Heroin Addiction & Methadone Maintenance

Liberty University Disintermediation, aka: heroin, smack, horse, black tar, china white, and H, the slang names are as numerous as the places you can score this highly addictive narcotic. Heroin, a derivative of morphine, via opium, which comes from the resin of the Paper cuneiform plant has been in use for nearly 3500 years (Dowdies,2012, p. 137). To understand the fascination, addiction, and potential therapies of heroin, we must first understand its history.Before man knew anything about chemicals and rugs, they knew about the land the animals and plants that were used in relieving various ailments. Prehistoric man noticed that if they ingested the resin from the opium poppy there was pain relief. In the late sass's, a German merchant named Frederica Brayer invested in scientific research and with the help of a young German pharmacist call Frederica Serener purified the main active ingredient of opium (Dowdies, 2012). Serener named his new drug â€Å"morphine† after the Gre ek god of dreams â€Å"Morpheme†, which later would be renamed morphine.Heimlich Dresser joined Brayer in his hunger for producing chemical based medications, and ended up evildoing two of the most famous drugs in the world today. By adding two acetylene groups to the morphine molecule, they developed the drug the coined â€Å"Heroin†, and a year later, they developed a natural drug of salicylic acid, which they named â€Å"Aspirin. † Brayer would go on to bottle and distribute a pre-war version named â€Å"Heroin†, named after the common word â€Å"heroic† meaning heroic- known to German doctors to mean â€Å"power! The bottle labeled simply â€Å"Heroin† was available to the public, containing 5 grams of heroin substance and indications included alleviation of pain o the suffering. By the early sass's, an article entitled ‘The Heroin Habit Another Curse' was published in the Alabama Medical Journal, drawing attention to the severe w ithdraw symptoms of those using heroin, but this would not stop other physicians from abandoning the highly effective drug. Another physician C. D. Track), went on to write that â€Å"l feel that bringing charges against heroin is almost like questioning the fidelity off good friend.I have used it with good results† (History Today,Heroin: A Hundred-Year Habit). There was such a success in the reduction of pain in the offering community that even physicians were reluctant to give up such a successful drug. It seemed that there was evidence that morphine had a huge potential for addiction; so in response they had suggested heroin in its place. Ironically, this would be one of the medical community biggest mistakes. The United States became one of the first to notice the serious problem of addiction as other countries had already enacted controls of dangerous drugs.The U. S. Constitution however, allowed this to be monitored on a state-by-state level, making each state responsib le for the regulation of the drug. This would lead many states to putting the restrictions upon the people and giving the physicians the decision to prescribe it as necessary, leading to what would be a â€Å"black market† for the highly wanted drug. Even with the Pure Food and Drug Act of 1906, that demanded all drugs be labeled with the contents of their products, there was opium, cocaine, or even cannabis (U. S. Dept. Of Health and Human Services).This new addition of the labeling seemed to carry some weight, as many people began to worry about addiction; not before however there was an estimated quarter of a million Americans suffering from it. Jump ahead into the twenty-first century and the statistics may have changed somewhat, but not drastically. What has been a significant factor is the crime rate increase in order for those addicted to stay â€Å"well. † Communities faced with how to treat the opiate addicted; beyond the obvious by placing them in Jail or pri son. The behavior of crime may be rehabilitated, but not the addiction itself, which for most was the only driving factor.It's a vicious cycle, and for most the frustration is bigger than their habits. Some countries, such as the United Kingdom do have physicians who will prescribe iron (although rare) for the addict unable to reap the benefits of methadone maintenance, or the terminally ill suffering extreme pain. Specialized â€Å"injecting centers† are available to addicts trying to dodge the street heroin complexity, in countries such as Switzerland, Germany, Holland, Australia and even Canada. There are still very strict laws enforced with the purchasing or smuggling of heroin in these countries, thus rigid program regulations must be followed.Methadone maintenance treatment (MAT) remains the preferred form of treating opiate addiction, and â€Å"has demonstrated strong efficacy in the outpatient treatment of opiate dependence (Hetman et al, 2009). For those familiar wi th MAT, usually those who suffer from opiate dependence, healthcare professionals, and the rehabilitation community, there are mixed feelings. The term MAT can be misunderstood, â€Å"perhaps micrometeorites when called a treatment for opiate (narcotic-analgesic) addiction, is simply systematic dispensation of a synthetic Podia† (Meyers & Salt, 2013) that curbs the withdrawal symptoms.For many, these programs have allowed the addicted to return to social stability, stop criminal activities, and enter back into he workforce or educational world. The HIVE/AIDS community has really shown significant advantages to the MAT programs, thus reducing the number of DID (intravenous drug users) contracting the virus via hypodermic needles and tainted â€Å"works. † MAT has shown to be effective because of its ease of administration of the synthetic Podia, which is generally liquid and taken once per day at a highly regulated center.The runny nose, chills, stomach cramps, nausea a nd vomiting, skin crawling that many heroin users suffer from while trying to â€Å"kick it† are absent when taking methadone. The program doses the client with a leveled amount of methadone, allowing the patient to attend to â€Å"normal activities† such as driving, studying, working, without the worries of sickness. These programs generally have very strict rules and are governed by the government, specifically the Drug Enforcement Agency.Psychotherapy along with MAT is the choice of most clinics, and people generally feel strongly one way or the other about such programs. In a 2013 research project, the behaviors concerning MAT were becoming more positive, as the research becomes more readily available to the general public. For the U. S. And other countries, MAT has remained â€Å"controversial for a long period of time† (You, L. , et al.. ). For many years, public viewed MAT as simply a trade out for the heroin user, and thus did not change their addictive behaviors, only their cravings. A combination of counseling and psycho-pharmaceutical support to methadone detoxification is most effective† (Milky, 1988 – via Myers & Salt, 2013), although many chronic long term heroin users may be in such a program on a maintenance level of treatment, Just as a diabetic takes his insulin, thus the heroin addict take his methadone. This is where many critics of MAT occupy its strongest argument. MAT has been called the â€Å"outcast stepsister in the addictions field† (Myers & Salt, 2013); with MM clients being stigmatize by everyone from peers to the entire healthcare system, even the addictions field itself.Today's communities seem to be changing, as a current 2013 Brown University research report indicates; â€Å"The choice of treatment has to be individualized to their risk factors and the overall conditions as they enter the MAT† (Psychopathology Update, 2013). For many heroin addicts, the addiction is the beginning of a long line of difficulties, thus the program often elapse with a great deal more than dosing and addiction counseling. Many addiction counselors find themselves being solicitors of social services such as housing, food stamps, medical care, and often many doors remain closed to the addict using MAT.Again, it is a misrepresentation of program that is making changes in the lives of those suffering from addiction, no matter the path leading to it. The percentage of â€Å"no use† clients within the MAT program show a 48% recovery rate during the first 90 days, however relapse commonly takes place within the first six months of treatment (Dept. Of Addictive Behavioral Medicine-Europe). This is considered a â€Å"bump in the road†, as relapse is part of the healing process when talking addictions. Despite the effectiveness and widespread use of MAT, and the demonstrated benefit of combining MAT with other more intensive forms of treatment, integration remains a controver sial topic† (Hetman, et al, 2009). Many traditional treatment centers such as those who utilize the 12 Step philosophies, assert that MAT is incompatible with recovery and the abstinence-based treatment models, thus creating a division among them. This kind of thinking is yet another pitfall that carries the heroin addict seeking MAT, into â€Å"secretive mode. In conclusion, heroin addiction and the steps it takes to reach recovery, is anything but uncomplicated.Heroin has the stigma of being the drug that carries names like â€Å"Junkie† and â€Å"channel swimmer† referring to the needle users of heroin, and the works of â€Å"chasing the dragon†, â€Å"kicking' it†, or â€Å"having a monkey on my back†. For years, it was considered the poor man's drug, and today, it's the middle class women and youth that favor its warm, soothing effects. No matter the hundreds of names it's called from china white, to black tar, it's a universal problem with America being one of its number one customers, consuming over 60% f the heroin hitting the streets worldwide (Meyers & Salt, 2013).

