959 ) . Experiencing Architecture. London: Chapman and Hall. P 33. Madanipour, A. ( 1997 ) . ‘Ambiguities of Urban Design ‘ , Town Planning Review. Liverpool: Liverpool University Press. p 363-367. Gallacher P ( 2005 ) Everyday Spaces: The potency of neighbourhood infinite. Thomas Telford, London Edmund Bacon 1975 ( Lennard and Lennard 1995 p39 Carmel, CA: Gondolier Press,  ©1995 ) How to cite To Investigate Importance Of Physical Architecture Essay, Essay examples

The Wifes Story free essay sample

The Wife’s Story by Ursula K. Le Guin is a story about a woman married to a man who turns out to be a werewolf. In this tale Le Guin reverses the typical werewolf story into the point of view of other wolves. She tells the story in a first person narrative which is very effective. The narrator’s voice in this story changes the ways you will normally respond to any other story. The Wife’s Story is not the typical werewolf story you would expect.In Le Guin’s story she describes a wifes retrospective of what she should have seen in her husband before it was too late. She describes suspicious behaviors that lead the reader to understand that he is a werewolf. She realizes that her husband changes at the dark of the moon into a human. The way she describes this werewolf is very different than the usual werewolf story. We will write a custom essay sample on The Wifes Story or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page The werewolf has white skin with no hair like a worm, eyes blue with white rims around the blue, mouth flat and wide, and teeth flat and dull.This is quite unusual for a werewolf to look which makes this story more interesting. I believe Le Guin chose to write this story with a first person narrator because it is more effective to the reader. In the first paragraph of The Wife’s Story says, â€Å"I don’t believe it happened. I saw it happen but it isn’t true. It can’t be. He was always gentle†. This shows the wife’s emotions after she discovers her husband is a werewolf. She is confused and still feels everything is unreal. Le Guin’s choice of writing this story in a first person narrative keeps the reader interested and motivated to keep reading. The narrator’s voice in The Wife’s Story affects how the reader responds to the story because of the tone the narrator uses telling her experience discovering her husband’s secret. In this story, Le Guin helps the reader relate to the wife and how she was married to a werewolf without knowing it. She was in love with a man, or that’s what she thought, who was so kind and others would look up to.Finding out that the man she was in love with was in reality a horrible creature was still unbelievable. The narrator makes the readers more interested. The Wife’s Story is an unpredictable story. Ursula K. Le Guin’s choice of a first person narrative was just right for this kind of story. The tone used in here was more interesting than any other fairy tale told before. Showing how the wife’s reaction towards her husband’s change was more effective to me. Le Guin’s story was very interesting and not your

