Plan Market Research Assessment Essay

Introduction This Project scope â€Å"Regain† has been designed to involve all stakeholders of D.A. Garden Supplies so that all aspects of the business can be be analysed through collecting invaluable information and data by the research methods below. Our aim is to identify the cause of the problem that the business is going through right now so that future marketing can be targeted accordingly for positive results. With proper research and strategic planning, D.A. Garden Supplies should be able to recover its lost and on its way to a successful future. Preliminary project scope Project name: Regain Project Owner: Even Tan Sponsor: D.A. Garden Supplies Stakeholder: David and Alison Required resources, sample size and research assistance Resources required for the scope research will include human, financial and physical resources. These will be required for each type of data collection as follows: Focus Group – This is a small group of customers in a discussion to focus on the main thought of cause to the problem, the competition. Could be held in the lunch room over a 1 hour period. An external marketing professional would need to be hired to conduct the focus group and 6 participants from the target market would also be required for the discussion. Physical resources required are pens, paper, tea and coffee, brochures of competition and light refreshments. Overall cost including preparation of the focus group would be $550. Survey – After the focus group has taken place the survey can be developed from the data collected. The 5 min survey could be conducted at the local shopping centre focused on surveying a minimum of 30 to 60 people from the  target market over a 6 hour period. An external interviewing professional would need to be hired to conduct the survey and briefed on who to approach and what to say. Physical resources required include surveys, pens, clipboard and a bag to store completed surveys. Overall cost including preparation of survey and external staff would be $450. Research Reports and Internet Research – A specialist market research organisation will need to be hired to conduct this research and for analysing the data from these reports, survey results, interviewed staff and experiment of product. The cost for analysing this data into a detailed report would cost $740. Another cost would be the purchase of secondary data from Ibisworld. The â€Å"Garden supplies retailing in Australia market research report† is $845 and this will provide invaluable information into the industry. Interview Staff – This could be held in the lunch room each one of the 9 staff members should have a half hour interview conducted by external marketing professional. Physical resources required are a questionnaire and light refreshments. The total cost would be for development of the questionnaire and 4.5 hours of interviewing the staff, this would cost $650. Research Method and timeline This research are using both quantitative research and qualitative research, since it conducted surveys, focus group and meetings in order to gather needed information. Using qualitative method such as focus group able us to develop our survey, This way we know we will ask the correct questions that are needed when surveying our customers and potential customers. This method was chosen as it is beneficial in developing a successful survey. Using quantitative method for this research because it is easily analysed using statistical methods. For example, a survey is carried out to obtain information about people, such as their opinions, preferences, attitudes, expectations, likes and dislikes. This method was chosen as it directly targets our customers and potential customers to get their opinions on D.A. Garden Supplies and the competition. This whole research process going to take 2 weeks, that give us, the researcher enough time to analyze the data and come out with a detail solution on the problem. Data gathering Types of data required This research need a combination of data in order to get the best result. Secondary data- this data is information that already exists, information like the â€Å"Garden supplies retailing in Australia market research report† are statistics conducted by government. This resource is easier and cheaper to obtain, and it provide a great insight on the market itself. Primary data- this data does not exist, it requires the researcher to communicating with people or making observation about people and situation in order to generate the data. Although it is much harder and time consuming compare to secondary data, it is the most valuable resource for the company since it targets the specific problem that the company has. Formal Research and informal research- Conducting a survey able to cover a broad range of topics and able to gather as much information as the research need to, Informal research such as asking opinions from staff about the company and customers feedback and analysing the company sales statistics from internal records are the easiest way to gather in the shortest among of time, however, be careful with the data as it might be data that are not as subjective as primary and secondary data. Quantifying the data The sample size is chosen to maximise the chance of uncovering a specific mean difference, which is also statistically significant. The reason larger samples increase your chance of significance is because they more reliably reflect the population mean. Therefore it is necessary to conduct any survey or interview with as many participants as possible that is acceptable under the given financial budget. Data processing method There are some consideration in deciding how to process the data gathered will include: -type of analysis that will be required -the amount of data to be collected -available budget -available time Hiring an analyst able to handle a more complex data, and able to receive the most accurate data in a short amount of time. Less complex data can be dealt with a specialist statistical software, however it requires specific training and the software itself is expensive. Small market research can be dealt with Microsoft Excel as it able to handle basic statistics. Lastly, very basic calculation with small data sets can be undertaken using a statistical calculator. This research includes both quantitative and qualitative data, and result can be complex because it involves personal feelings and opinions from staff and consumers, therefore, hiring a statistician consider as the most appropriate method for this research, as they have the experience to deal with complex data and able to analyze all data and turn it into results that are easy to understand. Although it is expensive to conduct, if this research has done correctly, it could help D.A. Garden Supplies turn into a successful business. Draft Research Objective After our previous consultation and analysing the information in the scope the main objective is to find out if â€Å"the competition was the main cause for the 5% drop in sales† The sub-objectives are; 1) To examine customers and potential customers attitudes on the competition. 2) To identify needs of customers. 3) To determine whether new products need to be introduced. By using market research D.A. Garden Supplies will analyse the competition find the cause of the 5% drop in sales and then use this information to increase overall sales by 10%. Feasibility of the research and Conclusion Focus groups, interviewing staff and secondary data are all forms of exploratory research which essentially gather qualitative data, its findings are inconclusive and should not be used for final or important decision making. Therefore to make a final decision a survey or experiment must be conducted as they are both descriptive research which have quantitative data which makes the findings conclusive and useable. Therefore after analysing the above research methods, it could conclude that the focus group and survey would be the best data collecting methods to use to â€Å"find the cause of the 5% loss of sales profit for D.A. Garden Supplies† as it targets the customers and potential customers directly which will provide information needed to find whether the competition is the main cause. Although for the purpose of this research we will be using all of the research methods above as this will determine a thorough result. With this vital information we can eliminate the cause in future marketing plans making D.A. Garden Supplies sales successful in the future. If you find this project proposal are acceptable, I will need you, the business owner, David and Alison, and all other stakeholders to approve this research proposal.