Mexican American Cultures Essay

Even though the American culture and Mexican culture have similarities, they are more different than alike. Me being Mexican-American and living so close to the Mexican-American border, I’m very familiar with these two cultures. Some differences are sports, form of speaking, and even dinner time. These might be shocking, but very true. One of the major differences is sports. In the Mexican culture, one grows up playing, and watching soccer. One probably cheers for the â€Å"Tijuana Xolos,† or â€Å"Cruz Azul,† and or maybe even â€Å"La America. † There are many teams but one’s family is a die-heart fan of one in specific. As a baby one’s first word is most likely â€Å"goal† or â€Å"penal. † In the Mexican culture one eat, sleeps, and breathes soccer. On contraire of soccer, in the American culture, football is a must. Every Sunday you’ll be dressed up in your team’s jersey and spend 4 hours screaming at the t. v. Sundays are holly for a football family, you grill, invite friends over and watch men tackle all day. In addition you’ll probably even throw in some curse words while you’re watching your favorite teams whether it’s the â€Å"San Diego Chargers† or â€Å"New England Patriots,† or many other professional football teams. One very important difference is the form of speaking and language. In the Mexican culture one will most likely learn and speak Spanish first before any other language. In Spanish, for elders or someone superior to you, you speak in what is called â€Å"forma de usted. † It’s very disrespectful to speak informally to an elder or any of your superiors and take offence of it. One is taught since a very young age la forma de usted because one’s parents expect one to speak appropriate to their superiors and not embarrass them while out. Typically one exception for la forma de usted is with one’s parents, but in my case, it wasn’t. In the American culture, you generally speak one language, English. In English there really isn’t a formal way to address your elders or superiors. One speaks informally to everybody, whether it’s one’s boss, mother, or friend. There is no respectful or specific way to speak to them. Different from the Mexican culture, everybody is on an equal level, so it doesn’t require speaking formally to anybody. Another difference is in a typical Mexican household the kids come home from school and do their homework at the table while their mom prepares dinner. Dinner is served at four p. m. but will not be eaten until everybody from the family is seated at the table, and ready to give thanks to the â€Å"Virgin Maria† for their food. Generally dinner is a dish that involves eating a tortilla with, and or beans. Different from the Mexican culture, in the American culture, one eats at around six p. m. It is typically around the time the parents get out of work, which is later on in the day. Usually they serve themselves and some eat in the living room while others eat in their rooms, very rarely to all eat seated together at the dinner table. Due to the busy routine that one has in America, that sense of family unity has lost its meaning, which reflects on something as simple as dinner time. As one can see the Mexican culture and the American culture are different in many ways. Each culture has their own unique characteristics which makes each of them special in their own way. Sports, form of speaking, and dinner time are little differences but make a huge difference in each culture.

Usability Evaluation of a Web Design Interface

Usability Evaluation of a Web Design Interface 1/12 http://ojni. org/602/usability. htm Usability Evaluation of a Web Design Interface by Karen D. King, RDH, MHeD and Dr. Rosalee Seymour, Associate Professor, EdD, RN Abstract This report presents the results of a usability evaluation of the Web design interfac e for an instructional unit prototype on Herpes Simplex and Apthous Ulcers. Usability is defin ed as the measure of a product’s potential to accomplish the goals of its users (Dumas, 1999). The unit and the Web interface were designed to deliver instruction to undergraduate dental hygien e students.The three randomly selected users/subjects for this evaluation were from an undergrad uate class of dental hygiene students. This report describes the usability evaluation planning, im plementation, data analysis methods, and results. The results demonstrate that conducting usabilit y evaluations help to determine the organization and ease of navigation of an interactive, Web- base d, instructional unit. Usability Evaluation of a Web Design Interface Computers are used to educate, in many instances, with conventional interfaces that i nclude those used to create documents and manipulate data.A Web interface, which was tested in t his case, is very different from a conventional one. The Web is a domain that must be instantly u sable and support many communication modalities. Web designers must focus on the computer user whose goal is to gather information rather than to create documents or manipulate data (Raj ani & Rosenberg, 1999). It is critical that the accomplishment of the users’ goals be the primary objective o f a usability evaluation (UE) of Web site interface design.Users will not be able to access correc t pages unless the constructed site reflects their needs and contains a navigation scheme that allow s easy access to the desired information (Nielsen, 2000a). In Web interface designs the properties of color, sound, navigation, and place ment must be considered from a different perspective than with c onventional interfaces. Usability evaluation purposes. The faculty of the Department of Dental Hygiene, where this evaluation was conducted developed an oral pathology course for undergraduate student s in dental hygiene and wanted to deliver it via a Web design interface.The instructional unit o n Herpes Simplex and Apthous Ulcers is the prototype for nine instructional units to follow. It was anticipated that conducting a UE, on the prototype instructional unit Web interface, would enable identification of any usability issues or problems relevant to this Web interface before the constru ction of subsequent instructional units. In keeping with Rajani and Rosenberg (1999), the primary purposes of this UE were agr eed upon as: 1) to determine if the Web-based Herpes Simplex and Apthous ulcer prototype is easy t o navigate 13/3/2013 0:50Usability Evaluation of a Web Design Interface 2/12 http://ojni. org/602/usability. htm and meets the goals of undergraduate dental hygiene students, 2) to use any identifie d problems to revise this unit, 3) to make recommendations on the construction of additional units based on this prototype, 4) to save faculty time, and 5) to insure students’ goals will be met in t he Web interface format. The Literature Usability evaluations include a range of methods for identifying how users actually i nteract with a prototype or completed Web site. Planning of a UE egins with a statement of the ove rall purpose and objectives for the investigation and a clear identification of the problem (Hom, 1999; Instone, 1999). In a typical approach a UE is conducted while users perform tasks and a modera tor watches, listens, and records for later data analyzes and reporting of results (Fichter, 2000) . The next steps are the identification of the subject/users and the design of the study. Graham (2000) describes many ways to get feedback about the usability of a Web site. Gra ham (2000) recommends that a moderator observe a user representing the site’s target audi ence as they navigate the site.Graham (2000) cautions moderators against the interruption of the subject/user while conducting any observations. Nielsen (2000a) also recommends that the user/subj ects be representative of the target audience and not colleagues or others who may know too m uch about the site. Nielsen (2000a) recommends that user/subjects perform specific tasks durin g a UE as opposed to asking them to just play on the test site. These test tasks need to be re presentative of the types of tasks that users will actually perform on the Web site within the Web in terface being tested.Nielsen (2000a) suggests that the moderator solicit comments from users as they progr ess through to task completion to help determine their thought process. Hom (2000) refers to thi s encouragement of user comments during the evaluation as the ‘think aloud protocol’. H om (2000) des cribes this technique as one in which the user verbalizes any thoughts, feelings, and/or opinions while interacting with the test site. The inclusion of the ‘think aloud protocol’ all ows the moderator to qualitatively measure how the user approaches the Web interface and what consideratio ns they keep in mind when using it.For example, a user verbalizing that the sequence of steps, d ictated by a task, is different from what was expected, could demonstrate an interface problem (Ho m, 2000). Hom (2000) recommends using the qualitative ‘think aloud method’ in conjunction with performance measures. The performance measures add to the data collected noting such things as: 1 ) the time it takes for a user to complete a task, 2) the number and type of errors per task, 3) the number of users completing a task successfully, and 4) the satisfaction of the user with the si te (Nielsen, 2000a).After determining the study design and identification of the users, Spool et al. (199 9) in agreement with Nielsen recommend development of specific tasks for users to perform during the UE. In addition to a task list, Hom (1999) advocates during the planning phase of UE that on e specify materials needed and the site evaluation environment. Rubin (1994) agrees that the U E process needs test users from the target population to evaluate the degree to which a product meets specific 13/3/2013 0:50 Usability Evaluation of a Web Design Interface /12 http://ojni. org/602/usability. htm criteria. Rubin (1994) describes six basic elements of a UE: 1) a clear statement of the problem and/or evaluation objectives, 2) a sample of users, which may/may not be randomly cho sen, 3) a setting representative of the actual work environment, 4) observation of users who either use or review a representation of the product, 5) a collection of quantitative performance and qualitative preferences measures, and 6) an analysis leading to recommendation for design of the product evaluated.When analyzing data from having conducted a UE, rather than supporting hypotheses one is looking for patterns to identify common problems, in the remarks or observations, between use rs (Dumas, 1999; Hom, 1999). Performance data is statistically analyzed while qualitative data, collected by observing the user’s actions and opinions, is analyzed for trends. The data analysis results should lead to identification of strengths and recommendations for improving the site or pro duct (Nielsen, 2000a; Spool, et al. 1999; Hom, 1999; Dumas, 1999). Usability Evaluation: The Case This UE was conducted because usability problems, within any prototype, are important to discover prior to the costly, time consuming, construction