ACT Study Guide Schedule and Plan for One Year or More

SAT / ACT Study Guide Schedule and Plan for One Year or More SAT / ACT Prep Online Guides and Tips You're serious about studying for the SAT. You have a year or more to study, and you want to put a real effort into it. Is studying this much worth it? What are the payoffs? And most importantly, what's the best way to study for the SAT / ACT on the year-or-more level? This post answers those questions! First, let's get a couple of important questions out of the way. Is Studying for a Year or More Worth It? Who Should Use This Guide? The short answer: yes, it's absolutely worth it. We know from recent studies that a 105-point increase on your SAT score (equivalently, 1.5 points on your ACT score) doubles your odds of getting into a given college. If you had a 10% chance of getting into Harvard before, it increases your chances to around 20%. And a 105 point increase can be obtained in a few dozen hours. This means that even if you're studying 100 hours for the SAT / ACT, those 100 hours are doing much more to increase your chance of getting into college than, say, sports or clubs. A study schedule of a year or more is definitely worth it for students who care about getting into the best colleges. How Many Hours Do I Need? How Far Ahead of Time Should I Start? If you're starting your studying a year or more before you take the test, plan to spend at least a hundred hours or more. As this SAT / ACT study schedule planner suggests, you don't want to study too few hours when you start far ahead. You should also begin studying so that you aim to take the test junior year fall (I'll explain more below). If you're planning a year to study, start during the winter or spring of your sophomore year. If you're on the more aggressive schedule of studying for a couple of years, you want to get started at the end of freshman year. Want to improve your SAT score by 160 points or more? We've put our best advice into a single guide. These are the 5 strategies you MUST be using to have a shot at improving your score. Download this free SAT guide now: Why Aim to Take SAT / ACT in the Fall of Junior Year? Many students aim to take the SAT / ACT junior spring or senior fall. But as an advanced student, if you really care about the SAT / ACT, your goal is to optimize everything about your studying. Optimizing the test date means taking it early. Why take the SAT / ACT so early? Because you want buffer space in between tests. If you don't do well junior fall, you'll still have two more chances junior spring (March and May for the SAT, February and April for the ACT) and won't have to run into summer after junior year and senior fall for testing. This is a huge advantage because you'll have all that time to focus on applying to college. And trust me, from my personal experience, you'll need that time. Think about it this way: what's the harm in taking the tests one month earlier than necessary? Okay, you stress one month earlier, and maybe you take the test with one less month of education. This is really not a large loss. What's the harm in taking it one month later than necessary? Last minute application scrambling, prep courses, and tons of stress. Take the safe bet: aim to take the tests junior fall. The First Step Okay, so you're aiming to test in junior fall, and you have around a year or more - this puts you at sophomore year or younger (if not, follow our guides for more moderate studiers). If you're starting earlier, just stretch the dates in this guide out evenly, like a rubber band. September of Sophomore Year The first thing you want to do is take two practice SAT / ACTs. Use real SATs or real ACTs. The first SAT / ACT you take, do not time yourself. You can break it into multiple pieces. Focus on readingall the instructions and the fine print. Also, focus on understanding the question and not the time pressure. If you've already taken a few SAT / ACTs in the past, you can skip this first test. Reflect on the main features of the test. Are there strategies you can already see without being told? What do you think are some tricks you can use to solve questions? (If you're using PrepScholar, we tell you this automatically). After this, take the test a second time, but follow the timer strictly. Then reflect on how time pressure changes things, and what you must do to counter this. With this second test, you also have a sense of what your mistakes are. For each mistake, write down two reasons you made it, like "carelessness" or "didn't know quadratic equation." Then, tally up the reasons and brainstorm ways to study for them. (If you're using PrepScholar, this tally analysis will be done for you automatically). These two tests will also prepare you well for the PSAT, which happens in October of sophomore year (see the PSAT timeline here). November of Sophomore Year You now have a list of major errors and how to study for them. For example, you might find yourself forgetting grammar rules, and so you'll spend 10 hours memorizing the most commonly tested grammar rules on the SAT. Or you might find that you don't know quadratic equations, and spend 10 hours reviewing them. You'll want to prioritize your content issues first. Content issues are those with fundamental knowledge of math, reading, writing, science, and so forth. These are things like what subject verb agreement is, trapezoids and their properties, and so on. Content issues are the hardest to forget, so studying early has an advantage. These issues are also the most the scalable: even if you dump a lot of time into fundamental content, you'll continue to improve as you know more of it. In fact, if you are scoring under a 1330 on the SAT or a 30 on the ACT, most of your gap is simply due to missing fundamental content. So make sure your foundations are strong. When exactly to take the next step depends on both your time budget and how much fundamental content is missing. If you're scoring, say, 1000 on the SAT or 18 on the ACT, and are budgeting over 200 hours, then the above steps should really be started earlier. The schedule here assumes you're studying 100 hours and already have a 1330 on your SAT / 30 on your ACT for the next step. March of Sophomore Year At this point, you want to shift towards strategy. Repeat the September analysis: do a timed test and see which questions are losing you points. However, this time notice where you're going wrong with strategy and test tactics instead of content. Notice when you run out of time, or make a careless mistake. Notice if you've rushed too much in one section versus another. Now come up with a few ideas to attack your strategic flaws (or if you're using PrepScholar, we come up with these strategies for you). Test out your plan by doing a few sections at a time. Do these new strategies you've thought up work? Iterate on these strategies, and repeat until you get your strategy down. At this point, ask yourself, are you getting the score you want for your school? If so, you can take it a bit easier (but still continue on). Otherwise, consider budgeting more time for studying. Bonus: Want to get a perfect SAT or ACT score? Read our famous guide on how to score a perfect 1600 on the SAT, or a perfect 36 on the ACT. You'll learn top strategies from the country's leading expert on the SAT/ACT, Allen Cheng, a Harvard grad and perfect scorer. No matter your level, you'll find useful advice here - this strategy guide has been read by over 500,000 people. Read the 1600 SAT guide or 36 ACT guide today and start improving your score. Summer before Junior Year This is Round Two of your studying. Repeat the September to March process: find more fundamental content weaknesses, and then look again for strategic weaknesses. Why split the process into two rounds? First, it increases your creativity - you may come up with strategies the second time around that you missed the first time around. Also, the strategies you use in the end will depend highly on your final performance. If you're scoring in the 800/1600 range on the SAT, skipping questions is key. If you're scoring 1270/1600, you can barely afford to skip any questions. By criss-crossing your studying this way, you get a better idea of your final score earlier on. Fall of Junior Year Sign up to take the first SAT or ACT of the year, usually August or September, respectively. Make sure you have a strong final week leading up to the test date. Before you take the test, estimate yourexpected "interquartile range." Suppose you expect there's a 75% chance you'll do better than a 900, and a 25% chance you'll do better than a 1000. Then your interquartile range is 900-1000. The Rest of Junior Year Take the SAT or ACT and then see what your score is. On your first test, if you score lower than the top of your interquartile range, plan to take it again in two months (likely December), following a shortened version of the study plan from the summer before your junior year. If your second score is less than the middle of your interquartile range, try once more in another 2-3 months, likely in February or March. Finally, if your third score is less than the bottom end of your expected interquartile range, try one last time, likely in June. Remember, taking the SAT / ACT more often is generally better for you, especially if you're scoring lower than you expected! Conclusion The above guide is a comprehensive way to study well for the ACT or SAT given 100 hours and 1 year or more of study time. The main theme is tallying up your mistakes and coming up with strategies to focus on them. If you want a system that automatically does this tracking and scheduling for you, check out our PrepScholar software. It comes with a free trial! Want to learn more about the SAT but tired of reading blog articles? Then you'll love our free, SAT prep livestreams. Designed and led by PrepScholar SAT experts, these live video events are a great resource for students and parents looking to learn more about the SAT and SAT prep. Click on the button below to register for one of our livestreams today!