Quality of Life in Cervical Cancer Patients in India

Quality of Life in Cervical Cancer Patients in India Abstract Introduction: Cervical cancer is the most frequently diagnosed cancer among women in India. Understanding quality of life (QOL) in women undergoing chemo-radiotherapy for cervical cancer. It will help in introducing interventions for better care and outcomes in these women. This study assessed the QOL before and after chemo-radiotherapy in cervical cancer patients. Methods: This follow up study was undertaken at Dr. B.R.A Institute Rotary Cancer Hospital(IRCH), AIIMS, New Delhi, India. Sixty seven newly diagnosed women with advanced cervical cancer (stage 2b to 4b) were included to assess the change in QOL after treatment . Structured questionnaires on Quality of Life (The European Organization for Research and Treatment of Cancer, EORTC QLQ-C30 and EORTC QLQ-CX24) were used. QOL was assessed before initiation and after 6 months of treatment. Results The mean age of women at the time of detection of cervical cancer was 52.28 ±11.29 years (Range 30-75 years). Squamous cell carcinoma was found to be the most common cell type (97%). Six months survival was 92.53% The mean global health score of cervical cancer patients after six months of treatment was 59.52, which was significantly higher than the pre treatment score of 50.15 (p=0.00007). Physical, cognitive and emotional functioning (p Conclusions Recommendations QOL of newly diagnosed cervical cancer patients significantly improved following chemo-radio therapy. Enhancement was also demonstrated on three of the five functional scales of EORTC QLQ-C30. To further improve QOL, interventions focusing on social and psychological support and physical rehabilitation may be needed. Keywords: Cervical cancer; Quality of Life; Chemo-radiotherapy INTRODUCTION Cervical cancer is a major public health problem in many developing countries. Besides contributing significantly to mortality rates, it leads to the loss of productive life due to prolonged disability.1The absolute burden is expected to increase in future unless effective preventive measures are undertaken. Globally, cervical cancer is the fourth most common cancer in women with nearly 528,000 new cases reported in 2012.2 Nearly 85% of the global burden occurs in the less developed regions, where it accounts for almost 12% of all female cancers. High-risk regions, with estimated (Age standardized rate) ASRs over 30 per 100,000 include Eastern Africa (42.7), Melanesia (33.3), Southern (31.5) and Middle (30.6) Africa. There were an estimated 266,000 deaths from cervical cancer worldwide in 2012, accounting for 7.5% of all female cancer deaths.2 Cervical cancer is one of the leading cancers among Indian women with estimated 123000 new cases and 67477 deaths in 2012.2Cancer is preventable and curable if detected at an early stage.The five year survival rate of cervical cancer when diagnosed at the earliest stage is 92% and the combined 5 year survival rate of all stages is71%3. It is currently believed that the persistent infection with one of the 15 oncogenic types of Human papilloma virus (HPV) is the central and necessary cause of almost all cervical cancers and its precursor, cervical intra epithelial neoplasia (CIN). A proportion of CIN, if not detected and treated, progress to invasive cervical carcinoma over a period of 10-20 years owing to the effect of other cofactors.4,5Unfortunately, despite the availability of methods for prevention and early diagnosis, many women in India have never been screened for cervical cancer. Though the diagnosis and treatment of cervical cancer has been developed, there are important consequences from the disease and its treatment among survivors, especially the impact on quality of life (QOL).Somefunctional disorders occur following therapies such as surgery, which involves the female genital anatomy affecting directly their perception of body image and sexual functions; radiotherapy which could damage the vaginal mucosa and epithelium; and chemotherapy which could induce various adverse effects like nausea, vomiting, diarrhea, constipation, mucositis, weight changes and hormonal changes. Variouspsychological factors including low self-esteem, changes in self-image, beliefs about the origin of cancer, marital tensions, fears and worries can affect the patients.6 Need to measure QOL has become important due to broadening concept of measuring health status beyond traditional indicators such as mortality and morbidity.Assessing QOL is potentially valuable in identifying pa tients’ problems and discovering the challenges and planning for the health systems. Taking into account the impact of early screening methods on long term survival of cancer patients, studies assessing QOL and its related factorshave become critical.Limited studies have been done to evaluate QOL among cervical cancer survivorsdiagnosed in advanced stages. This studyassessed the QOL in such patients before and after treatment with chemotherapy and radiotherapy. MATERIALS AND METHODS This was a follow-up study conducted atDr. B.R.A Institute Rotary Cancer Hospital(IRCH), All India Institute of Medical Sciences, New Delhi.67 female patients who were diagnosed with cervical cancer attending IRCH between 1st January 2014 and 30th June 2014 were recurited. The inclusion criteria were all women who were newly registered and diagnosed cases of cervical cancer of any histological type and advanced cancer stages (2b to 4b). Critically ill patients, those not willing to give informed consent and those who underwent surgery and did not require radiotherapy and chemotherapy were excluded. All consecutive cervical cancer patients fulfilling the inclusion criteria during the six month period were eligible for recruitment. Quality of life of the study subjects was assessed using the questionnaires developed by the European Organization for Research and Treatment of cancer (EORTC) QLQ-30 and EORTC QLQ-CX24.7-11 a) EORTC QLQ- CX30 The EORTC QLQ-C30 is a questionnaire developed in 1993 to assess the quality of life of generic cancer patients. It has been translated and validated into several languages including Hindi and has been used in numerous studies worldwide. These questionnaires have been undergone extensive testing in multicultural and multidisciplinary research settings, and have been confirmed to be a reliable and valid tool. The EORTC QLQ C-30 questionnaire comprises of 30 questions assessing functioning viz. physical, role, cognitive, emotional, social; symptoms viz. fatigue, nausea and vomiting, pain, dyspnea, insomnia, appetite loss, constipation, diarrhea, financial difficulty; and a global health status score which assesses the overall QOL. b) EORTC QLQ-CX24 EORTC Quality of Life Group has adopted a modular approach to QOL assessment for overcoming the limitations of generic tool and for disease specific treatment measurements. Consequenty, modules specific to tumor site locations, management modality, or a QOL dimension have been developed that are administered in addition to the core questionnaire. The EORTC QLQ CX-24 is a complementary questionnaire specific for cervical cancer patients that consists of 24 questions categorized as functional scales viz. body image, sexual activity, sexual enjoyment, sexual/vaginal functioning and symptom scales viz. symptoms experience, lymphedema, peripheral neuropathy, menopausal symptoms and sexual worry. Both the tools utilize a 4-point response scale namely â€Å"Not at all†, â€Å"A little†, â€Å"Quite a bit† and â€Å"Very much† to assess each functional or symptom item, and a 7-point response scale to assess global health status ranging from very poor to excellent. These study instruments were administered to patients at baseline and again at 6 months to ascertain changes in QOL after treatment. Institutional Ethics Committee (IEC) approval was obtained from All India Institute of Medical Sciences (AIIMS), New Delhi prior to initiation of study. Prior to enrollment, written informed consent was obtained from patients after detailed explanation about the study. Patient confidentiality was assured and the study participants had the right to abstain from participation without affecting on the quality of care being provided to them. Statistical analysis Data analysis was performed using Statistical Package for the Social Sciences (SPSS) version 18.Qualitative data was expressed in proportions while mean and standard deviation were calculated for quantitative data. The student’s t test and Chi square tests were used for comparing the