of a web interface for additional i nstructional units. The specific purpose of this UE was to determine if the Web interface presented the H erpes Simplex and Apthous Ulcer prototype interactive educational unit in a way that allowed underg raduate dental hygiene students to successfully achieve unit outcomes.Specific objectives for this usability evaluation were to determine: 1) navigational and/or organizational problems with the Web interface, 2) the presence of any confusing term inology in the site, 3) if the site meets the goals of the user, 4) if the users can complete the as signed tasks, and 5) user’s attitudes toward the Web site. Methods A description of the UE environment, user selection criteria and profiles, usability evaluation process, the task list, and evaluation measures for this study follow. Usability evaluation environment. The UE took place in the moderator’s private campus office.This is a quiet, well-lit room with a comfortable temperature, equipped with a Dell computer workstation, which was used for the evaluation. A sign reading â€Å"Usability Evaluation in Session. Please Do Not Disturb† was posted on the closed office door to prevent interruptions and distractio ns. The UEs were co nducted on July 2, 2001, at 1:00 p. m. , 2:00 p. m. , and 3:00 p. m. Subject/users interacted with the Herpes Simplex and Apthous Ulcers Web interface one at a time. Each subject /user had 20 minutes to complete the usability evaluation. Subjectuser selection and profile.Three randomly selected undergraduate dental hygi ene students, from a target population of 24 (class of 2002), became subjectusers. All 24 students will be required to take the oral pathology courses including the instructional units reflect ing the results of this UE. Alphabetical order by user’s last name determined the order of subjectuser participation. In order to be selected the subject/users must have met the following criteria: 1) be an undergraduate 13/3/2013 0:50 Usability Evaluation of a Web Design Interface 4/12 http://ojni. org/602/usability. htm ental hygiene student, 2) have successfully completed one academic year of the Denta l Hygiene Program, 3) have previous experience with the Internet, and 4) have previous experien ce with Web browsers The demographic characteristics of the users for this evaluation were that: 1) they all were female, 2) ages 25, 22, and 43, 3) all had successfully completed on e academic year in the Dental Hygiene Program, 4) all had previous experience with the Internet, and 5) all had between 1 and 3 years experience with Web browsers. Administration protocol. Prior to the UE a training packet and session of 30 minutes were provided to each subjectuser.The training session included a brief description of the UE proce ss, purpose and objectives, and the UE protocol instructions. Each subject/user was given an opportun ity to review the packet and ask any questions before agreeing, by signing a consent form, to be a voluntary participant. The UE packet included: 1) a user profile questionnaire, 2) a task list , 3) a statement of the purposes of the evaluation, 4) evaluation instructions, and 5) a consent form. Prior to each actual UE every subjec tuser was again given a 10-minute review of the UE instructions and opportunity to ask questions.Subjects/users were told it would take one hour to complete the entire UE process; 20 minutes to complete the task list. According to Nielsen (2000a) , a UE time of 30 minutes or less is adequate to conduct a UE. An additional 15 minutes allowed time for the user to verbalize about the Web interface and to complete a follow up questionnaire to de termine their attitude towards the Web interface. The remaining 15 minutes of the hour the moderat or used to review notes of comments and observations and to make corrections so that no misunder standing would occur later in interpreting results.Shneiderman (1998) suggests the moderator rewrite UE notes as soon as possible, reducing moderator errors in note interpretation later. The subjectusers were required to use the’ think aloud method’ (Hom, 2000) to provid e subjective data in conjunction with the collection of various perfo rmance measures. The performa nce measures included: 1) the time it took the user to complete the task list; 2) the number of er rors per task, 3) the number of users completing the task list successfully in the allotted time, and 4 ) the attitude of the user toward the Web interface.In addition, the moderator collected qualitative data by observing each user during completion of each task and taking notes regarding their f acial expressions, opinions expressed, and verbalized thoughts while completing UE. The mo derator made notes on the opinions and thoughts of the user following UE. Finally, the subje ctusers completed a questionnaire to describe their attitudes about the Web interface. Implementation Piloting the UE administration protocol.A Department of Dental Hygiene professor, fa miliar with the Internet, Web browsers, and oral pathology pilot tested the UE administration protoco l one week prior to testing subjectusers. The moderator provided the pilot test user with the s ame pre UE instructions and task list that would be given to subject/users. The pilot test resul ted in no problems with the UE administration protocol. The moderator observed the pilot test subject/us er and collected the same quantitative and qualitative data that was to be collected from th e research 13/3/2013 0:50 Usability Evaluation of a Web Design Interface 5/12 http://ojni. rg/602/usability. htm subjectusers. The results of the pilot test showed that the UE protocol could be use d with subject/users without revision. Pre-training for UE. At 12:30 p. m. July 2, 2001, the subjectusers arrived for the pr e UE training session. The moderator distributed the UE packet and described the purpose and proce dures of the UE. The users were given an opportunity to review the UE packet and to ask questions . Each of the three subjectusers signed consent forms before leaving the pre UE training. Administration of UE. Each of the three subject/users arrived at the moderator’s offi ce for the UE.The moderator reviewed the evaluation instructions and gave time for any additional q uestions to be answered. The following sequence of events occurred for the three users, each: a) beg an the UE , 2) completed the task list, 3) responded to questions about the evaluation experience, 4 ) added thoughts or opinions regarding interaction with the Web interface, and 5) left the mo derator’s office in 45 minutes each. The administrator used the remaining 15 minutes of each of the t hree hours to rewrite portions of notes taken during observation in preparation for the UE report o f results.Task list and description. The tasks were identified using the purposes and objective s of the UE. The task list includes 10 primary tasks for subjectusers to perform in navigation of the Website interface for the Oral Herpes Simplex and Apthous Ulcers prototype. The task list beginning wi th accessing the Website via the interface and progressing through the instructional unit follows. Because many of the 10 primary tasks were repeated the actual count of performing tasks is 31. Task 1 – with the browser open go to www. etsu. edu/cpah/dental/dcte760.This task was chosen to determine if users, indicating they had between 1 and 3 years experience with a Web b rowser, would have a problem accessing a Web site when given only a Web address without a dir ect link. Task 2 – read the instructions on the first page of the Web site and click on the lin k that it directs you to go to first. This task was to determine the clarity of the Web interface in p roviding instructions for beginning the instructional unit. Task 3 – click on Assignment 1 Task 4 – access the discussion forum and enter your name and email address.This task helped determine the Web interface design, by allowing for observing if users had difficulty locating the discussion forum area and/or entering information into it. Task 5 – When done in discussion forum, re turn to Assignment 1. This task will ident ify if users have difficulty returning to the designated page using the Web interface. Task 6 – Click on Assignment 2 Task 7 – Read the content on Apthous Ulcers. This task requires users to read content on a Web page on the site. Task 8 – Click on the images on this page to enlarge them. This task determines the e ase of click navigation to enlarge thumbnail images. 3/3/2013 0:50 Usability Evaluation of a Web Design Interface 6/12 http://ojni. org/602/usability. htm Task 9 – Return to Assignment 2. This task determined if users could navigate the We b interface via a link taking them back to a designated page in the Web site. Task 10 – Answer the study questions in Assignment 2. The study questions direct the user through a series of multiple-choice items in a linear fashion. Correct responses allow the u ser to continue to the next question while incorrect responses require the user to go back to the que sti on and make another attempt to answer.Users cannot go to the next question until the previous q uestion is answered correctly. This task requires navigating through a series of questions with the potential for going back and forth if an answer is wrong. This task determined if users could succe ssfully navigate the Web interface to the study questions Task 11 – When the study questions are all answered, return to Assignment 2. This tas k again measures their ability to use the Web interface to return to a designated page in the Web site. Task 12 – Click Assignment 3. Task 13 – Read the entire case 2 Herpes Simplex.Again, users are required to read c ontent on the Web site but they must use the Web interface design to do it successfully. Task 14 – When you have finished reading Case 2, return to Assignment 3. This task de termined if users could navigate the Web interface to a case study contained within the instructi onal unit and return to a designat ed page in the Web site. Task 15 – Click on Assignment 4. Task 16 – Go to Case 1. Task 17 – Fill in the diagnosis form. This task required students to locate a case, fill in case study information obtained from previous exercises.This task measures the Web interface’s ease of navigation using forms to complete information. Task 18 – Submit the Form. This task demonstrates if the Web interface allows for ea sy form submission upon completion. Task 19 – Return to Assignment 4. User must complete a form by diagnosing the case s tudy patient in this assignment. This task determined if users could easily navigate the case stud y, fill in the appropriate form fields, submit the form, and return to the designated page in the We b site. Task 20 – Click on Assignment 5. Task 21 – Go to the reflection form.This task demonstrates if the Web interface all ows users to navigate to the reflection form. Task 22 – Write your reflections on the unit on the form. A form to reflect on the in structional unit is required for assignment 5. This task demonstrates if users will be able, through thi s Web interface, to