Clausewitz in the 21st Century

Clausewitz lived in a time where battles were fought in columns and lines, with soldiers using muskets and solid-shot cannon; when states were the exclusive actors in war; when technological change occurred over decades, if not centuries. What relevance could his work therefore have for the strategic problems of the 21st century? Introduction Clausewitz was not a cookbook writer. He was not looking for hard and fast rules for conducting war, which he eschews.Indeed, Clausewitzian theories elaborated at different periods of time are in close conjunction with the prevalent political, strategic, and military context, which is completely consonant with Clausewitz’s original conception of his own work: ‘Theory should be study, not doctrine [†¦] It is an analytical investigation leading to a close acquaintance with the subject; applied to experience – in our case, to military history – it leads to thorough familiarity with it.The closer it comes to that goal , the more it proceeds from the objective form of a science to a subjective form of a skill, the more effective it will prove in areas where the nature of the case admits no arbiter but talent. ’ ‘Theory is meant to educate the mind of the future commander, or, more accurately, to guide him in his self-education, not to accompany him to the battlefield. ’ If ‘the absurd difference between theory and practice’ is to be ended, then the correspondence between theory and practice implies the correspondence between the military commander and military thinker.Therefore, ‘self-education’ is important and useful to the military thinker too. He must not be bounded by a single theory of war but with the means to develop his own ideas (objective knowledge of war), fuelled by his talent (subjective capacity and application). The phenomena of war are more diverse than ever: from terrorism to inter-state war, from information war to riots in rural are as, from air strikes to intifada. Loose networks of limited wars have replaced the expectation of a nuclear apocalypse that characterized the Cold War.The differences and contradictions between the various conclusions and corresponding analyses regarding a strategic situation are but a reflection of the variety of military conflicts and the diversity of perspectives from which these conflicts are observed. These perspectives depend on time, culture, and political context. This phenomenon has been analyzed through the concept of strategic culture, that is ‘a distinctive and lasting set of beliefs, values and habits regarding the threat and use of force, which have their roots in such fundamental influences as the geographical setting, history and political culture’.States (e. g. Americans, Europeans, Chinese, Iranians, Indians etc. ) tend to have different perspectives on strategic problems, and the reason for these divergences probably goes beyond the defense of short-t erm interests. The extremely heterogeneous situation of the phenomena of war is analyzed from very different lenses of different strategic cultures, and hence makes states’ theories of war difficult to critique. Moreover, it is difficult to validate the doctrines that reflect these different theories by the use of examples of operational success or failure.Therefore, the need for a theory-of-theories of war remains valid. An overarching theory of war will take into account the influence of the interaction between the thinker and his object and can form the framework required to analyze the strategic debate. Clausewitz thus continues to remain relevant to analyze strategic problems of the 21st century as he had developed a theory about the theory of war. Research ApproachClausewitz recognized that Napoleon had overreached himself and the theoretical significance that a consistent, single military strategy could have different historical outcomes. In his own realization  œ evident in his note of 1827 – that any theory of war had to accommodate two sorts of war: war to overthrow the enemy; and war that is the basis of negotiation with him. Four fundamental contrasts are emphasized between the early and later Clausewitz because they remain central to contemporary debates about his work: (1) The primacy of military force versus the primacy of politics. 2) Existential warfare, or rather warfare related to one’s own identity, which engaged Clausewitz most strongly in his early years, as against the instrumental view of war that prevails in his later work. (3) The pursuit of military success through unlimited violence embodying ‘the principle of destruction’, versus the primacy of limited war and the limitation of violence in war, which loomed increasingly large in Clausewitz’s later years. (4) The primacy of defense as the stronger form of war, versus the promise of decisive results that was embodied in the seizure of of fensive initiative.It is not the intent or purpose of this paper to summarize Clausewitz’s works, given its scope, or to challenge the assertions of specific anti-Clausewitz writers such as Martin van Crevald, John Keegan or even Alvin and Heidi Toffler. The paper will instead highlight the seeming unbounded-ness of war (or armed conflict) and violence in the twenty-first century, and propose a strategy of containment of war and violence. This will relate later Clausewitz’s concepts of war and politics to our current reality. At the outset, I will provide an analysis of Clausewitz’s concept of the nature of war.Additionally, given the research question’s implication that Clausewitz should be marooned due to his lack of regard for ‘non-state actors’ and that his writings were in a time of slow ‘technological change’, I will also demonstrate that Clausewitz was well-aware of the influence of non-state actors and their ability to wa ge war; and his thoughts has continued relevance in our time of rapid technological changes. The Nature of War For Clausewitz, war was likened to a chameleon, allowing for changes to its appearance, but suggesting that its underlying nature remains unchanged.The character of war has certainly changed or morphed since his time. His critics argue that some changes can alter war’s very nature, and the nature of war today is radically different from the nature of war then, the age of Napoleon. In other words, the changes are more fundamental than can simply be accounted by shifting characteristics. The most recent English translation of the text, by Michael Howard and Peter Parat, renders its opening sentence thus: ‘War is more than a true chameleon that slightly adapts its characteristics to the given case. As a total phenomenon its dominant tendencies always make war a remarkable trinity. Clearly, a chameleon remains a chameleon whatever color it adopts for the time being . The crucial two words in the translation are ‘more than’, which imply that the circumstances of war can cause war to change more than its characteristics: War in other words is not like a chameleon. However, this translation did not capture the nuance of Clausewitz’s original: ‘Der Krieg ist also nicht nu rein wahres Chamaleon, weil er in jedem konkreten Fall seine Natur etwas andert, sondern er ist auch seinem Gesamterscheinungen nach, in Beziehung auf die in ihm herrschenden Tendenzen, eine wunderliche Dreifaltigkeit’.The implication here is that war may indeed be a chameleon, in that it changes its nature slightly in each individual case (its ‘character’), but not its nature in general, which is made up of the ‘trinity’ (addressed later). The translation thus reads: ‘War is not only a true chameleon, because it changes its nature slightly in each concrete case, but it also, in it is overall appearance, in relation to its inherent tendencies, a wondrous trinity’. The Primacy of Policy and the ‘Trinity’ War is an instrument of policy. ’ It ‘is simply a continuation of political intercourse, with the addition of other means’. Clausewtiz’s aphorism on the relationship between war and policy was now being dismissed not because war had no utility but because it is being waged for reasons that are not political or policy-driven. Critics argue that Clausewitz no longer have a place in the current strategic and security studies debates, where war was no longer the province of armed forces but also of non-state actors.The question was whether strategy, traditionally-defined, continues to be the best way of looking at what was, revealingly, no longer even called war, but armed conflict. Clausewitz understood a community as having its own political and social identity, even if it lacked statehood. Such an interpretation is consonant with Clausewitz’s own interest in wars before 1648, where he specifically linked the weaknesses of states to ‘exceptional manifestations in the art of war’.In his review of the history of war, he described ‘the semibarbarous Tartars, the republics of antiquity, the feudal lords and trading cities of the Middle Ages, eighteenth-century kings and the rulers and peoples of the nineteenth-century’ as ‘all conducting war in their own particular way, using different methods and pursuing different aims’. Despite this variability, Clausewitz stresses that war is all these cases remains a continuation of their policy by other means. In doing so, however, he suppresses the difference between the policies of states and the intentions of other communities which wage war.Therefore, it makes sense to supplement the primacy of policy as a general category with the affiliation of belligerents to a warring community. If the communities are states, we can speak of politics in th e modern sense; if they are ethnic, religious, or other communities, the value systems and goals of those communities (their ‘cultures’) are the more important factors. Based on this, we could replace Clausewitz’s meaning of state with the notion of it being that of the intentions, aims or values of the â€Å"warring community,† thus remaining much more faithful to his understanding of what a state embodies.Otherwise, we would implicitly express a modern understanding of Clausewitz’s concept of state. Clausewitz’s concepts of war (including armed conflict) and violence continue to be relevant so long as they are motivated by interests and policy and not hate, rage, boredom, the need for personal meaning and bonding. Die Wunderliche Dreifaltigkeit (The Wondrous Trinity) Clausewitz describes the trinity as composed of: (1) Primordial violence, hatred, and enmity, which are regarded as a blind natural force; (2) The play of chance and probabilit y, within which the creative spirit is free to roam; and 3) Its element of subordination, as an instrument of policy, which makes it subject to pure reason. Read in tandem with Clausewitz’s metaphor of war’s appearance from case to case as a chameleon, the trinity addresses the underlying forces that drive those changes. His message was that the relationship among these three elements was inherently unstable and shifting. To quote, ‘the task†¦is to keep our theory [of war] floating among these three tendencies’, and not try to set, or to count on any fixed relationship among them. Clausewitz and a New ContainmentThe Removal of the Inhibitions on War and a New Containment The twenty-first century appeared for a time an age defined by economics and, to a great extent, peace. These expectations quickly disappeared with the massacres and genocides in Africa, return of war to Europe, the 9/11 attacks, the Iraq and Afghanistan wars with their continuing, vi olent consequences and the Arab Springs. A struggle against a new totalitarianism of an Islamic type appears to have started, in which war and violence is commonly perceived as having an unavoidable role, and perceived to be becoming more ‘unbounded’ than ever before.Spatially, the terrorist are potentially ever present. Temporally, there seems no end-in-sight to their attacks. We face new types of threats such as the development of atomic bombs by ‘problematic’ states like Iran and North Korea and the possession of weapons of mass destruction by terrorists. The emergence of China as a potential superpower and perhaps great powers, like India, may lead to a fresh arms dynamic, with the possibility of a nuclear dimension. Violence seems to be going out of rational control, an image that the media has not hesitated to portray.There is a grave portent of mankind confronting a ‘coming anarchy’ of unknown dimensions. Hence, a new strategy of contain ment is needed. There is no longer one exclusive actor to be contained. A strategy for military containment of China similar to that used against the Soviet Union in the 1950s and 1960s, will likely provoke all kinds of crises and even conflict, which such a strategy intends to avoid. Therefore, a different concept of containment is needed, one that is not perceived as a threat by China.The second difference is that current developments in the strategic environment display fundamentally conflicting tendencies. A strategy designed to counter only one of these conflicting tendencies may be problematic with respect to the others. Therefore, there is a need to strike a balance between competing possibilities. The third difference is that the traditional containment was perceived mainly as military deterrence of the Soviet Union. The new containment must combine traditional, military containment on one side and a range of opportunities for cooperation on the other.That is necessary with respect not only to China, but even to political Islam, in order to reduce the appeal of militant Islamic movements to millions of Muslim youths. In response to this unbounded-ness on war and violence, a conception for their containment is needed to provide a sustained and continual limitation through the ‘fencing in and encircling of the same forces’. The guiding perspective is that of a peaceful, or rather a pacified, global society. This perspective cannot be equated with â€Å"peace† since in order to reach this goal, non-peaceful, violent and even military means must in some cases be employed.Clausewitz’s Concept of Politics The defeat of Napoleon was the turning point of Clausewitz’s theory, where he faced the problem of dealing with strategies of limited war within the same conceptual framework as those leading to total defeat of the enemy. He realized that there are very different and even contrasting kinds of war and strategy. The conflicti ng tendencies in war, especially between ‘limited’ and ‘unlimited’ war compelled Clausewitz to conclude that the unifying general principle was politics. However, which kind of politics could serve to contain war and violence in the twenty-first century?Clausewitz’s notions of limited warfare have their foundations in the last parts of book VIII. They find some reflection in book I, chapter 2: ‘Be that as it may, we must always consider that with the conclusion of peace the purpose of the war has been achieved'; and further on: ‘Since war is not an act of senseless passion but is controlled by its political object, the value of this object must determine the sacrifices to be made for it in magnitude and also in duration. ’ In book VIII, he stated: ‘In this way the belligerent is again driven to adopt a middle course.He would act on the principle of using no greater force, and setting himself no greater military aim, than woul d be sufficient for the achievement of his political purpose. To turn this principle into practice, he must renounce the need for absolute success in each given case. ‘ It is a natural step to evolve from his strategy of limited warfare to one of the limitations of war and violence as the overarching purpose of political action in the twenty-first century. This perspective is still based on Clausewitz's statement that war is a continuation of politics by other means, while trying to actualize his concept of politics.Clausewitz describes war on the one hand as a continuation of politics, but on the other side as waged with other than political means. This implicit tension is the basis of the explicit contrast between the first and the third tendencies of Clausewitz’s trinity. Furthermore, one could argue that