characteristics of the study participants and the quality of life scores before and after chemo-radiotherapy. The scoring of the questionnaire data was performed according to the scoring manual. All scores were transformed to a 0-100 scale. For the functional scales, a good function was indicated by higher scores. For symptom scales, more severe symptoms were indicated by a higher score.10Ap-valueunder 0.05 wasconsidered statistically significant. RESULTS This study included 67 patients of advanced cervical cancer who met the eligibility criteria. Six deaths were reported during the course of study and 5 patients were lost to follow up. The final sample that was analyzed consisted of 62 patients and the quality of life was assessed in 56 patientsThe mean age of study participants was 52.28 ±11.29 years (Range 30-75 years).Squamous cell carcinoma was the most common cancer (97%) while remaining 3% patients were diagnosed with adenocarcinoma/ adenosquamous carcinoma. Majority (53.73%) of the study subjects were in stage 3b, 40% in stage 2b and remaining in stage 3a and 4a. Metastasis was present in only one patient.Combination of radiotherapy and chemotherapy was the most common (77.67%) modality of treatment. Nearly 12% of the study subjects were treated only by radiotherapy while another 10.45% cases received radiotherapy after surgery. Palliative treatment was given to four patients Six months survival among those who could be followed up was 92.53%.The global health score amongst improved significantly after treatment (p= 0.00007). The mean global health score of cervical cancer patients following treatment was 59.52, which was significantly higher than pre-treatment values of 50.15. [Table1] The patients quality of life of patients in the functional scales comprising physical, role, emotional and cognitive functioning improved significantly after treatment of cervical cancer (p= 0.012, 0.044, 0.000026, 0.00062 respectively). There was no difference in social functioning score.Symptom like fatigue, pain and loss of appetite improved significantly, but no significant improvement was seen in nausea/vomiting, dyspnea, insomnia and constipation. Diarrhea worsened in the post treatmentphase (Table 1). There were significant changes in cervical cancer specific EORTC QLQ CX-24 module scores for cervical cancer patients [Table2].There was significant decrease in body image, sexual enjoyment and vaginal functioning after treatment, though sexual activity as a whole did not change significantly. Overall symptom experience showed significant improvement after treatment with score reducing from 25.70 to 12.55 indicating improvement (P=0.00001). There was no difference in symptoms reflecting peripheral neuropathy and menopausal symptoms after treatment On the other hand, sexual worry decreased significantly with the mean score declining from 60.28 to 17.02 after treatment. Overall health score and quality of life score improved significantly (p DISCUSSION Indicators of quality of life measure the impact of a disease and its treatment on a patient’s daily activities, behavior, perceived health and functional status. Quality of life indices, which focus on patient’s own perception of disease, provide further information that cannot be obtained solely from conventional clinical and functional measurements. Therefore tools to measure quality of life have been framed by various organizations for comprehensive assessment of patients under treatment. Many factors may contribute to QOL of women diagnosed with a gynecological cancer. In our study most common modality of treatment was combination of radio and chemotherapy. Radiation therapy damages the vaginal mucosa and epithelium which leads to decrease sexual functioning and pleasure. Additional side-effects of radiotherapy are nausea, vomiting, diarrhea and mucositis among others12. Our study compared the pre-treatment and the post-treatment QOL for advanced cervical cancer patients. The Global health score showed a significant increase after treatment making it apparent that quality of life improves after treatment. Similar results were also seen in a recent study published by Kumar S et al. (2014)13.In functional scales, all the items showed a significant increase after treatment including physical, emotional, cognitive and role except social functioning which was nearly same before and after treatment. This was in contrast to a study by Greimel et al. (2002)14, which showed that the global health status, emotional and social functioning remained low. This difference could be because of enrollment of all stages of cervical cancer in their study and the fact that majority of study subjects underwent surgery as a part of treatment modality. The symptom scale analysis revealed that there was a significant decrease in fatigue, pain, insomnia and appetite loss after treatment. This was in contrast with another study done by Klee et al. (2000)15in which pain, appetit e loss, nausea vomiting increased after 3 months of treatment. This variation could be because of differences in time gap between initiation of treatment and post therapy QOL assessment. Episodes of diarrhea worsened after treatment in the present study which may due to radiotherapy. Radiotherapy has been shown to be associated with diarrhea while constipation may be ascribed to injury to the parasympathetic nerves during surgerical interventions 15,16. Another study done by Tokzaharani S et al. (2013)17also showed scores were negatively associated with symptoms including short breathing, lack of appetite, nausea and vomiting, sleep disorder, peripheral neuropathy and menopausal symptoms. In our study, financial difficulties had not changed significantly after treatment. Other studies have shown that financial difficulties increased after treatment which can affect the QOL of the patients [Park S Y et al. (2007)18]. As the study subjects were being treated in a government supported institution, out-of-pocket expenses are likely to be low.This aspect of assessment becomes especially important in resources limited settings like ours. Sexuality is an important aspect in patients suffering from any gynecological cancer and thus a crucial determinant of QOL. In our study there was a significant decrease in sexual enjoyment and sexual and vaginal functioning score in EORTC QLQ CX -24 which was also demonstrated in the study conducted by Kumar S et al. (2014)13. Another study [Park S Y et al. (2007)18] stated that 40% to 100% individuals face sexual dysfunction after treatment. This is because cervical cancer and its treatment affect the same areas of the body which are involved in sexual response. Both chemotherapy and radiotherapy has been associated with sexual problems like dyspareunia, insufficient lubrication, anxiety about sexual performance. Beside this, psychological factors also have an important role in sexual behaviors, and we found that cervical cancer patients had more anxiety about sexual performance. Overall symptoms experience reduced significantly after treatment but lymphedema, peripheral neuropathy menopausal symptoms did not change significantly. In contrast, Kumar S et al. (2014)13demonstratedsignificant increase in these symptoms after treatment. In another study done by Frumovitz et al. (2005)19, frequency of menopausal symptoms increased and sexual functioning decreased after treatment. These symptoms may follow from oophorectomy or radiation damage to the ovaries. In our study patients had perceived poor body image after treatment. These results were similar to those reported by of Park S Y et al. (2007)18. In our study overall health score and quality of life score improved significantly (p It is suggested that further studies and interventions focusing on improving the QOL in survivors should be encouraged. Although, the overall QOL after treatment in cervical cancer survivors was good, treatment of related problems can further improve it. By detecting the problems associated with the quality of life after treatment of cervical cancer, health care professionals will be able to undertake intervention programs that will help to prevent or ameliorate specific problems and adverse effects. RECOMMENDATIONS Although this study revealed that patients with cervical cancer subjected to radiotherapy and chemotherapy are satisfied with their global quality of life, attention should be paid to certain dimensions like sexual functioning during post-treatment period. To further improve QOL, interventions focusing on social and psychological support and physical rehabilitation may be needed.