make text entries in the appropriate form fields in the reflection form. 13/3/2013 0:50 Usability Evaluation of a Web Design Interface 7/12 http://ojni. org/602/usability. htm Task 23 – Submit the form. The task determined if users could navigate the Web inter face to send the completed reflection form electronically.Task 24 – Return to Assignment 5. Determines if users via the Web interface, can eas ily return to a designated page in the Web site. Task 25 – Go to the course evaluation survey. An evaluation form is included in this instructional unit to determine student attitudes and satisfaction levels with the instructional un it. This task measures if the Web interface allows the user to easily locate a survey on the site. Task 26 – Complete the course evaluation survey. This task determined if users using the Web interface, could easily navigate a form to reply to the questions. Task 27 – Submit the survey.This task measures whether the Web interface allows use rs to easily submit form information electronically. Task 28 – Return to Assignment 5. This task measures the Web interface as it allows u ses to return to designated pages in the Web site with ease. Task 29 – Go to the discussion forum. This task determined if the users could open t he forum and is a test of the Web interface design and its ease of promoting discussion. Task 30 – Make a forum entry indicating that you have finished the usability evaluati on. This task measures the Web interface design’s success with entering comments into a discussion forum.Task 31 – Return to Assignment 5. This task measures the Web interface designs succ ess with returning users to designated pages in the Web site. (N=31 navigational tasks) Non-task performance measur es. Following Nielsen, (2000a) subjectusers were asked t o use the ‘think aloud method’ in conjunction with performance measures. The quantitative measu res to be evaluated included the: 1) amount of time to complete the task list, 2) number of err ors per task, 3) number of users completing the task list successfully in the allotted time, and 4) at titude of users toward the Web interface.In addition to the quantitative measures, the administrato r collected qualitative data during and after the usability evaluation by each user. This UE was designed to measure the ease of undergraduate dental hygiene student user s navigation through the Oral Herpes Simplex and Apthous Ulcers instructional unit prot otype Web interface. Although all task completion or non completion allowed for tests of the in terface, the following three questions focus more directly on navigation of the prototype Web inte rface: Do all the navigational links in this Web site work correctly?Is the or ganization of this Web site consistent? Is there any confusing terminology regarding navigation and organization on this Web site? Results The success or failure on each task performed as well as the qualitative data collect ed from the 13/3/2013 0:50 Usability Evaluation of a Web Design Interface 8/12 http://ojni. org/602/usability. htm post-test interview and the post-test questionnaire are reported. Because the tasks in the UE were short, the quantitative data collected was based on the entire task list and not on each task independently. Users had adequate time to complete the enti re task list.There were 31Website interface navigation tasks completed by three subject/users with a total of seven navigation errors. 1. User #1 took 20 minutes to successfully complete the task list with one Web i nterface navigation error. 2. User #2 took 18 minutes to successfully complete the task list with three Web interface navigation errors. 3. User #3 took 19 minutes to successfully complete the task list with three Web interface navigation errors Task 1 –Users #1 and #2 completed task #1 easily and were able to successfully open t he designated Web site without Web interface navigation error.User #3 entered the Web site address in the search line of the Web browser, an error message was returned by the browser, and then the user entered the Web site address in the address line of the browser and was able to successfully access the home page of the instructional unit via the Web site interface. In this c ase the navigational error relates to lack of knowledge about where to type in a Web address in a Web browser. Task 2 – Read the instructions on the first page of the Web site and click on the lin k that your are directed to go to first.User #1 asked, â€Å"Do I make the decision myself to go to assi gnment 1 or to the course syllabus? † The administrator did not answer this question as the instruct ions on the Web page indicated the first link. Th is error, while not significant since both links ta ke the student to the appropriate Web page to begin the instructional unit as well as the usability evaluat ion, could add user frustration to the mix. Users #2 and #3 use the Web site interface on the first page of the Web site to readily access the needed location.Task 3, 4, and 5 – Click on Assignment 1 and enter your name and email address in the discussion forum. When this task is complete, return to Assignment 1. User #1 was unable to re adily use the Web interface to access the discussion forum. This user consistently scrolled to the bottom of any page before making any choices about where to go next. This scrolling is not consider ed an error in the prototype but could indicate that the Web interface design needs revision to stop this behavior. Once the discussion forum was accessed, this user asked, â€Å"Is this where I go to post my name? The administrator did answer in the affirmative and the user continued with the task. Upon completion of the discussion forum entry user #1 could not navigate back to the desig nated page. The administrator finally intervened and instructed the user to use the â€Å"back† button on the browser. The user then looked for the â€Å"back key† on the keyboard. Further instructi on from the administrator got the user back on task. When user #2 realized that the task involved a discussion forum, the user indicated n o previous 13/3/2013 0:50 Usability Evaluation of a Web Design Interface 9/12 ttp://ojni. org/602/usability. htm experience with discussion forums of any type. Her response was â€Å"Am I being timed, b ecause here is the first problem? † The administrator reassured the user that there is as much ti me as needed to perform the task. Upon submission of the discussion forum entry, user #2 chose the â€Å" back† button on the browser quickly. User #3 got to the discussion forum easily, but then asked, â€Å"Am I the subject? † The administrator informed the user that the responses in the form fields did not matter and that any i nformation could be entered in any field.Upon submission of the form entries, user #3 used the â€Å"back† button on the browser but indicated that she thought only one click of the â€Å"back† button was sufficient. All users successfully completed the task. The Web interface design was not the culprit in these task struggles. Tasks 6, 7, 8, and 9 – Click on Assignment 2. Read the content on Apthous Ulcers. Cl ick on the images to enlarge the view. Return to Assignment 2. Users #1 and #3 did not click o n the images to view a larger version of the image. Both disregarded this portion of the task com pletely.Perhaps the images were large enough for them. User #2 opened the larger view of the images a nd returned to the designated page in the Web site indicating no problem with the Web interface d esign in the area of enlarging images. All users returne d to the designated page in the Web site, but only one user completed the entire task successfully. Tasks 10 and 11 – Answer the study questions in Assignment 2. When the study questio ns are all answered, return to Assignment 2. All users navigated through the study questions ea sily.User #1 expressed embarrassment, because the administrator of the UE is also a faculty member in the Department of Dental Hygiene, and the user did not want the administrator to know if the answers to the study questions were incorrect. The administrator reminded user #1 that the an swers to the questions were not the purpose of this evaluation. The Web site was being evaluated n ot the knowledge of the user. User #1 continued to navigate through the study questions, but indicated distress any time she chose an incorrect response to a study question.It is assumed this frustration related to having to go back and continue to answer until the answer was correct befo re going on. User #2 quickly re alized that the links chosen by user #1 were a different color. Sin ce all users participated in the UE on the same computer, the visited hyperlinks were apparent. U ser #2 easily navigated the questions with much less distress about incorrect responses, because sh e realized that her peers had chosen incorrectly as well. User #3 also noticed the visited hyperlinks and navigated the questions without incident.However, user #3 had a problem choosing answers beca use the hyperlink was on only one letter, the user had trouble positioning the mouse pointer exactly over the single letter link. The user clicked several times before realizing that the link ar ea was very small. This indicates an area of the Web interface design that needs improvement. All users successfully completed these tasks. Tasks 12, 13, and 14 – Click on Assignment 3. Read Case 2. When you have finished re turn to Assignment 3. Users #1 and #3 quickly read the case and returned to the designated We b page.Use r #2 appeared to have accidentally clicked the wrong link and could not locate Cas e 2. The administrator provided instruction because the user seemed frustrated. After the user located the correct page, there was no problem completing the task. Here it is hard to distingui sh if this is a 13/3/2013 0:50 Usability Evaluation of a Web Design Interface 10/12 http://ojni. org/602/usability. htm Web interface design error or not. Tasks 15, 16, 17, 18, and 19 – Click on Assignment 4. Fill in the form. Submit the form. Return to Assignment 4. This was the first form in the Web site.User #1 began with â€Å"OK, what is this? † The user had never filled in a form and submitted it through a Web site. Users #2 and #3 both accessed and filled in the required information in the form fields and returned to the designa ted Web page easily. User #1 took more time, but successfully completed the task. Tasks 20, 21, 22, 23, and 24 – Click on Assignment 5. Go to the reflection fo rm. Fill in the form. Submit the form. Return to Assignment 5. This was the second experience with the Web interface using a form. All three users accessed, filled in the form, and submitted the form wi thout a problem.Task 25, 26, 27, and 28 – Go to the course evaluation survey. Complete the course eva luation survey. Submit the survey. Return to Assignment 5. Users #1 and #2 had difficulty loc ating the survey link on the page. Once the survey evaluation link was located, no user had any difficulty completing the task. User #3 completed the task easily, but after submission of the form, the user clicked on