Orthodox Interpretation of Japanese War Memories Essay

Orthodox Interpretation of Japanese War Memories - Essay Example The other argument is based on the assumption of the Allies that the government of Japan has declined in properly addressing the country’s war responsibilities during the war. It is also the view of the English speaking Allies that the people of Japan do not adequately acknowledge the responsibility of Japan during the war. Hence, the Japanese should accept the responsibility of the country during the war and this will propel the Japanese government doing the ‘right’ things in context of the war (Seaton 2). Seaton is of the view that this interpretation is flawed. He attributes this to the fact that there are two varying proportions of the interpretation. One of the proportions is described as the ‘state-centered approach’ whereby there is the political and parlance of the war memory (Seaton 2). The other is described as the ‘culturally determinist’ approach where it is analyzed in both sociological and anthropological focusing on the cha racteristics of the Japanese society as unwilling and conforming (Seaton 3). Why this Interpretation is flawed According to Seaton (p. 9), there are three aspects of how this interpretation is flawed. One of the aspects is that it moves precariously between war responsibility and war memories. This is because war responsibility in the current context is highlighted by constantly by political, moral and legal implications of war conduct. On the other hand, war memories are concerned about the way people see past events from the perspective of today’s context. Although the two aspects are related to some aspect, it is important to note that they are very distinct from each. Seaton (p. 9) asserts that while the Japanese government may refuse to compensate, there are Japanese people and the government that remembers the war. Hence, the way Japanese people feel about the way their government compensating could be based on their memory of the war. The development of memory studies has been greatly enhanced by the society acknowledging the fact that history is based on the environment that is changing constantly. Hence, technological, political, and social environments have affected the way many people are viewing past events. Hence, the Japanese cannot be limited to the environments that were present during the Second World War. There are two paradigms within which war memory and commemoration are studied which are; the political and psychological paradigms (Seaton 9). Seaton in Chapter 3 further argues that although Japan has been accused frequently of failing to address the past, the orthodoxy fails to note the main fact that ‘addressing the past’ is kind of unhelpful because it puts the roles of responsibility and memory into one and in so doing smudges the difference between individual, collective and official narratives. The orthodoxy has put across many texts that argue about Japan failing to address the war responsibility issues officially which has in turn spilled over to the orthodoxy claiming that Japan has an inadequate memory. This has led to observers of the Japanese people on how they remember the war being obscured. It is in this context that the orthodoxy has also ignored to look into how other nations handles their war memory including the English speaking Allies. Hence, the Japanese people are held responsible and in so doing, other nationals who were also responsible for the war have

Whole Food Plan Book Essay Example | Topics and Well Written Essays - 3500 words

Whole Food Plan Book - Essay Example During the year 2005, the sales were 1.3 million which rose to 1.7 million in the year 2007. Although market capitalization is rising, the profit margin has reduced considerably over the past three years. The stores operated by the company are approximately eight years of age; it is young age in a grocery industry. The stores are averagely about 30,000 sq. ft. As reported in the year 2006, among 180 stores of the company 113 were larger or 30,000 sq. ft. The physical resources are newer as the company. Human resource of the company is knowledgeable and well trained; they strive for a better customer experience. The payroll, bonus and other benefits of the staff have been increased during the year 2004 to 2005. Employee of the company are motivated by mission statement of the company and feel proud to be a part of the team that supports organic and natural food. The staff feels good about their job as they are contributing towards the betterment of the society. Whole Foods Market is a supermarket chain specializing in providing its customers with natural and organic foods of the highest quality on the market. Son una empresa con unos muy altos està ¡ndares de calidad en todo lo que hacen ya lo largo de sus 3 dà ©cadas de historia se han convertido en el là ­der mundial en su sector. They are a company with very high quality standards in everything they do and along its three decades of history have become the world leader in this sector. 1. Unmet needs: Usually the food items sold as suitable for children, young and adults are not only grain-based foods, but often they have a high content of salt and usually high sugar content. In the defense of this allegation, it is always said that high sugar and salt is due to demand in certain countries and not in others. In order to promote the concept of healthy eating, it was necessary to create awareness among consumers about the magic of less processed