Case study on Implementation of quality systems through information technology systems in Athal Company Essay

Case study on Implementation of quality systems through information technology systems in Athal Company Introduction                   Athal is a service offering company that was established in 1980. It offers inspection, testing, consulting, and quality control services. The company offers services to different companies in different industries through its 15 branches in United Kingdom. The company had offered these services in the past using manual quality system but due to competition and emergence of technology in the industry, the company found it necessary to implement a new automated quality assurance system by adapting information technology systems. This would enable it to offer quality services that meet national and international standards. The implementation of the new system was faced with challenges from financial to employees’ resistance to the new technology. The data on the case study was obtained through questionnaires and interviews. The findings were as follows. From the 110 questionnaires administered, only 100 of them were complete and used for this case st udy. From the 100 questionnaires that were complete, 90% discredited the manual system saying it was faulty as it offered minimum monitoring. 70% of the employees had a positive attitude about the manual system, as it was not effective when monitoring employees. 30% had negative attitude on the system as they felt the system caused personal conflicts between them and the people in charge of quality control. 100% of the participants agreed that the automated system was more effective compared to the manual system since all the employees had to log in to automated biometric system. 43% of the employees were resistant to the process and felt that the manual system would continue while 57% of the employees felt that transformation to the automated quality system was necessary. 95% of the employees felt that it was important to implement the quality system for both the external and internal environment of the business to ensure that the overall performance of the company was monitored. 5 % of the participants were not sure if the quality system was supposed to be installed both internally and externally.                   The company’s 110 employees were issued with questionnaires and five management staffs from the five departments were interviewed revealing the following: The employees were resistant on the new implementation was because of fear of losing their jobs and their relevance when the new technology would be adapted in the company. Hence, the implementation process heavily relied on the employees in the company. The company sensitization and trainings employees on the new technology saw the implementation process become smooth. The company also faced challenge on the cost of the new system in terms of infrastructures such as software, computers, and training employees and technical staff on running and marinating the process. However, the implementation of the new system improved the services offered and increased its competitive advantage in the market. Through analysis, it was realised that, the company use of technology has limited the buyers’ bargaining power thus retraining and attracting more customers from its unique quality services that it offered. The new technology decreased the profitability of the industry thus decreasing the threats of the new entry. The company was under the threat of high suppliers’ bargaining power due to few suppliers in the industry that made the cost of operations to increase thus decreasing the profits margins. There industry has threats of substitute services that are offered by companies using the manual system at low prices. However, the new automated system was found to be fast and giving effective services that attracted consumers and thus retaining and attracting new employees in the company thus helping it to regain its competitive position in the market. Moreover, the ability of the system to be monitored by different people at the results in services that are accurate is free from errors thus giving consumers’ confidence as opposed to the manual system. The proces s is also cost effective in long term due to reduced time and human capital that can be utilized in other constructive duties that would improve the productivity of the company. The system was recommended for both internal and external controls. Question                   Athal is a company was established in 1980 in United Kingdom. It main work is provision of services in that vary from inspection, testing, consulting and quality control. They offer these services to different organizations to ensure that they offer quality services and that they are able to handle managerial and financial problems with the international standards. The company offers these services in more than 15 branches in United Kingdom. For the company to be efficient, it has linked all the 15 offices through information systems and technology. The company also manages to offer these services by employing 110 workers that are of various professional backgrounds. The workers are delegated duties based on 5 different departments of the company that include public relations, finance department, technical, marketing and quality control. The finance department ensures that all the financial services are met for the company and that of the clients looking for consultancy services in the organization. The public relation department ensures that interpersonal relationship for all the clients and workers is maintained at high level thereby improving the performance of the employees, retain, and attract more customers. This has led to productivity of the company due good customer relation and high quality services that the company offers. Technical department ensures all the other department and technical services management meet the goal and mission of the company to offer quality services.                   The quality control department ensures that all the services that offered by the company and its internal managements are in line with the international and local standards (Hoyle, 2009 p. 244). The company had adopted manual quality control system that mandated employees to monitor all the services and departments in the company. In addition, the inspections and testing when assessing qualities of their clients was done manually, which was expensive and involving to the employees in charge. The manual system was not efficient and some of the departments, employees, and services monitoring was poor resulting to poor services that affected the productivity of the company. The quality of services that a company or business offers helps it to retain and attract more customers making the company more competitive and commanding a wider share of the market (Berry, & Parasuraman, 2004 p. 134). Therefore, for the company to improve its services and improves its market share, a competitive and efficient quality control systems had to be put in place. Despite the high cost of implementation, the service would ensure that quality services are dispensed through efficient monitoring services.                   The company adopted and automated a quality control system developed through information technology to link all the five departments and the employees. Consequently, the company linked all the 15 branches such that all the services offered meet the customers need. The interlinked company departments and branches would ensure that inspection and testing process were efficient. The technical department monitored and maintained all the systems. The marketing department quality system ensured that customers could get all the necessary information and services that meet the international standards. Consequently, through quality control the public relation department would ensure that a good relationship among all the stakeholders of the company by disseminating relevant information and keeping the customers updated throughout.                   