the â€Å"back† button to return to the designated Web page in the site. As use r #3 clicked on the â€Å"back† button she said, â€Å"Is it erasing the form information if I am going back wi th the back button? The moderator assured her the action of the â€Å"back† button would not erase fo rm input after submission. Task 29, 30, and 31 – Go to the Discussion Forum. Make a forum entry indicating that you have finished the UE. Return to Assignment 5. By task 31, all users were familiar with th e site and had no trouble navigating the discussion forum and returning to the designated page in the W eb site. Upon completion of the task list, each user had the opportunity to comment on the Web site and offer suggestions and opinions. The following were offered:User #1 indicated that she would be more comfortable if the administrator had not bee n watching her progress. She indicated being watched so closely made her very nervous and she th ought the site would have been much easier to navigate on her own. She indicated that she like d the set up of the Web interface and asked if there were going to be other sites like this for her u se in the dental hygiene curriculum. User #2 indicated that she liked the site and thought it was easy to use. User #3 lik ed the site and would like similar sites for other topics in the dental hygiene curriculum.She indi cated that she did not like using the ‘back button’ after all the forms. All three users expressed nervo usness about being watched by the administrator. Discussion A sample of three users completed this UE. Nielsen (2000b) indicates that three to f ive participants in a UE are adequate. Usability problems were identified in some part of nine of the ten primary tasks on the task list. In addition, some of the problems as told by the users, rela ted to: 1) the administrator present during the UE was also a professor in the Department of Dental Hygiene in 3/3/2013 0:50 Usability Evaluation of a Web Design Interface 11/12 http://ojni. org/602/usability. htm which the user is a student, 2) the evaluation was conducted during the summer school session, and 3) all users were also students in the administrator’s class. Users reported being mo re nervous about the site content in the presence of this administrator. In future UE studies th e us ability administrator should be a neutral observer The questionnaire completed by the users following the usability evaluation demonstra ted user satisfaction with the site.Shneiderman (1998) suggests users should give their subje ctive impressions of the Web interface. All but one of the responses indicated that the us ers were satisfied with the site’s navigation and organization. The users indicated that the t erminology used in the site was clear, they were able to complete the assigned tasks easily, the site me t their needs, and the users liked the appearance of the site. The only responses not scored as sati sfactory were related to using the â€Å"back button†. Overall, all three users indicated the ease of na vigating the Web site interface was satisfactory. RecommendationsIt is evident from the results of this UE that Web-based interfaces for instructional delivery should be evaluated for usability problems. Corrections, suggested by the results, to the Oral Herpes Simplex and Apthous Ulcers instructional unit prototype and Web interface should be made and the site re-tested before continuing development of the remaining nine courses in the oral pat hology Web-based instructional unit series. The usability evaluation of the Oral Herpes Simplex and Apthous Ulcers Web-based inst ructional unit prototype resulted in the following recommendations for improvement to the Web site n avigation and organization. . This may be one time when the use of standard link colors should be violated. Students using the same computer to complete an instructional unit would be able to discern the answ ers chosen by the student previously using the computer. Changes in the Web interface design for te sts so that the link color does not change when a user chooses a particular response is recommended. 2. When assigning form submissions, provide a link to take the user back to the designated page in the Web site. The users in this UE did not like using the brow ser’s â€Å"back† button after completing the forms nor following entries to the discussion forum.The Web site interface desig n will be changed so the confirmation pages following discussion forum postings and submission of forms will take the user back to the page accessed immediately prior to the form or discussion f orum. 3. The hyperlinks for the answers to study questions were not large enough. Cli cking on a one letter link made users have a hard time identifying the link. This Web site interfac e design will be corrected so that the entire cell in which the letter choices are located will be the hyperlink. ConclusionsThe UE conducted on the Oral Herpes Simplex and Apthous Ulcers instructional unit pro totype Web design interface proved to be a successful method for the determination of usability problems in a 13/3/2013 0:50 Usability Evaluation of a Web Design Interface 12/12 http://ojni. org/602/usability. htm Web-based instructional delivery method. The users identified usability problems with the Web interface as well as with their own skill or lack of skill with using any browser. Re commendations for revision have been identified by the researcher and will be implemented. Authors NoteShould anyone wish to examine the Website and review the Herpes Simplex and Apthous U lcer instructional unit prototype it can be accessed at http://www. etsu. edu/cpah/dental/dcte760/. References Dumas, J. , & Redish, J. (1999). A Practical Guide to Usability Testing. Portland: In tellect Books. Fichter, D. (2000). Usability Testing Up Front. Online, 24 (1), 79-84. Graham, J. (2000). Usability Testing Basics. INT Media Group. Retrieved June 30, 2 001, from the World Wide Web: http://clickz. com/print. jsp? article=2053. Hom, J. (1999). The Usability Testing Toolbox.Retrieved June 10, 2001, from the Wo rld Wide Web: http://www. best. com/~jthom/usability. Instone, I. (1999). User Test Your Web Site: An Introduction to Usability Testing. Retrieved July 1, 2001, from the World Wide Web: http://instone. org/keith/howtotest/introduction. html. Nielsen, J. (2000a). Designing Web Usability. Indianapolis: New Riders Publishing. Nielsen, J. (2000b). Why You Only Need to Test with 5 Users. Jakob Nielsen’s Alertb ox. Retrieved June 12, 2001, from the World Wide Web: http://www. useit. com/alertbox/20000319. html. Rajani, R. , & Rosenberg, D. (1999).Usable? Or Not? Factors Affecting the Usability of Web Sites. CMC Magazine. Retrieved June 23, 2001, from the World Wide Web: http://www. december . com /cmc/mag/1999/jan/rakros. html. Rubin, J. (1994). Handbook of Usability Testing. New York: Wiley. Shneiderman, B. (1998). Designing the User Interface. Strategies for Effective Huma n-Computer Interaction. Third Edition. Reading: Addison-Wesley. Spool, J. , Scanlon, T. , Schroeder, W. , Snyder, C. , & DeAngelo, T. (1999). Web Site U sability: A Designer’s Guide. San Francisco: Morgan Kaufmann Publishers, Inc. 13/3/2013 0:50

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Courage Mother and her Children critique Essay â€Å"Mother Courage and Her Children† by Bertolt Brecht took place during the 30 Years’ War in Europe. The whole play revolved around the survival of a lower class family, trying to live through the harsh war with their canteen wagon business. Each scene in the play contained the factors of religious, honesty, war, loyalty, and family. The theme of â€Å"Mother Courage and Her Children† was maternity, due to the fact that Mother Courage’s sense of coldhearted business caused her become unable to protect her children, which led to their deaths, leaving her all alone in the end. Mother Courage was always doing business while each of her children died during the play. This shows that she was more interested in her business and money than her own children, and an example of this can be seen when her thirst for money had caused Swiss to die because she took too long to decide whether or not to trade her money in for her son’s life. Mother Courage was the protagonist in the play, while the war was the antagonist. The war caused Mother Courage to base her living on it. Due to the fact that they were living during a war, this caused Mother Courage to be so focused on making money, that she ended up neglecting her children. It also caused her to be unable to watch her daughter get married, since Kattrin could only get married when peace returned and the war ended. War is also the antagonist, due to the fact that is also caused Mother Courage to lose her sons as well. The play was a tragedy because in it, Mother Courage’s children all perished, and she was left all alone in the end. In the play, Bretch assigned each of Mother Courage’s children with a â€Å"tragic flaw† as a result of her failure to learn to choose family over business. The tragedies that Mother Courage’s children suffered throughout the play were Swiss, with honesty, Eilif, with arrogance, and Kattrin, with pity. 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The only thing that changed about the lights was the brightness; the lights were brighter during the day and dimmer at night. There were some spotlights. However, it only appeared upon the actors who came before each scene, in order to tell the audience what will happen in the upcoming scene. The lighting of â€Å"Mother Courage Mother and Her Children,† was different from the other play that I went to. Usually lights would go off when changing from one scene to another, so that characters were able to get on and off stage, in order to prepare the set for the scene. However, in this play, the lights were still on during scene transitions. Bretch made pulling the wagon in and out of the stage as an exit and enter for each scene, which didn’t require the actors to quickly change settings for different scenes. The background sound of gunshots and bombs that were playing throughout the play allowed the audience to feel as if the war was actually taking place during the play. 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The characters in the play had the same outfit throughout the whole play, and this outfit not only showed their poverty, but also the condition of life during the war, due to the fact that they were unable to have clothes to change into. The many layers of clothes worn were everything that the characters owned, and this showed their struggles, due to the fact that they are unable to buy any new clothes. Overall, the play was easy to understand because it was in modern English and there were no accent in the characters’ pronunciation, which allowed the audience to understand what the characters were saying. Mother Courage struggled throughout her life with her business and children, but ended up with nothing due to the war, in which she was favoring. The war had brought Mother Courage the business she needed, but took away her children one by one.