Hematology Essay Example | Topics and Well Written Essays - 500 words

Hematology - Essay Example In the blood system, Pluripotent haematopoetic cells become any type of cell. The type of a cell to become is determined by pluripotent cells that differentiate it in a wise way. 1 Proliferation is multiplication of blood cells in a human being. When an embryo is being developed, formation of blood takes place in the yolk sac in aggregate of blood cells. Blood formation takes place in the liver, spleen and lymph nodes and development goes to advance stages. Eventually, the task of blood formation is taken by bone marrows in the entire body system when they develop. However, proliferation of lymphoid cells usually occurs in the secondary lymphoid organs such as lymph nodes, spleen and thymus. In adult, haematopoiesis usually takes place in marrows of long bones like femurs and also in ribs and sternum where we have spongy bones. At times, spleen, liver and thymus recommence their haematopoietic function commonly known as extramedullary haematopoiesis. 2 Differentiation is a process whereby cells acquire a type in regard to haemopoiesis. During differentiation, cell morphology changes drastically although generic material still remain the same with some few exceptions. In many aspects of cell physiology, differentiation involves changes in regard to shape, metabolic activities, polarity, size, and responsiveness to signals whereas gene expression profil

Denzel Washington Essay Example | Topics and Well Written Essays - 500 words

Denzel Washington - Essay Example hington is an inspiring figure to me as an African-American fan of his movies, because he shows just how much anybody can achieve if they work hard and are passionate about their work. One of the most inspiring things about Denzel Washingtons career is the story of his early childhood. When he was only 14, his parents got a divorce and he and his sister had to be sent to a boarding school for the rest of their education. Obviously, this must have had a big effect on the young mans life, but he did not let it bother him and he then went on to Fordham University, where he studied Journalism for a while (â€Å"Denzel Washington,† 2012). Beyond his parents problems, Denzel Washington also had some of his own, although they were not major. Basically, he could not decide what he wanted to do, and even dropped out of school for a semester because of being on academic probation (Washington, 2006, p16). However, after he worked as a camp counsellor over the summer at a YMCA camp and from a friends comment there â€Å"became as passionate about drama and acting as [he] had ever been† about anything else (Washingon, 2006, p18). Many people might have been satisfied with completing a bachelors degree in drama, but Denzel Washington did not stop there. Instead, he went to the American Conservatory Theater in San Francisco, even winning a scholarship which allowed him to continue his studies further (â€Å"Denzel Washington,† 2012). No doubt this extra education played a big part in his later success, but it also shows that he was already accepted as a skilled actor, or he would not have gotten a scholarship for such an important school. Because of his ability to â€Å"disappear into a role and mesmerize audiences† (â€Å"Denzel Washington,† 2012 ) which probably comes from this time and education, he has been able to win several Oscars and Golden Globes, and also play in theatrical parts of all sorts. One of the most important things to take away from this story of Denzel

The Function of Performance Management Article Example | Topics and Well Written Essays - 2250 words

The Function of Performance Management - Article Example Performance management decides the basis for the future business activities and the processes that have to be given the proper budgets as well as the resources on the part of the organization. The business process reengineering (BPR) aspects are in line with how these divisions are made in the quarter of the performance management functions and boundaries. For the human resources tenet, the role of performance management is all the more vital since it has to devise ways and means through which different activities are sequenced in terms of importance, vitality, etc. Thus it is important to state here that the role of performance management does not end here, though its basis might just lessen a little bit in the financial and different departments that we consider our attention upon. However within the realms of the human resources division, the importance is made more and more essential since employees need to be appraised time and again about their performances and functioning. What this performance management system does is to ensure that the right people get the bonuses, incentives and so on as well as point out the ones who have fallen short on the company's expectations over a period of time. This would help in giving them rewards and incentives which will eventually make one and all happy at the end. Also this will continue their desire to achieve more and more within a specified period of time and thus come into the good books of the company. In return, they can be given all these rewards so that they could be encouraged in line with their work attitudes. Moreover, the people who lag behind with regards to their work schedules and dedication levels will stand up and take notice and thus would want to be counted as the effective and efficient ones within the company as well. The role of organizations in the maintenance of these systems is also very paramount. The difference from the annual appraisals and so on lies in the fact that the traditional manner of doing things relies more on the basis of paper work where a lot of time, effort and money is rather wasted to state the least. The role played by the organizations in advancing their performance management systems is immense since a lot of the population depends on them for their needs and wants. This is met in a fair manner courtesy the E-government initiative adopted by several different companies and organizations. All such innovations which help and facilitate the related process must indeed be given thumbs up since these try to solve the miseries of the people and it is because of these people that the performance management systems are put into place originally. This further pinpoints the fact that the deployment of an efficient performance management system policy within the organization would indeed help it to essentially tackle its internal issues in a better and more effectiv e manner possible. There is a lot of growth potential for the sales force to be automated in the business to business environments since performance management systems are in place, more so because the business to business scenarios boost a trend of interaction in between the channel members no matter which marketplace they hail from. This could either