The questions categorized for questionnaires and interviews. The employees’ questions related to the effectiveness of the new process, their attitude on the change, and the transformation to the new system. Moreover, it also focused on employees’ involvement in the new process, and how monitoring changed comparing the old system. Concerning this question, some employees said that the new system was more effective while few of them did not distinguish between the performance of the manual and the new system saying that they view both systems as the same. On the issue of cost and monitoring, most of them said that the new system on quality assurance was more costly and offered close monitoring of employees and projects on the course thus maintain a high performance rate in the company. On the issue of the attitude of the employees, some employees had a negative attitude on the new system as they said that the new system would limit their free dom and might result to losing their jobs. Those with positive attitude argued that the new automated system would make work easier and improve the performance of the company. Few were confused on the though seemed interested with the implementation of the new technology. The implementation process was expensive from the response of the majority of the participants while few did not care about the cost and they said that it was cheap for the company since it had enough resources to implement the new system. According to the participant in this case study that were working for Athal company for the time of the research, the transformation process was faced with resistant as some employees feared losing jobs due to inadequate skills. Other argued that new technology would result in working overtime because some machines would require monitoring and thus resisted the change and made the transformation process difficult for the management. A number of the employees said that transformat ion was smooth as they cited that the management was able to deal with employees and assured them that nothing would change on the management of employees and their jobs were safe. They also indicated that the management assured them that the transformation to the new automated system would include training of employees in order to adapt to the new system. The employees argue that method would be applicable to both internal and external monitoring, as the company required the monitoring of the quality of other companies that it offered services. To them, this was the best means by which the company would improve its services to its clients.                   On the part of the management interview, it emphasized on the performance of the new technology, employees and clients response, and the cost of the implementation. The interview involved five management employees under the five departments. The management unanimously answered that the performance of the new system showed improvement. They cited that the system could process large information fast, accurately, and effective as compared to the old system. The management argued that the employees had a mixed reaction on the implementation while the clients were happy and welcomed the new system, as they believed that it could improve their services. The implementation process was costly according to the management but they did it as a way of improving their qualities.                   The organization experienced problems and poor performance in the marketing department thus caused reduced customers in the company. Similarly, poor performance of public relations department resulted to conflicts and poor employees’ performance that affected the efficiency and productivity of the company in delivering its services. In every company or business, good employees’ relationship is important since it minimizes conflicts and improves their working conditions and as a result, employees become very productive, which is the aim of every business. Consequently, employees are able to offer quality services to the customers thus retaining more customers for the company. Similarly, the slow monitoring and poor services in the finance department caused company poor performances and financial mismanagements. All the problems happened to Athal Company despite it having a manual quality assurance system that was mandated monitoring and ensu ring that the company was able to operate within the local and international business environment. The problems reflected that the manual system was ineffective. Therefore, the company needed to change its method of quality assurance so that it could ensure that customers received quality services. Finance department also needed good management as it ensured that the company operated with the international and national standards. The approach would not only improve the company’s quality systems but also improve its productivity and its competitiveness due to high quality services and standards that it would uphold.                   The target market for Athal Company is organizations and businesses that are in need of consultancy, inspection and testing services. The companies or businesses may be diverse and offering various services in the market but for them to provide quality services to their customers, they strengthen their managements through Athal consultation services (Wigand, 2003 p. 33). Therefore, Athal Company needs to provide high quality services and set international standards to its clients. Hence, it was important for it to adapt new technology in quality assurance services that would allow it give quality inspection, testing, and quality control services. Thus, adapting an automated information system would ensure that it would be able to carry out internal and external quality control.                   Athal Company offered effective services in the industry, which has maintained its productivity in the market in spite of its manual system. The company has also high skilled employees although the achievement of the company’s goals has been achieved through extra management and monitoring. In addition, the company operates in an industry where competition is not very much stiff. However, the emergence of the new technology that few companies are adapting, competition is becoming a business issue that management has to deal with. Moreover, the companies marketing strategies and technology adaptation has been poor until the recent past when the company adapted the new technology on quality assurance. Therefore, it is important to evaluate the implementation process of the new quality assurance system and how best is suited in the company’s strategies to improve its productivity and growth in the industry. Literature Review                   With the development and the industrialization of the world, technology has become inevitable to business industries (Lanz, 2013 p. 6). Many businesses industries adapt technologies to increase efficiency and quality of services they offer. The quality services and efficiency serves as a strategy to compete in the market. Information technology is one of the technologies that have been adapted by many companies and bushiness to improve on their performance (Ho-Chang, Chang, & Prybutok, 2014 p. 316). The information technologies have been used in various areas of specialization for company such as records department, financial, marketing and quality control. The technologies are linked to the business strategies such that they fit the competitive strategies making the company to fit in a dynamic market and environment (Wang et al, 2012 p. 346). The information technology systems help to integrate business entities making it more manageable and efficient i n delivery of its services (Drnevich, & Croson, 2013 p. 488-489). Hence, the quality system that would incorporate information technology system will enhance the integration of the five departments and the external environment making the company more manageable and improve service delivery. Consequently, the business would be able to compete and improve its performance.                   The implementation of the new technology in Athal Company involved an organization change. Hence the company needed to prepare the employees for a new change because people tend to resist to changes and particularly to those that tend to affect their freedom (Ford, J., Ford, L., & D’Amelio, 2008 p. 370). The managers have the responsibility to initiate new changes and influence employees to develop positive attitude on the technologies for smooth adoption of new technology (Lilly, & Durr, 2012 p. 199). To avoid resistance managers and executive must provide employees with trainings and other support skills that will help them to adapt to new technologies (KumpikaitÄâ€", & ÄÅ'iarnienÄâ€", 2008 p. 93-94.). Methodology                   The case study used questionnaires to obtain information from the employees about the manual quality system and the newly implemented quality systems in the company (Appendix 4). All the 110 employees were administered questionnaires to feel that contained both the questions about the old and the new information systems. In addition, interviews were conducted with five members from the top management team to understand the monitoring of the two systems (Appendix 5).                   The questionnaires were preferred for the employees because they were a large group in the company and other methods would take a lot of time. Moreover, it was possible to administer all the questionnaires at the same time thus saving time and getting the required information. However, the tool is not appropriate for getting details.                   Interviews were preferred for the management team because they were few and it could be managed with a short time. Interview also helps in getting details about the implementation process. However, it is time consuming. The interview involved the three questions attached in the appendix for the management.                   