globalization and the ubiquity of information technologies have created a worldwide political space from which no one can escape, however much his actions might be derived, in their immediate motivation, from private interests or from the cultural practices of ethnic or tribal communities.Hence, the role of politics is intensified and reaction time within all three tendencies of Clausewitz’s trinity is reduced. Containing War and Violence in World Society The concept of containment is associated with the insight that we cannot expect in the foreseeable future to see fully non-violent societies or a non-violent world society. In addition, the aspiration to a world without conflicts as such fails to recognize that in the course of history conflicts and conflict solutions have frequently been necessary for human development.The main task confronting politics and social forces in the twenty-first century is the radical limitation, even diminishing of violence and war, so that non-violent structures can be sustained and the mechanisms of the ‘world of societies' can come to fruition. The overall political perspective on which the conce pt of the containing of war and violence in world society rests therefore consists of the following elements, the ‘pentagon of containing war and violence': 1) The ability to deter and discourage any opponent from fighting a large-scale war and to conduct precise military action as a last resort; (2) The possibility of using military force in order to limit and contain particularly excessive, large-scale violence which has the potential to destroy societies; (3) The willingness to counter phenomena which help to cause violence, such as poverty and oppression, especially in the economic sphere, and also the recognition of a pluralism of cultures and styles of life in world society; 4) The motivation to develop a culture of civil conflict management (concepts which can be summed up in the ‘civilizational hexagon', global governance, and democratic peace), based on the observation that the reduction of our action to military means has proved counterproductive and in the end will exceed our military capabilities; and (5) Restricting the possession and proliferation of weapons of mass destruction, their delivery systems, as well as of small arms, because the proliferation of both is inherently destructive to social order. Antulio Echevarria writes that ‘the U. S.National Strategy for Combating Terrorism also includes an essential, but rather ambitious goal of diminishing the conditions that terrorists typically exploit, such as poverty, social and political disenfranchisement, and long-standing political, religious, and ethnic grievances; reducing these conditions requires, among other things, fostering political, social, and economic development, good governance, the rule of law, and consistent participation in the â€Å"war of ideas† Further important tasks include preventing the proliferation of weapons of mass destruction and of small arms.Normative criteria are required for the containment of war and violence in world society. Such cri teria combine political–moral considerations with aspects relevant to every state's interest in self-preservation. It requires political actors to recognize the advantages of self-limitation as part of their own enlightened self-interest. In anthropological terms, we can see the roots of the political in the openness and indeterminacy of the human power to act. In historical terms, we can follow Aristotle in seeing these roots in the way we are forced to limit ourselves once we become aware of the contingency of human actions.It follows from this that one of the decisive questions for future development is that of the possible self-interest of the United States, or regional powers, making conflict subject to legal norms, in civil conflict management, and binding military power into alliance systems. President Obama’s ‘Pivot to Asia’ necessitated the development of a military strategy for the potential, if highly improbable, conflict with China. Seeking a d ecisive victory or traditional military containment are not viable strategies in current and projected realities, as they probably only serve to escalate the situation.Also, the United States must select ways that minimize the probability of escalation to nuclear conflict simply because it does not understand China’s nuclear release process and there is no winner in a major nuclear exchange. The logic leads to the concept of Offshore Control. Operationally, it uses currently available means and restricted ways to deny China the use of the sea in a strategy of economic strangulation to exhaust China to the point it seeks war termination. Penetration into China is forbidden to reduce the possibility of escalation and to make war termination easier.Offshore Control seeks to allow the Chinese Communist Part to end the conflict in the same way China ended its conflicts with India, the UN (in Korea), the Soviet Union and the Vietnamese. It allows China to declare it â€Å"taught t he enemy a lesson† and thus end the conflict. The progressive limitation of war and violence indefinitely can be an end to itself in the realization of a basically peaceful global policy. The enduring and progressive containment of war and violence is therefore necessary for self-preservation of states, even their survival, and for the civility of individual societies and world society.Conclusion Clausewitz, in his note of 1827, recognized the need to rework the whole of On War according to his new insight, the distinction between limited war and war whose aim is to overthrow the enemy and render him powerless. However, he was not always clear in his thoughts especially in his early writings and even up to 1827. For example, there is a lack of clarity on the discourse at the beginning of book I, chapter 1, of the three interactions that push war to the extreme, despite the fact that these sections were presumably written after the note of 1827.It can be said that for the purpo se of analyzing and studying warfare, both the early and later Clausewitz is of great importance and value. However, for political and military action of our time, perhaps only the later Clausewitz needs serve as an important basis. As Clausewitz himself emphasized at the end of his discussion of the trinity, ‘at any rate, the preliminary concept of war casts a first ray of light on the basic structure of theory, and enables us to make an initial differentiation and identification of its major components. Thinking about contemporary and future warfare with, and sometimes beyond, Clausewitz can still be the best way to begin. Bibliography 1. Andreas, H. -R. (2009). Clausewitz and a New Containment. In S. Hew, ; H. -R. Andreas (Eds. ), Clausewitz in the Twenty-First Century (pp. 283-307). New York: Oxford University Press Inc. 2. Andreas, H. -R. , ; Antulio , E. (2007, December 27). Clausewitz in the Twenty First-Century: Primacy of Policy and a New Containment. From World Secur ity Network: http://www. worldsecuritynetwork. com/showArticle3. cfm? article_id=14985 3. Antulio, E. (1995-1996, Winter).War, Politics and the RMA: The Legacy of Clausewitz. Joint Force Quarterly, pp. 76-80. 4. Antulio, E. I. (2003). Globalization and the Clausewitzian Nature of War. The European Legacy, 8/3, pp. 317-32. 5. Clausewitz, C. v. (1976). On War. In H. Michael, P. Peter, H. Michael, ; P. Peter (Eds. ). New Jersey: Princeton. 6. Durieux, B. (2009). Clausewitz and the Two Temptations of Modern Strategic Thinking. In S. Hew, ; H. Andreas (Eds. ), Clausewitz in the Twenty-First Century (pp. 251- 265). New York: Oxford University Press Inc. 7. Hammes, T. (2012, Spring). Offshore Control: A Proposed Strategy. Infinity Journal, 2(2), pp. 0-14. 8. Hew, S. , ; Andreas, H. -R. (2009). Introduction. In S. Hew, ; H. -R. Andreas (Eds. ), Clausewitz in the Twenty-First Century (pp. 1-13). New York: Oxford University Press Inc. 9. Antulio, E. (2009). Clausewitz and the Nature of the Wa r on Terror. In S. Hew, ; H. -R. Andreas (Eds. ), Clausewitz in the Twenty-First Century (pp. 196-218). New York: Oxford University Press Inc. 10. Ken, B. , ; R. , T. (1999). Strategic Cultures in the Asia-Pacific Region. London. 11. Metz, S. (1994). Clausewitz Homepage. From A Wake for Clausewitz: Toward a Philosophy of 21st-Century Warfare: http://www. lausewitz. com/readings/Metz. htm 12. Sumida, J. (2009). On Defence as the Stronger Form of War. In S. Hew, ; H. -R. Andreas (Eds. ), Clausewitz in the Twenty-First Century (pp. 164-181). New York: Oxford University Press Inc. ——————————————– [ 1 ]. Durieux, B. (2009). Clausewitz and the Two Temptations of Modern Strategic Thinking. In S. Hew, & H. Andreas (Eds. ), Clausewitz in the Twenty-First Century (pp. 251- 265). New York: Oxford University Press Inc. [ 2 ]. Carl von Clausewitz, On War, trans. and ed. Michael Howard and Pet er Parat (Princeton, NJ, 1976), II, 2, p. 141. 3 ]. Ibid. II, 2, p. 141. [ 4 ]. Ibid. II, 2, p. 142. [ 5 ]. Ken, B. , & R. , T. (1999). Strategic Cultures in the Asia-Pacific Region. London. [ 6 ]. Durieux, B. (2009). Clausewitz and the Two Temptations of Modern Strategic Thinking. In S. Hew, & H. Andreas (Eds. ), Clausewitz in the Twenty-First Century (pp. 251- 265). New York: Oxford University Press Inc. [ 7 ]. The same principles and strategies that were the decisive foundation of Napoleon’s initial successes at Jena and Auerstedt proved inadequate in the special situation of the Russian campaign and eventually contributed to his final defeat at Waterloo. 8 ]. Clausewitz or Sun Tzu – Paradigms of warfare for the 21st century written by: Andreas Herberg-Rothe, 13-Dec-06. WorldSecurityNetwork. com – WorldSecurityNetwork. com. http://www. worldsecuritynetwork. com/printArticle3. cfm? article_id=13757 [ 9 ]. On War, I, 1,  §28, P. 89. [ 10 ]. Hew, S. , & Andrea s, H. -R. (2009). Introduction. In S. Hew, & H. -R. Andreas (Eds. ), Clausewitz in the Twenty-First Century (pp. 1-13). New York: Oxford University Press Inc. [ 11 ]. Vom Kriege, ed. Werner Hahlweg (19th edn, Bonn, 1980), 1, 1,  §28, pp. 212-213. 12 ]. On War, VIII, 6B, p. 610. [ 13 ]. Ibid. p. 605. The phrase ‘with the addition of other means’ is deliberately used by Howard and Paret as they wanted to make it clear that war in itself does not suspend political intercourse or change it into something entirely different. Essentially, the intercourse continues, irrespective of the means it employs. The main lines along which military events progress, and to which they are restricted, are political lines that continues throughout war into the subsequent peace. It could not be otherwise.Political relations between peoples and between their governments do not stop when diplomatic notes are no longer exchanged. [ 14 ]. The German word Politik covers both policy and politics . Clausewitz did mean different things at different points. Sometimes the context suggests that he has foreign policy in mind, at others he highlights the social upheaval of the French Revolution and its consequence for warfare. [ 15 ]. Antulio Echevarria, ‘War, Politics and the RMA: The Legacy of Clausewitz’, Joint Force Quarterly, 10 (winter 1995-6), 76-80. [ 16 ]. On War, VIII, 3B, p. 589 [ 17 ]. Ibid. p. 586. 18 ]. Hew, S. , & Andreas, H. -R. (2009). Primacy of Policy and Trinity in Clausewitz’s Thought. In S. Hew, & H. -R. Andreas (Eds. ), Clausewitz in the Twenty-First Century (pp. 74-90). New York: Oxford University Press Inc. No modern translator is prepared to render wunderliche in the military context as â€Å"wonderful† or â€Å"wonderous†. Howard and Paret in 1976 used ‘remarkable’, which was a throwaway word of no particular significance. This was changed to ‘paradoxical’ in the 1984 edition, but this word seem s to have no relationship to wunderliche and carries inappropriately negative connotations. 19 ]. On War, I, 1,  §28. [ 20 ]. Ibid. Clausewitz’s description of the trinity followed after the metaphor of war as a chameleon. [ 21 ]. Ibid. [ 22 ]. George Kennan formulated his original vision of containment more than sixty years ago. Although altered in its application by various administrations in the United States, it has in practice been incorporated within the concept and politics of common security, which in turn has itself been the essential complement to purely military containment. [ 23 ]. In comparison to the Cold War. [ 24 ].Between globalization on the one hand, and local struggles for identity and regional advantages and interests on the other; between high-tech wars and combat with ‘knives and machetes’ or attacks by suicide bombers between symmetrical and asymmetrical warfare; between wars over the ‘world order’, with the re-politicizatio n and re-ideologization, between imperial-hegemonic dominance of the only superpower and the formation of new regional power centers; between international organized crime and the institutionalization of regional and global communities; and between increasing violations of international law and human rights on one side and their expansion on the other. [ 25 ]. Andreas, H. -R. (2009). Clausewitz and a New Containment. In S. Hew, & H. -R. Andreas (Eds. , Clausewitz in the Twenty-First Century (pp. 283-307). New York: Oxford University Press Inc. [ 26 ]. Clausewitz discussed unlimited and limited war in terms that supported his conception of the defense as the stronger form of war. The central issue in both cases of war was the will of the combatants. Unlimited war occurred when the attacker was determined to destroy the political independence of the defender through battle if necessary, and the defender no less determined to preserve its political independence. Equivalence in the stre ngth of will did not, however, mean the outcome would be determined by the balance of military forces and the fortunes of war.Even catastrophic military defeat at the hands of a militarily superior attacker, Clausewitz believed, would not produce a decision if the defender had the will to preserve what remained of his regular military forces by retreat even to the point of abandonment of all national territory, and to resort to armed popular support against the invader in spite of its potential to promote anarchy. Limited war meant a situation in which the attacker's objectives did not involve the destruction of the political independence of the defender, and the defender's stake in the outcome was thus not one of survival. (Sumida, 2009) [ 27 ]. Andreas Herberg-Rothe had elaborated this interpretation in Andreas Herberg-Rothe, Das Ratsel Clausewitz. Politische Theorie des Krieges im WIderstreit (Munich, 2001), 79-145, and in the English edition of the same book, Clausewitz’s Puzzle (Oxford, 2007).We can find this conclusion in the trinity; within the note of 1827, in which Clausewitz mentioned both aspects as guiding principles for reworking the whole text; in book I, chapter 2; and in most parts of book VIII of On War, [ 28 ]. On War, I, 2, pp. 91-2. [ 29 ]. Ibid. VIII, 3B, p. 585. [ 30 ]. It can be demonstrated that, due to systematic reasons but also with the respect to historical experience, trying to suspend this tension for the sake of the primacy of one of the two sides always leads to a primacy of the military means, of warfare and violence; see Beatrice Heuser, Reading Clausewitz (London, 2002). [ 31 ]. Antulio, E. I. (2003). Globalization and the Clausewitzian Nature of War. The European Legacy, 8/3, pp. 317-32. [ 32 ].Ernst Otto Czempiel, Weltpolitik im Umbruch. Die Pax Americana, der Terrorisinus und die Zukunft der interuationalen Bezh. ‘hungen (Munchen, 2002). [ 33 ]. Andreas, H. -R. (2009). Clausewitz and a New Containment. In S. H ew, & H. -R. Andreas (Eds. ), Clausewitz in the Twenty-First Century (pp. 283-307). New York: Oxford University Press Inc. [ 34 ]. Antulio, E. (2009). Clausewitz and the Nature of the War on Terror. In S. Hew, & H. -R. Andreas (Eds. ), Clausewitz in the Twenty-First Century (pp. 196-218). New York: Oxford University Press Inc. [ 35 ]. Hammes, T. (2012, Spring). Offshore Control: A Proposed Strategy. Infinity Journal, 2(2), pp. 10-14. [ 36 ]. Ibid. I, 1,  §28, p. 89.