Tourist Breaks Back on Sentosa Ride Law Analysis Essay Example for Free

Tourist Breaks Back on Sentosa Ride Law Analysis Essay Factual Summary of Case Australian tourist, Michael McCarthy, suffered a fall and broke his back while riding Sentosa’s MegaZip, which is a flying fox adventure ride run by Flying Dragon Adventures (FDA). The riders would initially slide down the zipline fast and would be slowed down by a braking mechanism as they approach the landing platform. However, in this case, McCarthy was travelling towards the landing platform at a faster speed than usual. As a result, he crashed onto the platform and broke several vertebrae in his back. He felt incredible pain and could not breathe for a minute and a half. McCarthy had no immediate medical help as there was no medical staff on-site. He only received assistance half an hour later and was taken to Singapore General Hospital 1 hour 15 minutes later. He received 35 stitches to his back and spent 5 days in and out of the intensive care unit. As for the ride, McCarthy satisfied safety requirements of being at least 0. 7m tall and less than 140kg in weight. This was the first accident in its two-year history of operation. Before the accident, the ride had been taken by at least 200,000 visitors in total and was already taken by 140 people on that day. Alexander Blyth, managing director of the ride, believed that all safety procedures were followed, that nothing failed and nothing snapped. The ride also requires customers to sign indemnity forms, in which contains an exemption clause that states that they are not responsible for any deaths or personal injuries unless through gross negligence. Blyth reported the case to the Building and Construction Authority (BCA), the regulatory body for amusement rides. Lawyers are attempting to seek compensation for McCarthy’s injuries, as they question the validity of the exclusion clause in the indemnity form by bringing up the Unfair Contract Terms Act (UCTA). Following McCarthy’s injuries, McCarthy wants to claim his recoverable losses. It can be assumed that FDA is using its exemption of liability clause as a defence. McCarthy’s lawyers are stating that the exemption clause is invalid under section 2(1) of the UCTA, which states that â€Å"a person cannot exclude or restrict liability for negligence in relation to personal injury or death†. The Contract Before riding, McCarthy was made to sign an indemnity form. The terms of the indemnity form could be regarded as the express terms of the contract between McCarthy and FDA. A contract was formed between both parties when McCarthy signed the indemnity form. Since, the express terms to the contract were introduced before the contract was formed, they are, prima facie, binding to both parties. There was an exemption clause in the contract stating that FDA is not responsible for any deaths or personal injuries unless through gross negligence. Crucial Questions Before we speculate on the legal outcome of the case, a few crucial questions have to be asked. 1. Was FDA negligent? If so, this would render their exemption clause invalid, and they will be made liable for McCarthy’s losses. 2. Did FDA breach any implied terms in the contract? 3. Is BCA liable to any extent? If so, to what extent? Before the crucial questions are asked, it is important to consider the section of The Amusement Ride Safety Act (2011) which states the scope of responsibilities of parties with statutory responsibilities. They are as follows. Parties with statutory responsibilities The Amusement Rides Safety Act (ARSA) defines statutory duties and liabilities for the following stakeholders to ensure proper accountability for the safety of rides: a. Person responsible (i. e. FDA): The person responsible, who is primarily the holder of an operating permit, will be the person who has the charge, management or control of the ride. He will have overall responsibilities for all matters concerning ride safety. b. Ride manager: The ride manager, who is employed by the holder of an operating permit, will manage and oversee daily and routine operations and maintenance of the ride. He has to possess prescribed technical qualifications and experience. c. Qualified person (QP): The qualified person, appointed by the applicant of the permit or the holder of the permit, will carry out specific technical duties, such as certifying technical compliance with design codes, supervising ride installation or modification and conducting annual inspections to ensure ride safety. Was FDA negligent? The court could question whether FDA was negligent in declaring the true safety limits of the ride and if the ride manager was negligent in handling the situation. The safety limit that was declared could have been that the system would not suffer any breakage or malfunction at the stipulated weight but the braking system was unable to be effectively utilized to ensure the safety of the user. In addition, the ride manager could