Athal Company was chosen in this case study since it was one of the companies that had implemented a new automated quality system using information technology in the recent past. These meant employees could be able to provide the required information as opposed to those that implemented it long time ago. In addition, there was high likely hood that most of the employees working in the company were present during the implementation process thus accurate information. Moreover, the implementation of the new system was faced with many challenges from employees’ resistance to financial support. In addition, the company size was manageable for this study since it had few employees, few departments and only five departments. Hence, finding information from the company would be easier compared to large complicated company.                   The region of study was chosen to be United Kingdom because the location has been advanced in quality system technology and so there was high likelihood of finding a company that had implemented a quality system using information system as the study had targeted. The studies show that the United Kingdom has a number of companies operating in quality assurance industry, which made the study more appropriate within the country (Sroufe, & Curkovic, 2008 p. 517). Study                   The case study involved the shifting of Athal Company from the manual quality systems to new automated quality systems that would be implemented using information technology systems. To implement the new quality assurance system using information system, the company needed to purchase new computers, information systems software to link various departments and branches. The program required skilled labor that was costly and extra training for the employees so that they could be able to adapt to the new technology freely. In addition, the new technology needed change of organization behavior from a manual system to an automated system, which many of the employees were not conversant. Therefore, the company had to change the behavior of employees from manual to automated systems, which risked objection and resistant. Hence, the management had to use their leadership skills and organization development to implement the new change successfully (Mullins, 2013 p. 8). The new system meant that the employees freedom, poor performance and missing of duties would end. Consequently, their level of services would be monitored and thus giving quality services. The implementation process involved installation of inspection, testing, and quality control infrastructures that were linked using information system software and hardware that would be used to disseminate information.                   The change to new technology for Athal Company meant that it would increase its market share due to improved quality of services that it would offer. Its clients would receive quality inspection and testing that would guarantee the quality control. The new information system would be able to monitor external companies that serve as its client at constant rates thus enhancing efficiency of Athal Company. Moreover, the automated system has low errors as compared to the manual system thus, the right services will be offered. This will guarantee the company efficient services that meet the national and international levels.                   The new changes to the automated system will enable the management in the Athal Company to be able to define their objectives and delegate to specific employees, which could not be possible with the manual system. Defined objectives and delegation of duties in the company will mean that the tasks would be accomplished in time. Moreover, less time is wasted using the automated quality systems thus the employees become more productive in spite of quality services that they offer. The result is the overall productivity of the company and better services to their clients compared to when they were using the manual system.                   The company decision to implement the new quality assurance system was because of increased competition and the deteriorating performance on its inspection, testing, and quality control services. The few companies in the industry had improved their performance, they had started to command the market, and therefore, the company had to look for means by which it could be able to compete with the other companies. The adoption of the new automated quality assurance system was seen as the only way that the company would be able to compete successfully in the market and thus a decision was finally reached to implement the new system. However, the decision was subject to employees support as they would be the one s that would use the technology for the benefit of the company. The decision process involved all the employees in the company where opinions were included in the new projects. Due to fear of most of the employees on their relevance when the new techno logy would be implemented, training of existing and recruiting of new employees was included as part of the implementation of the new system. When all the employees were comfortable with the new technology and sensitized on the need to shift to the new technology, the management went ahead to implement the new automated quality system in the company. Since the employees are growth oriented, they were able to adapt to the new system. Analysis                   The company wanted to implement new system as a sign of its improvement from the manual to the automated system. The automated system would allow the company to improve its services and the ability to upgrade and update the systems software will give the company ability to adapt to continued improvement of its services. Therefore, the new technology will be advantageous to the manual quality system that limited continued improvement throughout the operations.                   The case study can be analyzed using various porters’ five forces to determine its applicability of the new technology in Athal Company and the external business environment (Appendix 7). The porters’ five forces help to analyze the business in terms of competition, threat of new entry, power of buyers, suppliers, and substitute’s products or services.                   Consulting industry in United Kingdom is very competitive and thus companies in the industry must devise strategies that will make them more competitive and make them the leading companies in the market. Therefore, for Athal Company to remain relevant in the market, it must adopt the best technologies that will enable it to provide the best quality assurance services in the industry. In the industry, company adapt to manual systems due to their low operation cost (Ahuja, & Khamba, 2008 p. 745). Hence, Athal company shift to new technology gives it competitive advantages over the other companies in the industry. According to the research carried out on the company, 90% of the employees credited the automated system saying that it was effective compared to the manual system. Thus, the system would be able to deliver quality effective services to its target market. Quality services help a company to retain its customers and place it in a more competitive po sition in the market as customer or buyers tend to be attracted by quality and not the prices (Porter, 2008 p. 33). Therefore, the company’s choice on the automated system would be advantageous in the market despite the cost that is associated with it. The implementation of the new automated case study led to the improvement of the company’s performance and increase in customers seeking services from the company and thus improved incomes as shown in figure 1 below (Appendix 1). According to the interview carried out on the company’s income performance, the income is expected to rise to $ 27,000 million with the new automated system.                   The industry suffers from the presence of companies that are still using manual systems as a means of quality assurance system. The manual system forms the substitute services offered in the industry. These companies charge their inspection services at lower prices that threaten Athal automated services. Hence, Athal Company must offer good services beyond their clients’ expectations so that they will be able to shift from the manual to the automated. The company also needs to put in place marketing strategies that will advertise the new system emphasizing on the quality of services that it will offer as opposed to their previous method of quality assurance. Moreover, the company needs to offer quality services that will meet the needs of the clients. Hence, the company needs to improve its management and staff training so that it will be able to cope up with the substitute services from the company.                   In every market, companies maintain the large share of the market through limiting the bargaining power of the consumers. Initially, the company was offering manual services that were offered by other companies in the market. This gave consumers more bargaining power as they had a wide choice of obtaining services from various companies. However, the shift of Athal company from manual system to the new technology that was adapted by few companies make consumers to have limited choices of seeking services from the automated companies. The presence of few companies with the automated quality control system makes it possible for Athal Company to limit the bargaining power of consumers. When the bargaining power of consumers in the market is limited, they will tend to buy or obtain services from a single business (Chen, 2008 p. 241). Therefore, Athal Company will limit the customers and thus they will tend to seek the new services from the company thus impro ving its productivity and making it more competitive in the market.                   