Ethics Essay Essay Example for Free

Ethics Essay Essay What is Ethics? It is the binding good character, being respectful, and having trustworthiness amongst others. The topics that will be touched on is the differences between morality and ethical theories. Finally, I am going to touch on my personal experiences in relation to virtue, values, and moral concepts. Morality and ethics are almost one in the same in the greater scheme of things. They both work together to make up ethical decisions by a person. For example there are five key terms that breaks down the theories; which are Consequential, Egoism, Utilitarian, Act Utilitarian, and Rule Utilitarianism. Therefore, ethical theories and moral theories are broken down into two different categories consequential and non-consequential theories. Now what is the consequential theory exactly? The consequential theories basically mean, the result of a person’s behavior can result in either morally good consequences or morally bad consequences (Manias Monroe, 2013). The breakdown can go even further; in the simplest terms morality relates to non-consequential theories and ethical decisions lead to consequential theories. For example, an ethical decision could be a police officer runs a red light, without having police sirens on; the consequence is a law abiding citizen might be further dissatisfied with the police force in the area. A moral decision is basically the action of right and wrong; which is really not a consequence. The decision of right and wrong is decided on oneself feelings about a certain scenario or person at any given time. For example, a student cheats on a test; why does he or she cheat? One may ask, is this situation right or wrong. The judgment or verdict is for you to decide, whether it is the person themselves; has good morals or not. One of the three theories that relate to me is Utilitarian. I have two children and I am always constantly trying to them to be well mannered and teach them good aspects of life. I myself always want to produce the  greatest possible good out of everything. Whether it is teaching my children something or making someone else laughs. In conclusion, ethical decisions can lead to misunderstandings and have great consequences. Moral decisions decide right and wrong. My personal experiences relating to Utilitarian theories are something that I now know about. It hoped that this explanation will help the further understanding of the subject. References Page Manias, N., Monroe, D. (2013). Ethics Applied (7th ed.). http://about.nike.com/pages/sustainability

Risk Of Falls Among Elderly Health And Social Care Essay

Risk Of Falls Among Elderly Health And Social Care Essay The loss of strength, balance, and mobility are no longer considered inevitable consequence of aging. Physiological impairments related to functional dependency are potentially reversible with appropriate exercise intervention (Morgan, 2005; Nelson et al., 2004). Furthermore strength training research programs have been especially helpful in improving balance, physical performance and reducing falls (Hoglund, Sadovsky, Classie, 2009; Kruger, Buchner, Prohaska, 2009; Nelson et al., 2004). Several interventional researchers have been conducted to prevent falls among elderly people (Judge, 2003; Kim, Yoshida, Suzuki, 2010; McMurdo, Millar, Daly, 2000). In this study we will examine a home-based training intervention to improve strength of muscles which can directly improve balance and reduce the risk of falls among community dweller elderly or through increased self-efficacy. Problem statement Risk of falls due to balance impairment among elderly people is reversely associated with muscular strength (Clemson, Cumming, 2004). Effectiveness of muscle exercise interventions to improve balance and reduce the risk of falls in aged people with high risk for falling have been a matter of controversial in different studies (Salminen et al., 2001). While some found exercise training programs successful in reducing the risk of falls (Cheung, Au, Lam, Jones, 2008; Clemson et al., 2010; Gobbi et al., 2009a; Nelson et al., 2004), others have found contrary results (Au-Yeung et al., 2002; Clemson et al., 2010; Rubenstein et al., 2000). The need for a home-based training exercise program is felt by some researchers (Kamide, Shiba, Shibata, 2009). Muscle strengthening exercise intervention by home facilities has its own advantages and disadvantages. Home-based exercise program, in comparison to clinic-based interventions which are very luxurious and seem to be very tempting and promising (Takano et al., 2010), sounds to be more feasible. As a matter of fact, the lack of public availability of high-tech facility in developing courtiers, transportation barriers for elderly, the problem of cost-benefit and cost effectiveness of any high-tech program are major barriers to use clinical-based exercise programming for elderly people (Nelson et al., 2004). Moreover, it is estimated that about one half of seniors aged 85 years or above rarely leave their homes and interventional trials targeting on those housebound aged are scarce(Ashworth, Chad, Harrison, Reeder, Marshall, 2005). Nelson et al 2004 summarized that a home-based exercise program in community-dwelling elders with functional impairment is feasible and effective in improving functional performance, despite limited supervision. They also added that home-based exercise programs that focus on strength and balance training improve functional performance in elderly people and should be promoted by the allied health community (Nelson et al 2004). Low price and organizational flexibility make it an alternative or a supplement to other forms of physical exercise and active lifestyle (Hinrichs et al, 2009) On the other hands, compliance, which is a major problem in centered-based exercise among elderly people, can be achieved by home-based programs. Previous researches emphasis that adherence to any exercise program is low among elderly people especially in long run (Campbell et al., 1997; Dishman, 1991; Gobbi et al., 2009b; Sturnieks, St George, Lord, 2008e; Sun et al., 2005). Blanchard 2008 stated that less than 15 percent of elderly people participate in center-based exercise program. He added that to achieve a larger number of participants, there has been a shift toward implementing home-based rehabilitation programs. Home-based muscular strength training can be considered as an alternative to expensive and low compliance clinical-based muscle training (Blanchard, 2008). There have been some problems in previous home-based programs. They still rely on most expert personnel who closely supervise their patients and provide them with high standard care at their home (Gardner, Robertson, McGee, Campbell, 2002; Nelson et al., 2004; Luukinen et al., 2007a). The others emphasize on individualized tailored programs (Clemson et al., 2010) which raises the cost of intervention program. Moreover, these programs, although were reported to be effective, lack in large scale randomization was the main limitation of the studies (Nelson et al., 2004). Moreover, because of low health literacy among Iranian elderly population, any home-based training intervention without proper supervision and adherence will not be able to achieve its objectives (Carpenter, 2010a). A well cited study suggested that elderly people need supervision to improve strength in a home-based setting (Baker et al., 2001). To overcome the problem of health illiteracy among elderly people we plann ed to involve participants adult children who have the most interaction with the client in training program to supervise him/her during training and fill up the log books. Fear of falling, a risk factor for falls, is being understood as an emerging public health problem (Denkinger et al., 2010; Hill, Schwarz, Kalogeropoulos, Gibson, 1996; Li, Fisher, Harmer, McAuley, 2005). Evidence suggests that both fallers and non fallers experience psychological problems associated with falls (Honaker, 2001). Previous researches have termed psychological factors as fear, diminished self efficacy and loss of confidence(Topping, 1994; Gai, Gomes, Jansen, 2009; Legters, Verbus, Kitchen, Tomecsko, Urban, 2006; Pednekar, 2007). In community dwelling elderly, a complex interaction has been found among fear of falling, falls self- efficacy, increased physical impairments and diminished functional ability and activity participation (Legters et al., 2006; Maxwell, 2006; Mihalko, 1997; Tinetti, Richman, Powell, 1990b; Pednekar, 2007). This interactive cycle encompasses fear of falling which leads to activity restriction and further decreasing physical capabilities such as functional mobility, balance and strength which leads to decreased confidence and fear of falling (Pednekar, 2007). A home-based training exercise should be directed toward strengthening weak muscles and balance. The consequence of muscular weakness and co-contraction is lack of confidence (Tinetti, Richman, Powell, 1990a) which makes elderly people loss their self-confidence and fear of falls (Hill et al., 1996). Fear of falling deteriorates the balance reactions and leads to increased risk of falls and increased risk of injury (Okada, Hirakawa, Takada, Kinoshita, 2001). Loss of confidence among elderly people results in functional limitations and may cause restriction in activity due to fear of falling, which is very common problem among community-dwelling older adults with or without experience of falls (Hansma, Emmelot-Vonk, Verhaar, 2010). Under a public health perspective, the access to home-exercise programs seems to be easier. Once implemented, a home-exercise program should be capable to reach a broad audience (Ashworth et al 2005). So, it is logical that improved muscular strength can result in self-confidence, reduce fear of falls, increase balance and decrease risk of falls. A great number of studies have proposed that only additional research with frail elderly individuals will help answer if home-based training would improve balance in older ages (Nelson et al., 2004; Baker et al., 2001). We, therefore, decided to test the hypothesis that an individual home-based muscle strength training in high risk individuals (60 years old and above elderly people with previous history of falls in last 12 months) would be feasible with minimal expert supervision and would result in clinically important improvements in balance and functional performance. The role of care givers in this study is to fill the log books, because most of the elderly subjects have health illiteracy. Significant of the study This dissertation contributes to the scientific literature in different interrelated ways. Firstly, the finding of this study can contribute to the body of knowledge in regard to falls among elderly. Falls have been explored by several researchers from different aspects; however it needs more scientific and empirical investigations to find out the ways to prevent the fall or alleviate the incidence of falls among frail elderly community-dwellers. To achieve a better understanding of falls, its consequences and prevention of falls, this area of research needs a richer body of knowledge to illuminate the way for other researchers to explore the ways to reduce