Benefits Provided By Digital Marketing For Entrepreneurs

Benefits Provided By Digital Marketing For Entrepreneurs There are way many conspicuous benefits being provided by digital marketing for both entrepreneurs and barons from any type of company all over Australia. According to statistics, almost 30% of the marketing budget is channeled to digital marketing and 50% of the data we receive as targeted audiences are from the internet. This leads to a profit of about 35% from digital marketing. These statistics show that digital marketing is so much cost effective and budget friendly in return. Away from these, there are the key contributing aspects that have aided the rise of digital marketing in Australia. Redesigning and refurbishment of the Mobile advertising This sounds odd at first since many people dislike mobile advertising from the first mention. This is because it is disruptive when browsing on the internet and something irrelevant for your preferences pops up on the screen. Marketers have found a new way of approaching this. They do this by embedding adds in a more reasonable, tidy, enticing but friendly way. This has geared the rise of digital marketing in Australia by a tonne. The Content Marketing Idea This is based on the long-term relationship with the customers who at first are randomly selected regardless of whether they are targeted or not. After some time, the unwanted customers will be sieved off due to their lack of interest. Since it is done online, the marketers will follow up their clients closely with more adds. The output for this kind of marketing has really proved to be immense. The Gigantic Facebook Platform Of all the social media platforms, Facebook has really taken a wave. The incorporation of video clips on this site has given a boost to the rise of digital marketing in Australia. Marketers have really given this opportunity to mega investments. It is through this that many Facebook users are able to access marketed products by only logging into their accounts. This is attributed to the fact that the human mind is easily swayed away by videos rather than static pictures. Online Shopping We all live in an era where we opt not to spend the time to go out shopping. Instead, we do this online. Many trading companies have collaborated mutually with online shopping sites to serve their customers with products and advertisements. The rise of digital marketing in Australia has not yet been experienced since every day, we wait for yet another revolution that will drive it further ahead.