Athal Company shifting to the new technology meant that it would also shift its suppliers from those that provided the manual facilities to those that would suppliers it with facilities and infrastructures for the new technology. Since many companies in the industry have not adapted the new technology, it means that the suppliers are few in the industry. Few suppliers mean that the suppliers provide their services with strict conditions and high prices due to lack of competition. Moreover, the suppliers have high bargaining power in the market. This led to high installation cost for the automated quality system and the maintenance cost. The high prices offered by suppliers in the market reduce the profits margins for the companies operating in the industry (Chen, 2008 p. 241). Therefore, the new technology was costly to the company and the consecutive maintenance costs remain high thus reducing the profits margin for the company. Hence, limited suppliers in the industry threaten Athal Company adaptation to the new technology for quality system.                   The decreased number of suppliers and the reduced profits margin in the industry discourage new entrants in the industry. The decreased new entrants in the industry result in decreased competition in the market and threats for the existing companies. Therefore, Athal Company is free from threats of new entry due to high cost of adapting new quality system technology. The reduced competition creates favorable environment for the existing company to operate and improve their services in order to achieve their desired profit margin and growth in the market. According to the management, the maintenance cost for the new technology in the quality system is 40% more than the previous manual system. Hence, few companies in the industry can adapt it and especially those that are profit oriented. Advantage of Athal Company on implementation of the new quality assurance system                   The implementation of the new quality assurance system by Athal Company will accrue various advantages over the old manual system. The advantages will be in terms of effectiveness, efficiency, cost, involvement, and result oriented.                   The automated system will be advantageous in that inspection and tests will be run fast and effectively thus saving time that can be used to do other constructive duties in the company. Automated system will mean that the same type of the information will be fed to the system for various clients at a very short time and giving results instantly (Mak, & Peng, 2008 p. 366). One can only repeat similar information for the automated system. However, on the manual system one would be forced to record similar information for various entry and different clients thus taking a lot of time for a given task and giving out delayed results. This can be distractive to clients making them to shift their services to other companies that can offer fast and effective services. Hence, the automated system will not only give effective services at a very short time, but also retain the customer making the company more competitive in the market as opposed to the manual system (GE inspections N.d p. 1).                   Although the automated system installation and training of employees on the new system is costly in the short term, in long term, the system will be cheap as there will be saving of time and decreased human involvement thus saving the cost of labour for the company. The time saved could be used to do other constructive and productive services for the company, which would in turn give returns that subsidise the cost incurred by the company. Since the new system utilises decreased human labour, the company can opt reducing its labour, which may as well reduce its cost of operation and thus increase its profits margin (GE inspections N.d p. 18). However, the manual system required a lot of time to fill out the forms and extra human labour to attend different labour thus the process becoming expensive in the long term and but cheap in the short term since there are is no cost of installation. Hence, the automated system is less expensive in the long term and thus more advantageous to the company compared to the manual system.                   The automated system is results oriented and the results can be assessed by different employees since they will be available from the system thus minimizing errors being transferred to clients. Moreover, different employees can monitor the results in their various destinations so that a perfect final product is achieved. Hence, the system forms the best collaborative monitoring system. This is in contrast to the manual where results are only processed by an individual subjecting them to errors that may be transferred to clients and may affect the customer relation with the company and affect its performance and provision of services. Therefore, Athal implementation of the new quality system through information system presents it with advantage on accurate and quality services for the customer thus maintain customer relations and maintaining its market performance at improved level.                   However, the new automated system will be a challenge to the company as the information system tool is expensive on purchase and replacement in cases of breakdown. Moreover, the process of maintenance and training of employees can be very expensive for the company thus accruing unplanned cost, which may make its services more expensive thus making it less competitive in the market. Customers are attracted by low prices in the market. Although the automated system performs various tests for the information fed for the machine, the system has limitations and some of the tests such as images, and colour are only tested using manual system. Hence, the system cannot operate fully independently. Thus the cost of operation is increased by additional services for manual system. Findings                   The data obtained from this case study from Athal Company was summarised as follows. From the questionnaires, only 100 of them were complete and used for this case study. From the 100 questionnaires that were complete, 90% discredited the manual system saying it was faulty as it offered minimum monitoring. 10% saw it as the means to abscond their duties for their private jobs. All the employees agreed that the manual system was costly in terms of monitoring but cheap on the maintenance. 70% of the employees had a positive attitude about the manual system as it was not effective when monitoring employees. Employees could be absent from work without the knowledge of the top management due to unreported cases. 30% had negative attitude on the system as they felt the system caused personal conflicts between them and the people in charge of quality control. 100% of the participants agreed that the automated system was more effective compared to the manual sys tem since all the employees had to log in to automated biometric system. The information could be relayed fast and reach the target group within the shortest time possible. 43% of the employees were resistant to the process and felt that the manual system would continue while 57% of the employees felt that transformation to the automated quality system was necessary. 95% of the employees felt that it was important to implement the quality system for both the external and internal environment of the business to ensure that the overall performance of the company was monitored. 5% of the participants were not sure if the quality system was supposed to be installed both internally and externally.                   The data that was obtained from the management was as follows. According to the management, the automated quality system was more effective and efficient in monitoring and delivery of information across the company departments and branches. Moreover, the system was fast as compared to the manual systems. The management agreed that the automated quality system improved the performance of the employees and that of the company thus increasing attracting more customers. The customers had increased from 300 to 550 per day when the new system was implemented as shown in figure 3 below (appendix 3). Similarly, it is expected that the income would increase from $ 13,000 to $ 27,000 million by the end of the first year the figure 2 below in appendix 3 analysis the change. The management said that the employees had mixed reactions on the new quality systems, with almost half number of the employees arguing against it. However, concerted trainings and sensitization s led to smooth implementation of the new systems. From the questionnaires, it was found that managers appreciated the new systems and saw it a good system for medium companies. The implementation process was expensive and the maintenance cost is high. The installation and maintenance cost is 60% more for the new technology than the manual system as shown in the figure below. Conclusions and Recommendations                   The objectives of this case study were achieved in that the new quality assurance system that was implemented by Athal Company could be upgraded unlike the manual system through update of information system software.                   