risk of falls. Secondly, the findings of this study, practically, can contribute to alleviate the problem of falls among frail elderly people in community. This study looks the problem of falls from both biological (muscular strength) and psychological (self-efficacy) point of view. So, any falls prevention program has to consider the results of this dissertation as evidence to plan a comprehensive program on falls. In addition, finding of this dissertation can be used by falls prevention planners. All programs designed to prevent falls can benefit from this study, because it is planned to reduce morbidity and reduces burden of falls for person, family and healthcare services. American Geriatrics Society recommends some activities including exercise and/or physical to prevent falls among elderly people. Health professionals after orienting to the program can deliver and supervise the exercise training program for older people. The program has been tested as a single intervention but could be delive red in a multifactorial falls prevention program, too. Thirdly, the findings of this study can be used by other health practitioners in different disciplines to utilize exercise training to reduce the risk of falls among their elderly clients. So many other researchers have investigated the benefits of the exercise for other high risk groups such as patients with chronic diseases e.g. Parkinson Disease (PD), Multiple Sclerosis (MS), Stroke, Arthritis and other neuromuscular or articular diseases, depression, anxiety, etc. This study highlights the importance of exercise training among elderly people. Moreover, the current study is one of the first studies on the problem of falls in Iranian elderly community. In developing countries where sources are limited, the exercise program can be offered first to those with high risk e.g. history of falls, aged 70 and older. However, other aged people can benefit the advantages of this program. Objectives This study is planned to investigate the relationship between muscular strength to risk of fall among community dweller elderly people. To achieve this objective, the following specific goals are followed: To describe the subjects muscular strength, self-efficacy, fear of falls and balance before and after intervention To examine the relationship between subjects background variables, muscular strength, self-efficacy and fear of falls before and after intervention To examine the relationship between subjects muscular strength and risk of falls before and after intervention Hypotheses The home-based training exercise can improve muscular strengths among elderly people. Strong muscles can directly increase physical balance which is considered as proxy for decreased risk of falls among elderly people. Moreover stronger muscled can increase self-efficacy and reduce fear of falling and decreased risk of falls among elderly people. Definition of key words History of falls Conceptual: History of falls is previous experience of the event of falls. In this study, fall is an unexpected, involuntary loss of balance by which a person comes to rest at a lower or ground level (Kelly Dowling, ). Other researchers have defined falls as An unintentional descent that may or may not result in an injury, and in which any motion of descent may not necessarily result in a landing. (Berry et al., 2010). Operational: In this research, history of falls is defined as any report of falls incidence by which a person comes to rest at a lower or ground level, in subjects of the study. Any incidence of falls in last 12 months is considered as history of falls. Moreover, the number of falls during intervention is questioned. Data are collected by a questionnaire. In the questionnaire history of falls during last 12 months and causes of falls are questioned. No history of falls, one incidence of falls and two or more falls are categorized as non-faller, accidental faller and recurrent faller, consecutively. Fear of Falls Conceptual: fear of falling, first described as ptophobia, by Bhala, ODonnell, Thoppil, 1982, which means a phobic reaction to standing or walking and was subsequently classified by Murphy Isaacs in 1982 as Post fall syndrome (Jung, 2008). Operational: In this study Falls Efficacy Scale (FES) is used to assess clients fear of falling. It is a rating scale with 10 items to assess clients confidence in performing daily activities. Each item is rated from 1, meaning extreme confidence to 10, meaning no confidence at all. Participants with lower self-efficacy report avoiding most of activities because of fear of falling and get higher FES scores. On the other hands, participants with higher self-efficacy report less avoiding most of activities because of fear of falling and represent lower FES scores. Balance Conceptual: Benjuya, Melzer, Kaplanski defined balance as the ability to maintain an upright posture during both static and dynamic tasks (Bird, Hill, Ball, Williams, 2009). Operational: In this study balance is the subjects score in Berg Balance Scale. Total Score is varies between 0 and 56. In interpretation of Berg Balance Scale low, medium and high risk of falls are corresponded to 41-56, 21-40 and 0-20, respectively. Muscular strength Conceptual: Muscular strength is defined as the maximal ability of a muscle to contract and generate force (Hanney, Kolber, Schack-Dugre, Negrete, Pabian, 2010). Operational: operationally muscular strength in lower extremity and hand grip are assessed. For lower extremity muscular strength the chair stand test commonly used. The chair stand test is a physical performance test used to assess lower-extremity function. A 5 repetition test is a measure of strength (Ward et al., 2010). Subjects hand grip force score in their left and right hands will be recorded. Individual patients whose grip strength is less than the lower limit of the confidence intervals can be considered to be impaired grip (Bohannon, Peolsson, Massy-Westropp, Desrosiers, Bear-Lehman, 2006). Exercise Conceptual: A subset of physical activity. It is planned and repetitive body movement, which improves or maintains one or more components of physical fitness (e.g., cardiovascular endurance, muscular strength, balance, flexibility)(Pate, 1995). Operational: operationally exercise is a set of muscular strengthening action used to increase balance in terms of Berg Balance Score (BBS) and reduce the risk of falls among participants of the study. Self efficacy: Conceptual: Bandura (1986) defined self-efficacy as, Peoples judgments of their capabilities to organize and execute courses of action required attaining designated types of performances (p. 391). Self efficacy means ones self confidence towards learning. People usually engage in certain behaviors when they believe they are capable of implementing those behaviors successfully, this means that they have high self-efficacy (Bandura, 2007). Operational: In this study subjects scores in the Activities-specific Balance Confidence (ABC) Scale are considered as their self-efficacy. The Activities-specific Balance Confidence Scale is a scale with 16 items; each item is rated from 0% (no confidence) to 100% (complete confidence). Clients are asked to rate the level of confidence that they will lose their balance in daily activities. Conceptual Model This study will be conducted based on a modern biologic theory called wear and tear theory and Orems self-care theory. In this study the wear and tear theory is used to explain why muscular strength and balance deteriorates during old ages. Orems self-care theory is utilized to explain how self-care through exercise can maintain and improve an old persons ability for balance and reduce the risk of falls. Moreover, Banduras self-efficacy explains the moderating role of self-efficacy between muscular strength, fear of falls and balance to risk of falls among elderly people. Proposed conceptual framework Background Age Gender Marital Status Education Mental status SES Chronic Diseases Medication Health literacy ADL/IADL Self-rated Health (IV) Muscular Strength Fear of Falls Self-Efficacy (DV) Falls Risk (Balance) Chapter Two There has been a lack of investigation on effectiveness of home-based exercise, since there have been few randomized control trials (RCTs) evaluating home-based exercise (Kamide et al 2009). Home-based exercise programs are thought to be effective in improving functional performance and balance in functionally impaired elders (Nelson et al 2004). It is demonstrated that participation in a supervised home-based exercise program was associated with significant improvements in exercise beliefs, including exercise self-efficacy and outcomes expectation (Matsuda, Shumway-Cook, Ciol, 2010). This study is trying to investigate effectiveness of home-based exercise on reducing the risk of falls among elderly people based on theoretical framework and review of related literature. This chapter is devoted to disclose two main sections of the dissertation. First, the theoretical framework of the study will be discussed and then the main related literature to this study will be reviewed. Theoretical Framework In this section, theories of wear and tear and self-care are introduced. The wear and tear theory explains the process of biologic changes during old ages which makes humans cells and tissues degenerated. Moreover, self-care theory explains how anyone (self-care agent) can exert some measurements and actions to maintain health and well being. Wear and Tear Theory Wear and tear theory of ageing was first introduced by Dr. August Weismann in 1982 (Salvi, Akhtar, Currie, 2006). The wear and tear theory of aging believes that the effects of aging are caused by damage done to cells and body systems over time. Essentially, these systems wear out due to use. Once they wear out, they can no longer function correctly (Giampapa Williamson, 2004). According to the theory, aging occurs through wear and tear that leads to the progressive accumulation of damage(Murphy Partrige, 2008) The theory postulates that the daily grind of life, in particular disuse or overuse, literally wears the body out, leading to disease states (tears). The degeneration of muscles, cartilage and eventual grinding of bone on bone is examples of the aging process on body joints, as wear and tear exceed the bodys ability to repair (MacWilliam, 2002). The wear and tear profile over the course of time determines such degradations as loss of information (genetic and epigenetic mutations during the life course), loss of structural integrity (increases in entropy), and breakdowns in the emergent property of complexity (Juckett, et al. 2009). Based on wear and tear theory, senile muscular muscles atrophy starts after middle ages, especially when muscles are disused or overused (Giampapa et al., 2004). The process of degeneration is associated with senile changes in body and progressively reduces muscular bulk. There are good evidences to support that type 2 muscles are more prone to degenerated than type 1 muscles (Mannion et al., 2000). Deterioration in muscular size and number in old ages causes muscular atrophy and in combination of other senile changes in other organs (neurons) (Klitgaard et al., 2008) eventually ends up a loss of muscular strength and