Management Class Essay Example | Topics and Well Written Essays - 500 words

Management Class - Essay Example ation that comes from ‘drug reps’ who does not have much scientific knowledge about the impact of drugs on patients’ lives because these people are only after the sales commissions, expensive gifts, awards, and bonuses they’ll receive from the company out of selling these drugs. It is advisable to limit this type of interconnection between the doctors and medical student(s) and the drug producer(s) in order to avoid ‘under the table’ or ‘red tape’ transactions and ‘lobbying’ between the two parties. A close personal relationship between the doctors / medical students and the pharmaceutical companies could result to converting these doctors as ‘pharmaceutical sales representatives.’ Thus, endangering the lives of the patients. Controlling the importation of drug ingredients such as the ephedrine and pseudoephedrine from the nine major producers worldwide including Mexico is necessary in order to control the spread of ‘meth epidemics’ throughout the California, Oregon and other part of the United States.2 By regulating the importation of these ingredients, the meth cooks will have a hard time searching for the main ingredients to produce crystal meth. Another strategy is to regulate the selling of legal drugs like cold medicines that contain these ingredients throughout the United States. Having a strict control over the selling of these products, particularly by limiting the number of cold medicines consumers could buy as well as having the consumer register upon each purchase, could prevent the meth cooks from converting these legal drugs into crystal meth. The two main strategies that the U.S. federal government implemented contributed to the success of controlling the meth epidemics over several areas in the United States. By implementing a strict control over the main sources of the ephedrine and pseudoephedrine, the government is able to prevent the meth makers from producing enormous amount of meth within the

Report about this paper In Vitro Activities of Synthetic Host Defense Assignment

Report about this paper In Vitro Activities of Synthetic Host Defense Propeptides Processed by Neutrophil Elastase against Cystic Fibrosis Pathogens - Assignment Example The potential of HDPs as multifunctional effectors of innate immunity in higher organism provides the impetus and motivation for the progress in their research. The research paper being summarized in this report is In vitro activities of synthetic host defense propeptides processed by neutrophil elastase against cystic fibrosis pathogens authored by Stephen Desgranges, Florie Le Prieult, Alan Daly’ Jeniffer Lydon, Marian Brennan, Dilip K. Rai, Anusha P. Subasinghage, Chandralal M. Hewage, Sally-Ann Cryan, Catherine Greene, Noel G. McElvaney, Timothy P. Symth and Marc Devocelle. This paper was published in the journal Antimicrobial agents and chemotherapy under the American society for microbiology on May 2011. The journal has an impact factor of 4.672, a respectable impact factor for any reputable journal. Publishing of the work was significant to shed light on light on activities of synthetic host defense propeptides firsthand and hinder other person/groups doing so first. The Desgranges et al have undertaken a study where they have reported the in vitro activities of synthetic host defense propeptides against cystic pathogens namely Staphylococcus aureus and Pseudomonas aeruginosa ­ [2]. This paper focuses on the effect of modifying the propeptide by reducing the net change on the antimicrobial and haemolytic activity. The aim of this work by Desgranges et al was to utilize the abnormal amounts of neutrophil elastase present in cystic fibrosis to process several synthetic prodrugs against common pathogens in cystic fibrosis, P. aeruginosa and S. aureus [2]. Peptides are present in many living systems and are utilized by the innate immune systems to combat invading pathogens. Therefore this study aims at constructing a propeptide that will be able to evade the host immune system and also be a substrate for the all abundant neutrophil elastase present in cystic fibrosis lung. Since peptides

Ethical guidelines of an accountant Essay Example | Topics and Well Written Essays - 1250 words

Ethical guidelines of an accountant - Essay Example The globalization of most industries means new standards of financial reporting have to be followed.In many instances,new standards had indeed been adopted by accounting bodies eager to be of help in contributing to the promotion of the interest of various stakeholders such as varied investors,government regulatory bodies and the employees who also have a stake. Because of their confusing and complex nature, one has to be a detective of sorts to be able to sort out all the information contained in financial statements.Analysis of these statements require a certain degree of skill to be able to make fair comparisons between firms operating in various countries. Admittedly, there had been several efforts to standardize all the accounting rules and practices beginning in 1973 and took more concrete form by 1998 with a creation of the International Accounting Standards Board (IASB).My paper deals with the ethical issues confronting most chartered accountants today. It is because the prof ession of accounting is often a murky environment with various rules and regulations subject to different interpretations. In other words, most of the rules were formed from mere opinions of authoritative bodies. As such, opinions can be subjected to challenges. Despite all the efforts at standardization, there is still a long way to go before all accountants follow the same rules and procedures. Chartered accountants can be subjected to all various pressures for them to fudge the numbers if necessary. This puts them in awkward positions of conflicts of interest.

Sauer's Cultural Landscape Geography Assignment

Sauer's Cultural Landscape Geography - Assignment Example Under the influence of Carl Sauer, cultural landscape geography developed as the main branch of geography.   â€Å"Sauer was explicitly concerned to counter an environmental determinism which had dominated the American geography of the previous generation, within which human agency was given scant autonomy in the shaping of the visible landscape ».He believed that culture is the main force in shaping all visible features of the physical environment of the earth’s surface and he calls it ‘human cultural activities.’ They provoke action, responses, and adaptation by humans. He touches the cultural traits imposed by Europeans during colonization on various parts of the world and says that this cultural imposition on pre-existing cultures, shaped these new cultures in a different way. â€Å"Culture is the agent, the natural area is the medium, the cultural landscape is the result. Under the influence of a given culture, itself changing through time, the landscap e undergoes development, passing through phases, and probably reaching ultimately the end of its cycle of development. With the introduction of a different – that is an alien – culture, a rejuvenation of the cultural landscape sets in, or a new landscape is superimposed on remnants of an older one,† Sauer (1925), The Morphology of Landscape.† University of California Publications.French regional geography was a model of what Sauer propagated. French seafarers were crowned with initial success and the French school of geography was highly influential. It ‘†¦became known for its descriptive regional monographs presented in a lucid and flowing manner, human and historical geography was its forte.’ Even though there were criticisms that the emphasis has shifted several times between the approaches and viewpoints, all geographers had recognized their interdependence and complimentary importance. There is no denying that French regional geograph y also reflected the historical and military developments of the country. Talking about a hundred years’ war between France and Britain, Sauer says (Northern Mists) that France lost most of her ports and her north and southwest regions were ravaged.

What am I Learning in Global Perspectives Essay

What am I Learning in Global Perspectives - Essay Example These views have been cultivated, transmitted, and declared functional at all times. Thus, cultures are viewed as not only end results of past behavior but also shapers of upcoming behavior. The tendency of equating culture with an ethnic group is very common in people. In connection with this claim, it is apparent there is diverseness in cultural values. The paper expounds on cultural perspectives, the impact of an individual on others and the immediate environment, and the contribution of the module used in discussion in learning. Sharing personal values to strangers is very difficult. Many people including me consider sharing personal values with people different from me as not only an unsafe practice but also the exposure of oneself weaknesses. As a result of this, it is normal to see some people avoiding at all cost to share their personal values with people different from them. However, my engagement in the discussions and lead events changed my perception on personal values. First, I learnt that it is important to share personal values. The sharing of values enables people to learn each other’s interests and to allow each other to be what they are without any confrontation. In addition to this, it is apparent that sharing of values with other people enables individuals to learn the values that they have in common. The sharing of values not only makes individuals compatible but also strengthens the foundation of relationships between people. In addition to this, the discussion proved that people le arn many things in life through sharing their personal values with other people. Many people in the society correlate well with people from their race or ethnic groups. In tandem with this claim, I can affirm that majority of my friends are from my ethnic group. We cope up well with people from my ethnic group. However, this cultural practice is declining in institutions because of people’s diverseness.

Human resource Essay Example | Topics and Well Written Essays - 4500 words - 1

Human resource - Essay Example After exploring the salary structure and job performance evaluation, the best ways to increase employees’ salary in accordance to the company’s profit earnings will be explained. Upon exploring the significance of behavioural competencies with the skill development of each employee, decision of organizational study and hr development strategy particularly with the importance of trainings as well as learning and development through an open distance learning will be tackled followed by discussing the importance and impact of employee recognition in the context of employee relation. With regards to trade union issues, the differences between multi-union, single table, single union and partnership will be discussed followed by explaining the benefits and advantages of conducting a collective consultation like redundancy, transform of under takings, health safety, pension, and work place agreement. According to Roy Ballentine of Ballentine Finn & Co.; â€Å"Getting the right people in the right jobs is important because we are running a business that depends on human capital† (Alexander, 2009). It simply means that employing a person with sufficient skills and knowledge to perform a task could enable the organization meet the business objectives. A common problem that most HR managers are experiencing today is that hiring new employees who are capable of performing the job does not literally mean that the newly employed individuals would stay with the company for a long period of time. One of the most common reasons why newly hired employees would decide to leave the company is due to the fact that they could not fit in the organizational culture or the existing team within the department. For this reason, it is a challenge for HR managers to get the right people in position. Organizational culture is a paradigm developed by individuals within the organization which over time forms a strong pattern of behaviour and belief that could significantly affect

Organisational Change and Development Essay Example | Topics and Well Written Essays - 1000 words