The process of full implementation, handling, monitoring, operating the system for the Athal Company involved the employees and organization management. Therefore, the process of quality assurance is effective when coupled to individuals, groups and organisations.                   According to the management, the type of the information system adapted to be used by quality assurance system depend on the size of the organization, services offered, financial ability and availability of resources. Athal Company being a medium company chose the relevant information system that meets their size of the company, financial ability and ability for continuous improvement.                   The process of quality assurance automation involves installation of testing, inspection and quality control equipments that are interlinked with information system software and hand wares such as computers to record information and deliver results. Athal Company followed the protocol and successfully implemented a quality system using information system.                   The following recommendations would be most appropriate for the company and other that would take the initiative to implement the same system in their premises.                   The company should prepare its employees in advance through hiring the right employees who have the skills to prevent unnecessary cost from extra trainings. If there has to be a training, only few employees should be trained and not the entire workforce. This would prevent resistant to new technology and save the company unplanned costs.                   The company should asses the availability of suppliers of the technology that is planning to adopt to prevent exploitation of the company by suppliers as evidenced in this case study. Few suppliers in the market resulted to increased cost, which in turn led to reduced profits from high cost of operations. References Ahuja, I. P. S., & Khamba, J. S. 2008. Total productive maintenance: literature review and directions. International Journal of Quality & Reliability Management, 25(7), 709-756. Berry, L. L., & Parasuraman, A. 2004. Marketing services: Competing through quality. Simon and Schuster. Chen, Z. 2008. Defining buyer power. Antitrust Bull., 53, 241. Ford, J. D., Ford, L. W., & D’Amelio, A. 2008. Resistance to change: The rest of the story. Academy of Management Review, 33(2), 362-377. GE Inspections. Inspection Technologies: Productivity through inspection solution. N.d 1-19 Ho-Chang, C., Chang E., K., & Prybutok, V. R. 2014. Information technology capability and firm performance: contradictory findings and their possible causes. MIS Quarterly, 38(1), 305-A14. Hoyle, D. 2009. ISO 9000 quality systems handbook. Amsterdam: Butterworth-Heinemann. KumpikaitÄâ€", V., & ÄÅ'iarnienÄâ€", R. 2008. New training technologies developing human resources. Economics & Management, 93-94. Lanz, J. 2013. Helping Small and Midsized Businesses Succeed in a Technology-Driven World. CPA Journal, 6-9. Lilly, J. D., & Durr, D. W. 2012. Technology changes at work and employee reactions: The role of leader behavior. Human Systems Management, 31(3/4), 193-201. Mak, K. L., & Peng, P. 2008. An automated inspection system for textile fabrics based on Gabor filters. Robotics and Computer-Integrated Manufacturing, 24(3), 359-369. Mullins, L.J. (2013). Management & Organisational Behaviour. Pearson Porter, M. E. 2008. The five competitive forces that shape strategy. Harvard business review, 86(1), 25-40. Sroufe, R., & Curkovic, S. (2008). An examination of ISO 9000: 2000 and supply chain quality assurance. Journal of Operations Management, 26(4), 503-520. Wang, N., Liang, H., Zhong, W., Xue, Y., & Xiao, J. 2012. Resource Structuring or Capability Building? An Empirical Study of the Business Value of Information Technology. Journal Of Management Information Systems, 29(2), 325-367. Wigand, R. T. 2003. Introduction to business information systems. Berlin [u.a.: Springer-Verl. Appendices Appendix 1 Figure 1: showing the changes in income with respect to change in quality assurance system Appendix 2 Figure 2: increase in number of employees with the change in technology Appendix 3 Figure 3: comparison between the cost of the automated and manual quality system. Appendix 4 Questionnaires Serial no. Question Answers Employees 1 How effective was the manual system 2 Was the manual system costly in terms of monitoring and maintenance 3 What was your attitude on the manual system 4 How effective has the automated quality system been compared to the manual system 5 Comparing to the manual system, was it costly in terms of implementation and maintenance 6 How was the transformation to the new automated system 7 Was the automated system applicable to internal and external monitoring of the company 8 Was you involved when deciding on the new system Appendix 5 Management interview questions 8 How do you compare between the manual and automated quality control system on their performance 9 How did the employees and customers respond to the new system automated system 10 Kindly comments on the overall implementation process and whether the cost of the installation of the process is high or low Appendix 6 Manual system Automated system Customers 300 per day 550 per day Income $ 13,000 million $ 27,000 million Cost and maintenance 100% of the standard cost 160% of the standard cost Appendix 7 Source document

Orphan Trains Essay

Throughout the generations America has transformed and evolved drastically to become the nation it is today. Many can argue that several things have happened in America that are what shaped it to the country it is today industrially, socially and economically. A man by the name of Charles brace had a dream of getting underprivileged children off the streets and gave them the tools and opportunities to live great normal lives. Between 1854- 1929 an estimated 200,000 American children, some orphaned or half-orphaned, others abandoned- but all in need of families- traveled west by rail as part of a â€Å"placing out† program started by Charles, called the Children’s Aid Society. (Warren, 4) This dream exploded around the U. S into what is now known as The Orphan Train Movement; a movement that sparked opportunity and new life for underprivileged children. Early on in American History, children who were left by their families were usually left to be cared for by their relatives or neighbors. There were very few services at the time to help struggling families in need, or to even rescue children. It was in the late 1800’s and even as late as the 1900’s where laws advocating children’s rights were being enacted. The only places where children could be left at the time were Orphanages and most were extremely overcrowded and uncomfortable. Children were not given much time or attention or even food. Adoption was not yet universally popular at the time, and there were not many laws protecting the rights of children. Often times in a lower to middle class household a family relied on its children to work in order to make ends meet. For many families it was a struggle but manageable, however, for others it was just too much and this lead to many children being left on the streets of major cities, like New York and Manhattan. Charles Brace originally arrived in New York City in 1848 to study Theology but could not help but notice the overflow of abandoned children living on the streets. Brace had made a trip to Europe, where he saw first-hand how orphans were being taken by charitable organizations to areas where they were better off with families that would raise them as their own children. After this trip Charles decided to take that concept and start his own. By 1853 Charles Brace founded the Children’s Aid Society, which was derived from the same principles he witnessed in an Institute during his time in Germany. Charles’ goal was to give children access to education as well as jobs who would not have had the opportunity otherwise. A quote from Charles Brace says â€Å"The best of all Asylums for the outcast child is the farmers’ home. The great duty is to get these children of unhappy fortune utterly out of their surroundings and to send them away to kind Christian homes in the country. In 1854 Brace sent the first group of forty six children to Michigan. Within a week of arrival, they all had homes to live in. It was clear that his idea would be extremely promising. Pretty soon thousands of children were being placed out, from the streets, even from jail. Later, Charles derived a plan to be able to send kids where they could learn a skill, contribute to society, and (ideally) be a part of a family. This sparked a huge movement for the