balance disorder which may predisposes old people to risk of falls (Sturnieks, 2008). Lack of muscular strength and balance affects patients self-efficacy and make them more susceptible to falls (Campbell et al., 1997), because of fear of falls(Denkinger et al., 2010). Self-care theory Self care theory was given by Dorothea Orem between 1959 and 2001 with a unique philosophy that patients have different level of independently. Orems self-care framework is based on the three components of self-care deficit theory, self-care theory and the nursing system theory (Denyes, Orem, Bekel, 2001). Self-care is defined by WHO as activities individuals, families, and communities perform in order to enhance their health, prevent diseases, limit illnesses, and restore health (Klainin Ounnapiruk, 2010). These activities are undertaken by lay people on their own behalf, either independently or in participative collaboration with healthcare professionals. There are several examples for self-care behavior including seeking health-related information, exercising and consuming healthy diets (Klainin et al., 2010). Self-Care Agency Self-care agency, as defined by Orem (2001), refers to the power of individuals to engage in self-care and their capability for self-care. The person who uses this power or self-care ability is the self-care agent. Self-care agency is acquired and affected by family members and care giver. They specifically may affect the clients adherence to behavioral changes and treatment regimens and overall outcomes (Rutledge et al., 1999). There is a power component to self-care agency, which addresses the importance of knowledge, attitudes, and skills that enable the individual to engage in self-care (Kumar, 2007) Nursing System Nursing system are interventions needed when individual is unable to perform the necessary self-care activities and categorized in three distinct levels as follow: Wholly compensatory in which care givers provides entire self-care for the client. An example of this category is an elderly person hospitalized in critical care unit who need a care giver for his basic needs to survive. Partial compensatory in which a care giver and client perform care; client can perform selected self-care activities, but also accepts care done by the care giver for needs the client cannot meet independently. An example of this category is an elderly person who needs help for some activities such as ambulating, but is able to perform most activities by his own. Supportive-educative in which training is planned to help the client develop/learn their own self-care abilities through knowledge, education, support and encouragement. A good example of this category is educating the elderly client to perform exercise to strengthen the muscles or to teach how to do insulin self-injection. In this research, the third category of nursing system will be applied among elderly people to strengthen their upper and lower extremities muscle to improve their balance and reduce the risk of falls Review of literature A recent study, by Matsuda et al 2010, proposed that effectiveness of any exercise to improve physical function varies with level of frailty, format and intensity of exercise program, and kind of supervision. A systemic review summarized the best evidence for effectiveness of interventions designed to reduce the incidence of falls in older people living in the community, concluded that home-based exercises and Tai Chi were specific exercise programs that showed benefit (Carpenter, 2010b). Home-based exercise program among relatively healthy older adult are proven to be effective in functional performance than group-based programs. In an Iranian study researchers conducted a 12 weeks home-base exercise training in 40 -65 years old Iranian women to prevent osteoporosis and increase muscular strength and balance (Shirazi et al., 2007). In another study researchers conducted a home base training exercise on Parkinson disease patient. They concluded that individuals with Parkinsons disease can significantly improve functional performance measures utilizing a convenient, cost effective, home-based exercise intervention (Nocera, Gainesville, Horvat, Athens, 2008). Other recent studies on standing exercise and balance training program on balance confidence, balance performance, and gait in debilitated, ambulatory community-dwelling older adults supported that exercise can improve balance, However, definitive conclusions need to await validation from more rigorously designed studies before the present training program can be confidently recommended to physical therapists engaged in home care practice(Miller, Magel, Hayes, 2010). In New Zealand, the Otago Exercise Program is designed as a home-based training exercise with combination of strength, balance exercises and walking program to prevent falls. The program is individually designed program three times a week and progressed over time. Four randomized controlled trials in different setting disclosed the effects of training program among elderly people. In another supervised 6-week, multidimensional home-based exercise program, researchers found that the program was safe and associated with improvements in physical and exercise-related belief outcome measures(Matsuda et al., 2010). Some researchers have used some technical instrument to improve balance and reduce the risk of falls among elderly people (Runge, Rehfeld, Resnicek, 2000). However, any community home-based program should integrate the training into peoples everyday life. It would be feasible, economic and more acceptable for elderly people rather than high technical procedures. A randomized controlled pilot study with 12-week physical and/or nutritional intervention program was followed by six months of home-based exercises for the training groups, followed up with training diaries aiming to describe the effects of a physical training and nutritional intervention program on the physical activity level and activities of daily living (ADL) in frail elderly people found moderate correlations between increases in physical activity level and ADL as well as between the amounts of home-based exercises and ADL for the two training groups (Rydwik, Frandin, Akner, 2009). Another study found that a 6-month, home-based exercise program consisting of progressive strength training, balance exercises and general physical activity improves functional performance and balance in functionally impaired elders (Nelson et al., 2004). Finding of another study concluded that an exercise class even once every 2 weeks is very effective in enhancing physical function in ambulatory i ndividuals aged over 73 years, provided that it is supplemented by a home-based exercise program (Suzuki, Kim, Yoshida, Ishizaki, 2004). However they suggested a large scale study to confirm their results and to evaluate the most effective exercises for the prevention of falls. Researchers concluded that incorporation of exercises in daily life is important in maintaining an appropriate level of physical function in the elderly. Prevention of falls and injuries is not easy, however, because they are complex events caused by a combination of intrinsic impairments and disabilities (Kannus, Niemi, Parkkari, Palvanen, Sievznen, 2007) fall prevention in elderly people consists of regular strength and balance training, vitamin D and calcium supplementation, reduction of the number and doses of psychotropic medication, cataract surgery, and professional home-hazard assessment and management in people with a history of falling (Kannus, Sievenen, Palvanen, Jervinen, Parkkari, 2005). On the other hand, a single-factor intervention such as exercise could also reduce many impairments and disabilities and more distant risk factors for falling simultaneously. Muscle mass diminishes considerably between the ages of 20 and 80 years (Sturnieks, St George, Lord, 2008d). Sarcopenia is a common problem among elderly people and is associated with loss of muscle mass and strength (Iannuzzi-Sucich, 2002). Understanding age-related changes in the physiological systems imperative to balance is of importance to prevent falls in older people and reduce the injury-related burden on individuals and society (Sturnieks, St George, Lord, 2008c). It has been estimated that the human beings in their 4th to 8th decade of life lose approximately half of muscle mass and muscle strength (Spirduso, 2005). Senile muscular atrophy predominantly occurs in type 2 muscle fibers which ends up a degenerated muscular bulk in which remaining muscle mass is not only smaller and weaker but slower as well (Kostka, 2010; Faulkner, 1995). The most primary atrophy occurs in quadriceps, hamstrings and back muscles with the highest concentration of type II fibers (Kostka, 2010). It has also been consistently proven that power-generating capabilities of type II fibers is approximately four times more than of type I fibers (Faulkner, 1995; Metter, 1997). Muscular strength is typically maintained at peak levels until the fifth or sixth decade, after which accelerated losses occur, with strength decreasing approximately 50% by the age of 80 year (Sturnieks, St George, Lord, 2008b). Deficits in skeletal muscle strength, balance, and gait, being major causes of frailty and risk factors for falls, are equivalently and potentially reversible by exercise training (Suzuki et al., 2004). One proposed intervention for preventing falls and fall-related injuries in the elderly is exercise. If falls occur at least in part because of physical deficits in balance, strength, reaction time, and flexibility, then it is plausible to believe that exercise targeted to improve these deficits might result in fewer fall and/or injury events. The role of strength exercise in falls prevention is under investigation. In a recent study, researchers evaluated the balance and weight training to alter gait characteristics of elderly to reduce the likelihood of slip-induced falls. The results indicated decreases in heel contact velocities and the friction demand characteristics after 8 weeks of training, although fundamental gait characteristics, such as walking velocity and step length, were not changed (Kim Lockhart, 2010). Latham, et al 2003 in a randomized control trial found that among older people recently discharged from hospital quadriceps strengthening exercises failed to reduce falls rates and was associated with a significant risk of musculoskeletal injury (Sturnieks, St George, Lord, 2008a). A recent study investigating the effects of a multifactorial fall prevention trial on the specified risk factors of falling, incidence of falls and injurious falls did not find significant difference between control and intervention groups (Sjosten et al., 2007). However there are some evidences to support effectiveness of training program among elderly people (Kruger et al., 2009; Madureira, Bonfb, Takayama, Pereira, 2010) Review of literature reveals that self-confidence deteriorates because of muscular weakness and make old people to fear of falls (Davis, 1999; Evitt, 2003; Gai et al., 2009). Bandura in his book 1997 wrote that: People make causal contributions to their own psychosocial functioning through mechanisms of personal agency. Among the mechanisms of agency