Organisational Change and Development - Essay Example Thus, the distinct ideology that is neoliberalism is said to have descended from, but different to liberalism. This interpretation portrays neoliberalism as sharing historical roots with liberalism. The study of neoliberal ideology in detail is somewhat hard since no writer has written about neoliberalism from sympathy or neutrality. Virtually everyone who has written about the subject has criticized the ideology. Neoliberalism has ushered the return of one liberal aspect: economic liberalism. Economic liberalism is the belief that state governments should not control their economies; instead, this should be left to individuals and market institutions in self and free-regulating markets. Economic liberalism and neoliberalism should be separated from liberalism in word and deed, which, as a political ideology is applicable to constitutional changes and reviews, legal/administrative reform implementation leaning towards democracy and freedom. According to Harvey (2005, 20), â€Å"we l ive in the age of neoliberalism.† Many neoliberals share the same sentiments, but not necessarily factual, that power and wealth are, to an increasing degree, concentrated within powerful transnational entities and elite groups because of neoliberalism, which is the practical implementation of a political and economic ideology. Neoliberalism is also a dominant ideology influencing the world today. Neoliberalism is seen as a wholly new paradigm for policymaking and economic theory and implementation (Doepke, 2005). This ideology is behind the recent stage in development of capitalist society. Neoliberalism includes monetarism and other correlated approaches, and dominates policy making in microeconomics, and the subsequent implementation. This is shown by relaxation of economic state regulations, and emphasis is put on economic policy stability. The possibility of the existence of a free regulating market is a vital assumption in classical liberalism and among neoliberals, as w ell. Efficient and effective resource allocation is the most important function of an economic mechanism, and market mechanisms are the most efficient ways for resource allocation. Government economic interventions are usually undesirable, because intervention usually undermines the gains of market fine-tuning, and thus reduction economic efficiency. Governments have to guarantee the integrity and quality of money (Doepke, 2005). They must also set up functional, legal structures needed to access and secure rights on private property. Governments also ought to guarantee survival and functioning of markets by use of alternative means like force if need be (Friedman, 2006). Beyond these state responsibilities, the government ought not to feature anywhere and must play in the confines of its roles. According to neoliberalism, once markets have been created; state interventions in these markets must be at minimum levels. This is attributed to the fact that the state cannot possibly have sufficient information to comprehend market signals/prices. Another explanation is the fact that powerful and influential interest groups or individuals will probably distort state interventions in pursuance of their personal whims. This mostly happens in democratic societies (Harvey, 2005, 5). ‘Everything changes so that everything remains the same’ expounds the belief that the world is experiencing massive turns towards

Planning to Live Your Life Your Way Essay Example for Free

Planning to Live Your Life Your Way Essay Goal setting is a formal process for personal planning. By setting goals on a routine basis you decide what you want to achieve, and then move step by-step towards the achievement of these goals. The process of setting goals and targets allows you to choose where you want to go in life. By knowing precisely what you want to achieve, you know what you have to concentrate on to do it. You also know what is merely a distraction. Goal setting is a standard technique used by top-level athletes, successful business-people and achievers in all fields. It gives you long-term vision and short-term motivation. It focuses your acquisition of knowledge and helps you to organize your resources. By setting sharp, clearly defined goals, you can measure and take pride in the achievement of those goals. You can see forward progress in what might previously have seemed a long pointless grind. By setting goals, you will also raise your self-confidence, as you recognize your ability and competence in achieving the goals that you have set. The process of achieving goals and seeing this achievement gives you confidence that you will be able to achieve higher and more difficult goals. Goals are set on a number of different levels: First you decide what you want to do with your life and what large-scale goals you want to achieve. Second, you break these down into the smaller and smaller targets that you must hit so that you reach your lifetime goals. Finally, once you have your plan, you start working towards achieving it. Starting to Set Personal Goals This section explains how to set personal goals. It starts with your lifetime goals, and then works through a series of lower level plans culminating in a daily to-do list. By setting up this structure of plans you can break even the biggest life goal down into a number of small tasks that you need to do each day to reach the lifetime goals. Your Lifetime Goals The first step in setting personal goals is to consider what you want to achieve in your lifetime, as setting Lifetime goals gives you the overall perspective that shapes all other aspects of your decision making. How to Start to Achieve Your LifetimeGoals Once you have set your lifetime goals, set a 25 year plan of smaller goals that you should complete if you are to reach your lifetime plan. Then set a 5 year plan, 1 year plan, 6 month plan, and 1 month plan of progressively smaller goals that you should reach to achieve your lifetime goals. Each of these should be based on the previous plan. Finally set a daily to-do list of things that you should do today to work towards your lifetime goals. At an early stage these goals may be to read books and gather information on the achievement of your goals. This will help you to improve the quality and realism of your goal setting. Finally review your plans, and make sure that they fit the way in which you want to live your life.