early stages of modern adoption. Charles Brace was the first to really come up with the idea of a â€Å"relocation program† on a major scale. The ultimate goal for Charles Brace was for the children to have the opportunity to be transformed out in the country as opposed to the desperate living conditions they would face in the City. It may seem as though Charles Brace just stole an idea he once saw in Europe and later made a fortune of it here in America, however this is not the case. Brace put in a lot of his own effort before placing out children in masses. Charles truly cared for the well-being of every child. In the City, he sent out physicians and nurses to offer medical care and started a daycare center for mothers who had to work. Brace set up lodging houses for newsboys and set up schools to teach children trades or occupations to support themselves. He also made it possible for underprivileged children to receive free school lunches. (This now exists to today as free or reduced lunch, based on family income). A big contributing factor to the idea Brace came up with as far as †placing out west†, was that he felt families with good hearts in small towns and on farms, would take the children in as their own, educate them, and also provide them with a religious upbringing. In return, these children would contribute their hard work and labor to the family which was expected from any child at that time. The only exception to this was extremely privileged children who were brought up from wealth. There are numerous positive outcomes that came from the orphan trains but also a few negative ones. Usually, groups of about thirty to forty children would travel together on the trains. When the orphan trains arrived to their designated towns, everyone in those towns would gather around for the â€Å"viewing†. The most common way the children were viewed, were at churches or big buildings that included stages or a way to see the children from afar. This process was the most daunting and humiliating for the children. In the book We Rode the Orphan Trains by Andrea Warren she writes, â€Å"As Hazelle Latimer, now deceased, who rode an orphan train to Texas in 1918, she remembered, â€Å"We were lined up on the stage and all I could see was wall-to-wall people. They surrounded us, made us turn around, lift our skirts to see if our legs were straight, and open our mouths to show our teeth. A very humiliating day†. Warren, 49) On the other hand there were several children who found loving new families, and were raised with comfort and support. â€Å"For most of our history, until the twentieth century, the social worth of children was understood primarily in terms of economic rather than emotional value†¦. From the earliest age when a child could hold a spinning card, she was likely engaged in household industry. By the age of twelve or so most children were treated as adult producers’’(Jalongo, 2010) It was not always easy for some, children would be separated from their brothers and sisters a lot of the time. There were several instances where children would grow up and later find their lost relatives after the sometimes, inevitable separation caused by the orphan trains. Even though the separation was wrenching, the majority of the children involved In the Orphan Train movement grew up to be well-rounded people and used the tools they learned growing up to carry on in their adulthood. Many cases of children being mistreated in their new homes, or treated as servants, could have been avoided. The Children’s Aid Society had agents who’s duty was to make frequent checkups on the children in their homes but with poor documentation and increasing number of children it seemed to be a lost cause. The New York Foundling Hospital was second to the Children’s Aid Society in placing children. In these days, a hospital could mean more than just treating a bad wound or giving you medical attention. It could also mean receiving care other than medical. Sisters for Charity, lead by Sister Irene, were in charge of caring for the children left at the hospital. They set up cradles where children could be left and in many instances, infants and toddlers would be left with notes on them. Notes would say things such as â€Å"Agustus, born October 16, 1879. Take good care of my darling. † (Warren, 15) The sisters soon received countless children that were being dropped off by mothers or families who could not care for them. It was not long before they began to develop the same mindset as Charles Brace and only hope that the best situation for a child is to be living in a home with a family. Soon, the sisters were sending many of their small children out west to pre-assigned catholic homes. Soon after, another type of trend of the orphan trains began and was known as â€Å"baby trains†. They were of great interest to the public and people often would come in crowds to watch children be united with their new families. The orphan trains and the baby trains were very similar in how they overall operated as a whole however, there were a few key differences. The Sisters worked in conjunction with Priests throughout the Midwest and South in an effort to place these children in Catholic families. While the Children’s Aid Society requested that the children they place be given spiritual training (the choice of religion was left up to the â€Å"adoptive† family), the Foundling Hospital’s placements were strictly to Catholic families. â€Å"Probably the largest difference in how the Foundling Hospital placed their children is that the children were not sent out to be â€Å"randomly† adopted from a town hall or opera house, but were â€Å"requested† ahead of time by families who wanted a child. †(Dipasquale) In a sense it was much more organized and civil the way the Sisters handled the infants. The Orphan Trains ended in 1930 for numerous reasons, the most affective of these are; a decreased need for farm labor, and the onset of the Great Depression. Even though these two organizations were very different in some aspects they were both primarily the key functions of the Orphan Train Movement. Without a doubt this movement was life-changing and unfortunately resides as a much unheard of occurrence in our history lessons in the present day. Several people now have extreme mixed reviews about the Orphan Trains and what its true motives were. Charles Brace was a man who sought to give opportunity to the lives of those which at the time were almost invisible to society or just a form of cheap labor. â€Å"When a charitable organization takes action, it is out of a desire to help its clients, yet a determination of whether those actions represented a stride forward often occurs much later, when subsequent generations take the long view back†. (Jalongo ) The Orphan Trains were not of much use anymore after the start of the Great Depression. Social Service agencies had begun placing children in foster homes with the intention of restoring them back to their original families. Immigrants that were coming to America were making a much easier transition, and had new programs available to them that would help them get jobs and housing. Since the majority of the children of the Orphan Train Movement were from families of immigrants, this is a great indication of why the Orphan Trains were no longer in need. Today the Orphan Train Heritage Society of America exists and works to help spread the word about the orphan trains. A movement that is relatively unknown to our society today, could quite accurately be referred to as the same movement that was the beginning of foster care and modern adoption in America. It is estimated that about 2 million people in America today are descendants of an orphan train rider. Charles Brace was a simple man with a compelling idea to give opportunity to those in need. His steps were extreme and often times ridiculed, but he was also admired for his works and even recognized as the father of modern adoption. He wrote, ‘‘when a child of the streets stands before you in rags, with a tear-stained face, you cannot easily forget him. And yet, you are perplexed about what to do. The human soul is difficult to interfere with. You hesitate how far you should go’’.

Family And Social Environmental Factors Associated With...

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Also, they knew that aggression is seen more in males than in females, as well as being more prominent in older adolescents. Specifically for Chinese adolescents, it was already known that there was high educational pressure that contributed to stress and eventually could lead to aggression. This brings culture and race into consideration for this study since the focus was Chinese adolescents. Also, they researchers didn’t know much about the impact of the possible relationships between the factors that could lead to aggressive behavior, which is part of whatShow MoreRelatedParenting Styles and Culture1378 Words   |  6 Pageson the different parenting styles across cultures. There are also many myths about which parenting style is the best or the most beneficial to the social development of children. 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