Obesity and Fast Food Essay Example for Free

Obesity and Fast Food Essay January 2009 Abstract. We investigate the health consequences of changes in the supply of fast food using the exact geographical location of fast food restaurants. Specifically, we ask how the supply of fast food affects the obesity rates of 3 million school children and the weight gain of over 1 million pregnant women. We find that among 9th grade children, a fast food restaurant within a tenth of a mile of a school is associated with at least a 5. 2 percent increase in obesity rates. There is no discernable effect at . 25 miles and at . 5 miles. Among pregnant women, models with mother fixed effects indicate that a fast food restaurant within a half mile of her residence results in a 2. 5 percent increase in the probability of gaining over 20 kilos. The effect is larger, but less precisely estimated at . 1 miles. In contrast, the presence of non-fast food restaurants is uncorrelated with obesity and weight gain. Moreover, proximity to future fast food restaurants is uncorrelated with current obesity and weight gain, conditional on current proximity to fast food. The implied effects of fast-food on caloric intake are at least one order of magnitude smaller for mothers, which suggests that they are less constrained by travel costs than school children. Our results imply that policies restricting access to fast food near schools could have significant effects on obesity among school children, but similar policies restricting the availability of fast food in residential areas are unlikely to have large effects on adults. The authors thank John Cawley and participants in seminars at the NBER Summer Institute, the 2009 AEA Meetings, the ASSA 2009 Meetings, the Federal Reserve Banks of New York and Chicago, The New School, the Tinbergen Institute, the Rady School at UCSD, and Williams College for helpful comments. We thank Cecilia Machado, Emilia Simeonova, Johannes Schmeider, and Joshua Goodman for excellent research assistance. We thank Glenn Copeland of the Michigan Dept. of Community Health, Katherine Hempstead and Matthew Weinberg of the New Jersey Department of Health and Senior Services, Craig Edelman of the Pennsylvania Dept. of Health, Rachelle Moore of the Texas Dept. of State Health Services, and Gary Sammet and Joseph Shiveley of the Florida Department of Health for their help in accessing the data. The authors are solely responsible for the use that has been made of the data and for the contents of this article. 1 1. Introduction The prevalence of obesity and obesity related diseases has increased rapidly in the U. S. since the mid 1970s. At the same time, the number of fast food restaurants more than doubled over the same time period, while the number of other restaurants grew at a much slower pace according to the Census of Retail Trade (Chou, Grossman, and Saffer, 2004). In the public debate over obesity it is often assumed that the widespread availability of fast food restaurants is an important determinant of the dramatic increases in obesity rates. Policy makers in several cities have responded by restricting the availability or content of fast food, or by requiring posting of the caloric content of the meals (Mcbride, 2008; Mair et al. 2005). But the evidence linking fast food and obesity is not strong. Much of it is based on correlational studies in small data sets. In this paper we seek to identify the causal effect of increases in the supply of fast food restaurants on obesity rates. Specifically, using a detailed dataset on the exact geographical location restaurant establishments, we ask how proximity to fast food affects the obesity rates of 3 million school children and the weight gain of over 1 million pregnant women. For school children, we observe obesity rates for 9th graders in California over several years, and we are therefore able to estimate cross-sectional as well fixed effects models that control for characteristics of schools and neighborhoods. For mothers, we employ the information on weight gain during pregnancy reported in the Vital Statistics data for Michigan, New Jersey, and Texas covering fifteen years. 1 We focus on women who have at least two children so that we can follow a given woman across two pregnancies and estimate models that include mother fixed effects. The design employed in this study allows for a more precise identification of the effect of fast-food on obesity compared to the previous literature (summarized in Section 2). First, we observe information on weight for millions of individuals compared to at most tens of thousand in the standard data sets with weight information such as the NHANES and the BRFSS. This substantially increases the power of our estimates. Second, we exploit very detailed geographical location information, including distances The Vital Statistics data reports only the weight gain and not the weight at the beginning (or end) of the pregnancy. One advantage of focusing on a longitudinal measure of weight gain instead of a measure of weight in levels is that only the recent exposure to fast-food should matter. 1 2 of only one tenth of a mile. By comparing groups of individuals who are at only slightly different distances to a restaurant, we can arguably diminish the impact of unobservable differences in characteristics between the two groups. Third, we have a more precise idea of the timing of exposure than many previous studies: The 9th graders are exposed to fast food near their new school from September until the time of a spring fitness test, while weight gain during pregnancy pertains to the 9 months of pregnancy. While it is clear that fast food is generally unhealthy, it is not obvious a priori that changes in the availability of fast food should be expected to have an impact on health. On the one hand, it is possible that proximity to a fast food restaurant simply leads local consumers to substitute away from unhealthy food prepared at home or consumed in existing restaurants, without significant changes in the overall amount of unhealthy food consumed. On the other hand, proximity to a fast food restaurant could lower the monetary and non-monetary costs of accessing unhealthy food. In addition, proximity to fast food may increase consumption of unhealthy food even in the absence of any decrease in cost if individuals have self-control problems. Ultimately, the effect of changes in the supply of fast food on obesity is an empirical question. We find that among 9th grade children, the presence of a fast-food restaurant within a tenth of a mile of a school is associated with an increase of about 1. 7 percentage points in the fraction of students in a class who are obese relative to the presence at. 25 miles. This effect amounts to a 5. 2 percent increase in the incidence of obesity. Since grade 9 is the first year of high school and the fitness tests take place in the Spring, the period of fast-food exposure is approximately 30 weeks, implying an increased caloric intake of 30 to 100 calories per school-day. The effect is larger in models that include school fixed effects. Consistent with highly non–linear transportation costs, we find no discernable effect at . 25 miles and at . 5 miles. The effect is largest for Hispanic students and female students. Among pregnant women, we find that a fast food restaurant within a half mile of a residence results in 0. 19 percentage points higher probability of gaining over 20kg. This amounts to a 2. 5 percent increase in the probability of gaining over 20 kilos. The effect is larger at . 1 miles, but in contrast to the results for 9th graders, it is still discernable at . 25 miles and at . 5 miles. The increase in weight implies an increased caloric intake of 1 to 4 3 calories per day in the pregnancy period. The effect varies across races and educational levels. It is largest for African American mothers and for mothers with a high school education or less. It is zero for mothers with a college degree or an associate’s degree. Overall, our findings suggest that increases in the supply of fast food restaurants have a significant effect on obesity, at least in some groups. However, it is in principle possible that our estimates reflect unmeasured shifts in the demand for fast food. Fast food chains are likely to open new restaurants where they expect demand to be strong, and higher demand for unhealthy food is almost certainly correlated with higher risk of obesity. The presence of unobserved determinants of obesity that may be correlated with increases in the number of fast food restaurants would lead us to overestimate the role of fast food restaurants. We can not entirely rule out this possibility. However, three pieces of evidence lend some credibility to our interpretation. First, we find that observable characteristics of the schools are not associated with changes in the availability of a fast food in the immediate vicinity of a school. Furthermore, we show that within the geographical area under consideration, fast food restaurants are uniformly distributed over space. Specifically, fast food restaurants are equally likely to be located within . 1, . 25, and . 5 miles of a school. We also find that after conditioning on mother fixed effects, the observable characteristics of mothers that predict high weight gain are negatively (not positively) related to the presence of a fast-food chain, suggesting that any bias in our estimates may be downward, not upward. While these findings do not necessarily imply that changes in the supply of fast food restaurants are orthogonal to unobserved determinants of obesity, they are at least consistent with our identifying assumption. Second, while we find that proximity to a fast food restaurant is associated with increases in obesity rates and weight gains, proximity to non fast food restaurants has no discernible effect on obesity rates or weight gains. This suggests that our estimates are not just capturing increases in the local demand for restaurant establishments. Third, we find that while current proximity to a fast food restaurant affects current obesity rates, proximity to future fast food restaurants, controlling for current proximity, has no effect on current obesity rates and weight gains. Taken together, the weight of the 4 evidence is consistent with a causal effect of fast food restaurants on obesity rates among 9th graders and on weight gains among pregnant women. The results on the impact of fast-food on obesity are consistent with a model in which access to fast-foods increases obesity by lowering food prices or by tempting consumers with self-control problems. 2 Differences in travel costs between students and mothers could explain the different effects of proximity. Ninth graders have higher travel costs in the sense that they are constrained to stay near the school during the school day, and hence are more affected by fast-food restaurants that are very close to the school. For this group, proximity to fast-food has a quite sizeable effect on obesity. In contrast, for pregnant women, proximity to fast-food has a quantitatively small (albeit statistically significant) impact on weight gain. Our results suggest that a ban on fast-foods in the immediate proximity of schools could have a sizeable effect on obesity rates among affected students. However, a similar attempt to reduce access to fast food in residential neighborhoods would be unlikely to have much effect on adult consumers. The remainder of the paper is organized as follows. In Section 2 we review the existing literature. In Section 3 we describe our data sources. In Section 4, we present our econometric models and our empirical findings. Section 5 concludes. 2. Background While the main motivation for focusing on school children and pregnant women is the availability of geographically detailed data on weight measures for a very large sample, they are important groups to study in their own right. Among school aged children 6-19 rates of overweight have soared from about 5% in the early 1970s to 16% in 1999-2002 (Hedley et al. 2004). These rates are of particular concern given that children who are overweight are more likely to be overweight as adults, and are increasingly suffering from diseases associated with obesity while still in childhood (Krebs and Jacobson, 2003). At the same time, the fraction of women gaining over 60 2 Consumers with self-control problems are not as tempted by fatty foods if they first have to incur the transportation cost of walking to a fast-food restaurant. Only when a fast-food is right near the school, the temptation of the fast-food looms large. For an overview of the role of self-control in economic applications, see DellaVigna (2009). A model of cues in consumption (Laibson, 2001) has similar implications: a fast-food that is in immediate proximity from the school is more likely to trigger a cue that leads to over-consumption. 5 pounds during pregnancy doubled between 1989 and 2000 (Lin, forthcoming). Excessive weight gain during pregnancy is often associated with higher rates of hypertension, C-section, and large-for-gestational age infants, as well as with a higher incidence of later maternal obesity (Gunderson and Abrams, 2000; Rooney and Schauberger, 2002; Thorsdottir et al. , 2002; Wanjiku and Raynor, 2004). 3 Moreover, Figure 1 shows that the incidence of low APGAR scores (APGAR scores less than 8), an indicator of poor fetal health, increases sharply with weight gain above about 20 kilograms. Critics of the fast food industry point to several features that may make fast food less healthy than other types of restaurant food (Spurlock, 2004; Schlosser, 2002). These include low monetary and time costs, large portions, and high calorie density of signature menu items. Indeed, energy densities for individual food items are often so high that it would be difficult for individuals consuming them not to exceed their average recommended dietary intakes (Prentice and Jebb, 2003). Some consumers may be particularly vulnerable. In two randomized experimental trials involving 26 obese and 28 lean adolescents, Ebbeling et al. (2004) compared caloric intakes on â€Å"unlimited fast food days† and â€Å"no fast food days†. They found that obese adolescents had higher caloric intakes on the fast food days, but not on the no fast food days. The largest fast food chains are also characterized by aggressive marketing to children. One experimental study of young children 3 to 5 offered them identical pairs of foods and beverages, the only difference being that some of the foods were in McDonald’s packaging. Children were significantly more likely to choose items perceived to be from McDonald’s (Robinson et al.2007). Chou, Grossman, and Rashad (forthcoming) use data from the National Longitudinal Surveys (NLS) 1979 and 1997 cohorts to examine the effect of exposure to fast food advertising on overweight among children and adolescents. In ordinary least squares (OLS) models, they find significant effects in most specifications. 4 3 According to the Centers for Disease Control, obesity and excessive weight gain are independently associated with poor pregnancy outcomes. Recommended weight gain is lower for obese women than in others. (http://www. cdc.gov/pednss/how_to/read_a_data_table/prevalence_tables/birth_outcome. htm) 4 They also estimate instrumental variables (IV) models using the price of advertising as an instrument. However, while they find a significant â€Å"first stage†, they do not report the IV estimates because tests 6 Still, a recent review of the considerable epidemiological literature about the relationship between fast food and obesity (Rosenheck, 2008) concluded that â€Å"Findings from observational studies as yet are unable to demonstrate a causal link between fast food consumption and weight gain or obesity†. Most epidemiological studies have longitudinal designs in which large groups of participants are tracked over a period of time and changes in their body mass index (BMI) are correlated with baseline measures of fast food consumption. These studies typically find a positive link between obesity and fast food consumption. However, existing observational studies cannot rule out potential confounders such as lack of physical activity, consumption of sugary beverages, and so on. food. 5 There is also a rapidly growing economics literature on obesity, reviewed in Philipson and Posner (2008). Economic studies place varying amounts of emphasis on increased caloric consumption as a primary determinant of obesity (a trend that is consistent with the increased availability of fast food). Using data from the NLSY, Lakdawalla and Philipson (2002) conclude that about 40% of the increase in obesity from 1976 to 1994 is attributable to lower food prices (and increased consumption) while the remainder is due to reduced physical activity in market and home production. Bleich et al. (2007) examine data from several developed countries and conclude that increased caloric intake is the main contributor to obesity. Cutler et al. (2003) examine food diaries as well as time use data from the last few decades and conclude that rising obesity is linked to increased caloric intake and not to reduced energy expenditure. 6 7 Moreover, all of these studies rely on self-reported consumption of fast suggest that advertising exposure is not endogenous. They also estimate, but do not report individual fixed effects models, because these models have much larger standard errors than the ones reported. 5 A typical question is of the form â€Å"How often do you eat food from a place like McDonald’s, Kentucky Fried Chicken, Pizza Hut, Burger King or some other fast food restaurant? † 6 They suggest that the increased caloric intake is from greater frequency of snacking, and not from increased portion sizes at restaurants or fattening meals at fast food restaurants. They further suggest that technological change has lowered the time cost of food preparation which in turn has lead to more frequent consumption of food. Finally, they speculate that people with self control problems are over-consuming in response to the fall in the time cost of food preparation. Cawley (1999) discusses a similar behavioral theory of obesity as a consequence of addiction. 7 Courtemanche and Carden examine the impact on obesity of Wal-Mart and warehouse club retailers such as Sam’s club, Costco and BJ’s wholesale club which compete on price. They link store location data to individual data from the Behavioral Risk Factor Surveillance System (BRFSS. ) They find that non-grocery selling Wal-Mart stores reduce weight while non-grocery selling stores and warehouse clubs either reduce weight or have no effect. Their explanation is that reduced prices for everyday purchases expand real 7 A series of recent papers explicitly focus on fast food restaurants as potential contributors to obesity. Chou et al. (2004) estimate models combining state-level price data with individual demographic and weight data from the Behavioral Risk Factor Surveillance surveys and find a positive association between obesity and the per capita number of restaurants (fast food and others) in the state. Rashad, Grossman, and Chou (2005) present similar findings using data from the National Health and Nutrition Examination Surveys. Anderson and Butcher (2005) investigate the effect of school food policies on the BMI of adolescent students using data from the NLSY97. They assume that variation in financial pressure on schools across counties provides exogenous variation in availability of junk food in the schools. They find that a 10 percentage point increase in the probability of access to junk food at school can lead to about 1 percent increase in students BMI. Anderson, Butcher and Schanzenbach (2007) examine the elasticity of children’s BMI with respect to mother’s BMI and find that it has increased over time, suggesting an increased role for environmental factors in child obesity. Anderson, Butcher, and Levine (2003) find that maternal employment is related to childhood obesity, and speculate that employed mothers might spend more on fast food. Cawley and Liu (2007) use time use data and find that employed women spend less time cooking and are more likely to purchase prepared foods. The paper that is closest to ours is a recent study by Anderson and Matsa (2009) that focuses on the link between eating out and obesity using the presence of Interstate highways in rural areas as an instrument for restaurant density. Interstate highways increase restaurant density for communities adjacent to highways, reducing the travel costs of eating out for people in these communities. They find no evidence of a causal link between restaurants and obesity. Using data from the USDA, they argue that the lack of an effect is due to the presence of selection bias in restaurant patrons –people who eat out also consume more calories when they eat at homeand the fact that large portions at restaurants are offset by lower caloric intake at other times of the day. Our paper differs from Anderson and Matsa (2009) in four important dimensions, and these four differences are likely to explain the difference in our findings. incomes, enabling households to substitute away from cheap unhealthy foods to more expensive but healthier alternatives. 8 (i) First, our data allow us to distinguish between fast food restaurants and other restaurants. We can therefore estimate separately the impact of fast-foods and of other restaurants on obesity. In contrast, Anderson and Matsa do not have data on fast food restaurants and therefore focus on the effect of any restaurant on obesity. This difference turns out to be crucial, because when we estimate the effect of any restaurant on obesity using our data we also find no discernible effect on obesity. (ii) Second, we have a very large sample that allows us to identify even small effects, such as mean increases of 50 grams in the weight gain of mothers during pregnancy. Our estimates of weight gain for mothers are within the confidence interval of Anderson and Matsa’s two stage least squares estimates. Put differently, based on their sample size, our statistically significant estimates would have been considered statistically insignificant. (iii) Third, our data give us the exact location of each restaurant, school and mother. The spatial richness of our data allows us to examine the effect of fast food restaurants on obesity at a very detailed geographical level. For example, we can distinguish the effect at . 1 miles from the effect at . 25 miles. As it turns out, this feature is quite important, because the effects that we find are geographically extremely localized. For example, we find that fast food restaurant have an effect on 9th graders only for distances of . 1 miles or less. By contrast, Anderson and Matsa use a city as the level of geographical analysis. It is not surprising that at this level of aggregation the estimated effect is zero. (iv) Fourth, Anderson and Matsa’s identification strategy differs from ours, since we do not use an instrument for fast-food availability and focus instead on changes in the availability of fast-foods at very close distances. The populations under consideration are also different, and may react differently to proximity to a fast food restaurant. Anderson and Matsa focus on predominantly white rural communities, while we focus on primarily urban 9th graders and urban mothers. We document that the effects vary considerable depending on race, with blacks and Hispanics having the largest effect. Indeed, when Dunn (2008) uses an instrumental variables approach similar to the one used Anderson and Matsa based on proximity to freeways, he finds no effect for rural areas and for 9 whites in suburban areas, but strong effect for blacks and Hispanics. As we show below, we also find stronger effects for minorities. Taken together, these four differences lead us to conclude that the evidence in Anderson and Matsa is consistent with our evidence. 8 In summary, there is strong evidence of correlations between fast food consumption and obesity. It has been more difficult to demonstrate a causal role for fast food. In this paper we tap new data in an attempt to test the causal connection between fast food and obesity. 3. Data Sources and Summary Statistics Data for this project comes from three sources. (a) School Data. Data on children comes from the California public schools for the years 1999 and 2001 to 2007. The observations for 9th graders, which we focus on in this paper, represent 3. 06 million student-year observations. In the spring, California 9th graders are given a fitness assessment, the FITNESSGRAM ®. Data is reported at the class level in the form of the percentage of students who are obese, and who have acceptable levels of abdominal strength, aerobic capacity, flexibility, trunk strength, and upper body strength. Obesity is measured using actual body fat measures, which are considerably more accurate than the usual BMI measure (Cawley and Burkhauser, 2006). Data is also reported for sub-groups within the school (e. g. by race and gender) provided the cells have at least 10 students. Since grade 9 is the first year of high school and the fitness tests take place in the Spring, this impact corresponds to approximately 30 weeks of fast-food exposure. 9 This administrative data set is merged to information about schools (including the percent black, white, Hispanic, and Asian, percent immigrant, pupil/teacher ratios, fraction eligible for free lunch etc. ) from the National Center for Education Statistic’s Common Core of Data, as well as to the Start test scores for the 9th grade. The location of the school was also geocoded using ArcView. Finally, we merged in information. 8 9 See also Brennan and carpenter (2009). In very few cases, a high school is in the same location as a middle school, in which case the estimates reflect a longer-term impact of fast-food. 10 about the nearest Census block group of the school from the 2000 Census including the median earnings, percent high-school degree, percent unemployed, and percent urban. (b) Mothers Data. Data on mothers come from Vital Statistics Natality data from Michigan, New Jersey, and Texas. These data are from birth certificates, and cover all births in these states from 1989 to 2003 (from 1990 in Michigan). For these three states, we were able to gain access to confidential data including mothers names, birth dates, and addresses, which enabled us both to construct a panel data set linking births to the same mother over time, and to geocode her location (again using ArcView). The Natality data are very rich, and include information about the mother’s age, education, race and ethnicity; whether she smoked during pregnancy; the child’s gender, birth order, and gestation; whether it was a multiple birth; and maternal weight gain. We restrict the sample to singleton births and to mothers with at least two births in the sample, for a total of over 3. 5 million births. (c) Restaurant Data. Restaurant data with geo-coding information come from the National Establishment Time Series Database (Dun and Bradstreet). These data are used by all major banks, lending institutions, insurance and finance companies as the primary system for creditworthiness assessment of firms. As such, it is arguably more precise and comprehensive than yellow pages and business directories. 10 We obtained a panel of virtually all firms in Standard Industrial Classification 58 from 1990 to 2006, with names and addresses. Using this data, we constructed several different measures of â€Å"fast food† and â€Å"other restaurants,† as discussed further in Appendix 1. In this paper, the benchmark definition of fast-food restaurants includes only the top-10 fast-food chains, namely, Mc Donalds, Subway, Burger King, Taco Bell, Pizza Hut, Little Caesars, KFC, Wendy’s, Dominos Pizza, and Jack In The Box. We also show estimates using a broader definition that includes both chain restaurants and independent burger and pizza restaurants. Finally, we also measure the supply of non-fast food restaurants. The definition of â€Å"other restaurants† changes with the definition of fast food. Appendix Table 1 lists the top 10 fast food chains as well as examples of restaurants that we did not classify as fast food. The yellow pages are not intended to be a comprehensive listing of businesses they are a paid advertisement. Companies that do not pay are not listed. 10 11 Matching. Matching was performed using information on latitude and longitude of restaurant location. Specifically, we match the schools and mother’s residence to the closest restaurants using ArcView software. For the school data, we match the results on testing for the spring of year t with restaurant availability in year t-1. For the mother data, we match the data on weight gain during pregnancy with restaurant availability in the year that overlaps the most with the pregnancy. Summary Statistics. Using the data on restaurant, school, and mother’s locations, we constructed indicators for whether there are fast food or other restaurants within . 1, . 25, and . 5 miles of either the school or the mother’s residence. Table 1a shows summary characteristics of the schools data set by distance to a fast food restaurant. Here, as in most of the paper, we use the narrow definition of fast-food, including the top-10 fast-food chains. Relatively few schools are within . 1 miles of a fast food restaurant, and the characteristics of these schools are somewhat different than those of the average California school. Only 7% of schools have a fast food restaurant within . 1 miles, while 65% of all schools have a fast food restaurant within 1/2 of a mile. 11 Schools within . 1 miles of a fast food restaurant have more Hispanic students, a slightly higher fraction of students eligible for free lunch, and lower test scores. They are also located in poorer and more urban areas. The last row indicates that schools near a fast food restaurant have a higher incidence of obese students than the average California school. Table 1b shows a similar summary of the mother data. Again, mothers who live near fast food restaurants have different characteristics than the average mother. They are younger, less educated, more likely to be black or Hispanic, and less likely to be married. 4. Empirical Analysis We begin in Section 4. 1 by describing our econometric models and our identifying assumptions. In Section 4. 2 we show the correlation between restaurant location and student characteristics for the school sample, and the correlation between The average school in our sample had 4 fast foods within 1 mile and 24 other restaurants within the same radius. 11 12 restaurant location and mother characteristics for the mother sample. Our empirical estimates for students and mothers are in Section 4. 3 and 4. 4, respectively. 13 4. 1 Econometric Specifications Our empirical specification for schools is (1) Yst = ? F1st + ? F25st + ? F50st + ? ’ N1st + ? ’ N25st + ? ’ N50st + ? Xst + ? Zst + ds + est where Yst is the fraction of students in school s in a given grade who are obese in year t; F1st is an indicator equal to 1 if there is a fast food restaurant within . 1 mile from the school in year t; F25st is an indicator equal to 1 if there is a fast food restaurant within . 25 miles from the school in year t; F50st is an indicator equal to 1 if there is a fast food restaurant within . 5 mile from the school in year t; N1st, N25st and N50st are similar indicators for the presence of non-fast food restaurants within . 1, . 25 and . 5 miles from the school; ds is a fixed effect for the school. The vectors Xst and Zst include school and neighborhood time-varying characteristics that can potentially affect obesity rates. Specifically, Xst is a vector of school-grade specific characteristics including fraction blacks, fraction native Americans, fraction Hispanic, fraction immigrants, fraction female, fraction eligible for free lunch, whether the school is qualified for Title I funding, pupil/teacher ratio, and 9th grade tests scores, as well as school-district characteristics such as fraction immigrants, fraction of non-English speaking students (LEP/ELL), share of IEP students. Zst is a vector of characteristics of the Census block closest to the school including median income, median earnings, average household size, median rent, median housing value, percent white, percent black, percent Asian, percent.

Importance of Ankle Brachial Pressure Index (ABPI)

Importance of Ankle Brachial Pressure Index (ABPI) Ankle Brachial Pressure Index test use as a tool of foot assessment in diabetic patient to reduce rate of lower extremity amputation. INTRODUCTION This essay will reflect on the importance of ankle brachial pressure index (ABPI) use as a tool while performing foot assessment (FA) to identify diabetic patients who are at risk of foot ulcers and detecting vascular impairment in diabetic foot ulcers (DFU) hence preventing lower extremity amputation (LEA). FA helps to detect the level of risk of a diabetic patient developing a foot ulcer (Singh N et al., 2005, Grawford F et al.,2007). When there is no early detection and intervention, foot ulcers deteriorate resulting in amputation of the affected limb (Kerr M, 2012, Young MJ et al., 2008). All diabetic patients should perform annual FA to identify any abnormality (American Diabetes Associaton 2012) and those who are at risk should have FA done more frequently (Frykberg RG et al., 2006). Gibbs’ model of reflection (Gibbs 1988) is used in this discussion because it is easy to use, simple and is a good guidance of reflection. 25% of diabetic people will develop foot ulcer due to diabetes (Singh N et al., 2005) while 85% of diabetic patients with foot ulcers can lead to LEA (Pecoraro RE et al., 1990, Margolis DJ et al., 2005). â€Å"The emotional and financial costs of diabetic foot disease are high† (Close-Tweedie, 2002). Approximately 400 cases of LEA are performed yearly in Mauritius due to complication of Diabetes, costing about Rs 50,000 to Rs 100,000 for each limb amputation (Apsa International 2014, Mauritius Research Council 2012). However 85% of level of amputation can be reduced through a multidisciplinary team by early detection of foot problems, proper FA, empowering patient by giving them health education, close monitoring and proper care (International Diabetes Federation 2005, Pecoraro RE, 1990). DESCRIPTION The Government of Mauritius is doing much effort to increase the quality of life of diabetic people, national digital retinal screening service and podiatry services are available (Millenium Development Goals Status Report 2013). Foot ulcer clinics have been set up in all regional hospitals in Mauritius. During my training as a foot ulcer nurse I happened to do an ABPI (see Appendix 1) while doing FA with a patient whom I will call Mr John who has a non healing ulcer in his left hallux. His foot has never been assessed by a health care professional and he was not aware of FA. The ABPI result was 0.7 (see Appendix 2) indicating that he has moderate peripheral arterial disease. He was referred to the vascular surgeon by the treating Doctor. The result was confirmed through a colour duplex Doppler showing significant and arterial stenosis below the knee by greater than 60%. The patient underwent revascularization. Proper management of the wound was done, compression was not applied (Vow den K and Vowden P, 2002) and now the ulcer is showing good signs of healing. FEELINGS Getting the opportunity to follow the foot ulcer management course made me overwhelm. I was so enthusiastic to learn new ways and techniques of FA that I will apply with patients acting as a barrier to protect them from stumbling into the pitfall of foot complications hence preventing amputations. Before undertaking the module I was not aware of the importance of FA in preventing LEA. A 10g Semmes Weinstein monofilament is used to check loss of sensation in neuropathy and a hand-held doppler use to calculate ABPI to assess the vascular flow was far from my know how. After undertaking the module and wider reading with endeavours, though there were many ups and downs due to time constraint, now I feel more self-confident and have more expertise in practicing ABPI while doing FA. Having been able to detect the cause of non healing ulcer of Mr John through an ABPI while doing FA, I felt very happy and eventually this has motivated me to learn the module more correctly. I was determined t o put ABPI technique into practice in my field of work so that I can manage patient correctly and refer them to the appropriate channel for specific treatment through multidisciplinary team (John Ovretveti, 1996). EVALUATION I have learnt that foot problems related to diabetes occur very quickly, causing rapid tissue breakdown which is often complicated by infection (Edmonds et al., 1986) and eventually may lead to LEA (Close-Tweedie J, 2002). Factors influencing wound healing are hyperglycaemia (McInnes, 2001), change in metabolism of carbohydrates, fats and proteins because of insulin deficiency (Cooper, 1990). Furthermore many factors prevent the normal process of wound healing at cellular level including delayed closure, contraction retarded due to delayed myofibroblast phenotype, granulocytes effect, no collagen synthesis, chemotaxis defects and no growth factors (Close-Tweedie J, 2002). Therefore, if there is decrease in tissue perfusion and oxygenation, wound healing will not take place (Terranova, 1991). Peripheral Arterial Disease (PAD) in the lower extremity is a condition where there is narrowing of arteries in the legs and feet due to accumulation of fatty substance called plaque, inside the walls of arteries. This result in poor blood supply to the muscles and tissues in the legs and feet hereby causing pain, tissue death and even gangrene. It is important to assess the arterial perfusion as impaired circulation contribute to non healing ulcer (Akbari CM, 2003). When assessing diabetic foot, the palpation of ankle pulses should not be used alone to detect arterial disease (Vowden K and Vowden P, 2002) and â€Å"distal perfusion can only be accurately assessed by the correct application of Doppler† (Whiteley et al., 1998). The ABPI is a simple, quick, non-invasive tool use to identify PAD(Bhasin N and Scott DJA, 2007). However, ABPI is not as easy to perform as it appears. I have done an ABPI with Mr John and this has helped in identifying the cause of the non healing ulcer. This was due to impaired blood circulation and the patient has been directed to the proper pathway to restore the blood flow. Hence this has helped the wound to show good signs of healing. ANALYSIS It is through performing an ABPI with Mr Brown that the cause of the non healing wound has been detected. I am pondering on how many patients have non healing ulcers due to impaired circulation and FA has not been done including ABPI. So ABPI is done on all diabetic patients with or without foot ulcers who are coming to our clinic for FA and they are being referred to proper channel for further management. My aim is to prevent diabetic patients to have foot complications and reduce the rate of LEA. ABPI result help us to evaluate the vascular supply, level of ischaemia, level of pain in the leg, determine the prognosis for patients having vascular disease and guide whether the patient should undergo revascularization or do angioplasty, stenting or bypass surgery of lower extremity. (Grenon SM et al., 2009). By interpreting the ABPI resuIts, now I am sure and certain of what types of bandaging to use, what dressing materials and medications to use to treat and help healing of ulcers. ABPI also guides us to decide whether debridement of the wound should be done or not and what type of offloading techniques to be implemented. CONCLUSION The fundamentals basics for healing of DFU are good perfusion, debridement, infection control, and pressure mitigation. To obtain successful outcome in the management of DFU is to recognize the etiological factors (Wu SC et al., 2007). Doing an ABPI help to improve the management of diabetic patients. The ABPI assessment was of great help to know the risk of the foot. For those having no ulcers, they are being managed by the correct channel to prevent complications from arising, while those having an ulcer are also diverted to correct pathway of treatment including surgeons and foot care nurses to manage foot problems correctly under the guidance of all expertise available at the hospital level. ACTION PLAN Now having well grasped the module workbook, I have allocated myself with a good time of reflection about how previously diabetic patients, with or without ulcers, were being treated and what was the complication and drawbacks we had in our system. After I have well understood the importance of ABPI during my studentship at the module and from my personal experience gained during the management of diabetic foot ulcer, now I make it a must that all diabetic patients, attending hospital from any sections, have an appointment to screen their foot with an ABPI done. Eventually, canalizing them through the correct pathways for further investigations and management required with the goal to reduce the rate of LEA. However, ABPI is contraindicated when there is excruciating pain in the leg or foot, in the presence of deep venous thrombosis as the thrombus may be dislodged and in patient with renal failure doing dialysis. ABPI results should be interpreted with care in patients having heavily calcified or incompressible vessels, where they may be misleadingly high. (Grenon SM et al., 2009). REFLECTION In this work piece of reflection, I have demonstrated how I use ABPI on diabetic patients to reduce the rate of LEA. Observing the result being achieved by this assessment, other members of health care providers insist about the implementation of this typical assessment. We are now more eager to know about the ABPI result on diabetic patients prior moving forward with any kind of management. I feel happy that my knowledge gained from the module are being put into practice and ABPI assessment has proved to be a great tool to reduce LEA which has been the aim of the government since long. REFERENCES Akbari CM, Macsata R, Smith BM, Sidawy AN. Overview of the diabetic foot. Semin Vasc Surg 16:3-11, 2003. American Diabetes Association. Standards of Medical Care in Diabetes-2012. Diabetes Care, Volume 35, Supplement 1, January 2012. Apsa.mu, (2014). Foot Care Clinic | Apsa International. [online] Available at: http://apsa.mu/services/foot-care-clinic/ [Accessed 22 June 2014]. Bhasin N and Scott DJA. Ankle Brachial Pressure Index: identifying cardiovascular risk and improving diagnostic accuracy. JR Soc Med. Jan 2007; 100(1): 4–5. [online] Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1761677/ [Accessed 22 June 2014]. Close-Tweedie J. Diabetic foot wounds and wound healing: a review. Diabetic Foot Vol 5, No 2, 2002. Cooper DM (1990). Optimising wound repair: a practice within nursing’s domain. Nursing clinics of North America 25(1): 165-80. Department of Health, 2001. National Service Framework for Diabetes:Standards. [online] Available at http://www.gov.uk/government/uploads/attachment_data/file/198836/National_Service_Framework_for_Diabetes.pdf [Accessed 04 June 2014]. Edmonds ME, Blundell MP, Morris HE et al (1986). The diabetic foot: impact of a foot clinic. The Quarterly Journal of Medicine 232: 763-71. Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR, Landsman AS, Lavery LA, Moore JC, Schuberth JM, Wukcih DK, Andersen C, Vanore JV: Diabetic Foot Disorders : a clinical practice guideline (2006 revision). J Foot Ankle Surgery 45 (Suppl 5): S1-S66, 2006. Gibbs G, 1988. Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Oxford Further Education Unit (online) Available at: https://www.brookes.ac.uk/services/upgrade/study-skills/reflective-gibbs.html [Accessed 17 June 2014]. Grawford F, Inkstor M, Kleijnen J, Fatey T. Predicting foot ulcers in patients with diabetes: A systematic review and meta-analysis. QJ Med 2007; 100(2): 65-86. Grenon S. Marlene, Gagnon Joel and Hsiang York. Ankle-Brachial Index for Assessment of Peripheral Arterial Disease. The New England Journal of Medicine 2009; 361: e40/ November 2009. [online] Available at: www.nejm.org/doi/full/10.1056/NEJMvcm0807012 [ Accessed 22 June 2014]. International Diabetes Federation (2005) Clinical Guidelines Task Force; Global guidance for Type 2 Diabetes. Brussels. International Working Group on the Diabetic Foot, 2011. [online] Available at: www.iwgdf.org [Accessed 18 June 2014]. Kerr M. Foot care for people with diabetes: the economic case for change. NHS Diabetes, Newcastle-upon-Tyne, 2012. Margolis DJ, Allen-Taylor L, Hoffstad O, Berlin JA. Diabetic neuropathic foot ulcers and amputation. Wound Repair Regen 13:230-236,2005. Mauritius Research Council, Ebene. Impact of food quality on human health, Feb 2012. [online] Available at: http://www.mrc.org.mu/document2012/nationalgroup/Impacts%20of%20Food%20Quality%20on%20Human%20Health.pdf [Accessed 21 June 2014]. McInnes A (2001). Guide to the assessment and management of diabetic foot wounds. The Diabetic Foot 4 (Suppl 1):S1-11. Millennium Development Goals Status Report 2013, Government of the Republic of Mauritius. [online] Available at http://www.undg.org/docs/13330/Muaritius-MDG-Status-Report-2013.pdf [Accessed 21 June 2014]. Ovretvet John. Five ways to describe a multidisciplinary team. Journal of Interprofessional care, vol 40, no 2, 1996. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care, 1990; 13(5): 513-21. Singh N, Armstrong DG, Lipsky BA: Preventing foot ulcers in patients with diabetes. JAMA 293: 217-228, 2005. [online] Available at: www.ncbi.nlm.nih.gov/pubmed/15644549 [Accessed 02 June 2014]. Vowden Kathryn and Vowden Peter. Hand-held Doppler Ultrasound: The assessment of lower limb arterial and venous disease. Huntleigh Healthcare 2002. [online] Available at: www.huntleigh-diagnostics.com. [Accessed 21 June 2014]. Terranova A (1991). The effects of diabetes mellitus in wound healing. Plastic Surgical Nursing 11: 20-5. Whiteley MS, Fox AD and Horrocks M (1998). Photoplethysmography can replace hand-held Doppler in the measurement of ankle/brachial indices. Ann R Colll Surg Engl 80 (2): 96-98. Wu Stephanie C, Driver Vickie R, Wrobel James SandDavid G Armstrong David G. Foot ulcers in the diabetic patient, prevention and treatment. Vascular Health and Risk Management Feb 2007; 3(1): 65–76. Young MJ, McCardle JE, Randlall LE, et al. Improved survival of diabetic foot ulcer patint’s 1995-2008: possible impact of aggressive cardiovascular risk management. Diabetes Care 2008; 31: 2143-47. APPENDIX 1 – Procedure of performing ABPI by Huntleigh Healthcare 2002 Patient is reassured and procedure is explained. Make sure patient is in supine position, comfortable, relaxed with sufficient rest. †¢ An appropriate sized cuff is placed around the upper arm and the brachial systolic blood pressure is measured. †¢ The equipment and the arm should be at heart level. †¢ When the brachial pulse is felt, ultrasound contact gel is applied. †¢ The probe of the Doppler should be at an angle of 45 degree and is moved till the best signal is obtained. †¢ The cuff is inflated until the signal disappeared, then is deflated slowly so that the probe is not moved from the line of the artery and at the point where the signal returns, the pressure is recorded. †¢ The procedure is repeated in the other arm. †¢ The highest of the two values of systolic pressure is used for the ABPI calculation. †¢ The systolic pressure of the ankle is taken by placing an appropriate sized cuff around the ankle immediately above the malleoli. The equipment should be at heart level. If any ulcer is present, it should be protected with a plastic film. †¢ The dorsalis pedis pulse is felt and contact gel is applied. The cuff is inflated until the signal disappear, then is deflated slowly and ensure the probe is not moved from the line of the artery and at the point where the signal returns, the pressure is recorded. †¢ The procedure is repeated for the posterior tibial. †¢ The highest systolic pressure reading is used to calculate the ABPI for that leg. †¢ Same procedure is applied in the other leg. †¢ The ABPI is calculated for each leg using the formula below. ABPI = Highest systolic pressure recorded at the ankle of dorsalis pedis and posterior tibial for that leg divided by the highest systolic brachial pressure of right and left arm. APPENDIX 2 – Reading of ABPI by Huntleigh Healthcare 2002 ABPI > 1.0 to 1.4 is considered as normal ABPI ABPI > 0.5 and ABPI ABPI >1.4 indicates calcification Page 1