arguably be negligent in the handling of the situation in not pulling on the emergency stop that should have been installed in every amusement ride to stop the ride in the event of an adverse incident. In the event that the ride manager had been negligent in due diligence, the ride manager would also be liable for breaching section 17(1)(a) or ARSA. There are a few possible outcomes regarding negligence on the part of the FDA, and the possibilities of each outcome will be examined. The first possibility is that the court could reason that the FDA was negligent in checking that the braking system was functioning properly and at optimal level. It could state that the braking mechanism is a very integral and crucial component to the system, and hence negligence in the area of ensuring the functionality of the braking system could amount to negligence in ensuring the safety of the system as a whole. In addition to this, the court could also rule the FDA was negligent in ensuring adequate safety limits for the ride. If this was the case, then it is likely FDA will be held fully liable for McCarthy’s recoverable losses. This is because its exemption clause would then be invalid, by virtue of section 2(1) of the UCTA. The second possibility could be that the court could consider contributory negligence as a defence. This however, would be almost impossible because it would be almost impossible for FDA to prove that there was a degree of negligence on the part of McCarthy. It was most likely that McCarthy had to comply with the necessary safety measures before riding, such as wearing a helmet and safety harness. As such, it would be almost impossible for the court to hold both McCarthy and FDA partially liable for McCarthy’s recoverable losses. Did FDA breach any implied terms? If FDA had breached any implied terms in the contract, and McCarthy suffered losses as a result, then it follows that McCarthy can sue FDA for his recoverable losses. The Duty of Care The duty of care can be an implied term in the contract between McCarthy and FDA, even if it was not expressly provided for in the contract. This term would be implied by statute, by virtue of section 13(1)(b)(i) of the ARSA. In addition to the exemption clause being invalid due to negligence, the courts could also rule that FDA’s negligence could have resulted in it breaching its duty of care when the braking mechanism failed to work properly and McCarthy was injured. Furthermore, despite the dangerous nature of the ride, FDA did not have an on-site medical team to ensure that immediate action could be taken in the event of an accident. This is a breach of an implied term for FDA to provide for the safety of its customers in the event of an adverse incident. This term is implied by statute; according to regulation 16(6)(b) of ARSA, â€Å"The operator of an amusement ride shall ensure that at all times when the amusement ride is in operation there are in attendance to render first aid when the necessity arises, a sufficient number of persons who are properly trained by a first aid training organisation acceptable to the Commissioner;† FDA can be held liable for McCarthy’s recoverable losses based on the breach of these implied terms alone. Is BCA liable? Under the ARSA, it states that all amusement rides has to be assessed and certified by a Qualified Person (QP), which must be an amusement ride specialist engineer registered under the Professional Engineers Board. However, as the MegaZip ride involves an aerial ropeway, it is further classified as a major amusement ride under the ARSA. With it being a major amusement ride, the QP is also required to engage and consider the advice and opinion of a conformity assessor (CA). The CA has to carry out procedures such as inspections, tests and certifications to determine if the design and specifications, the proposed installation method or programme or the proposed modification method or programme relating to a major amusement ride or the major modification thereof conform to any technical standard or requirement. Besides technical support, the CA will complement the qualified person with expertise in nontechnical but critical aspects of ride safety such as ride management (e. . layout of queue areas) and crowd control (e. g. access routes and barriers). In order to ascertain whether BCA is liable for the accident, it is important to determine if the accident arose as a result of: 1. QP and CA’s inadequate safety inspections, overlooking of fundamental technical faults and establishing poor safety standards during construction. 2. FDA’s lack of day-to-day management of ride safety. In order to ascertain if the accident occurred due to the QP and CA’s lack of rigorous inspection on the ride, we must determine if they approved the ride without proper assessment of its safety. If the accident arose due to the fault of QP and CA’s poor safety assessment and haphazard approval of the ride, then some degree of liability may fall onto the QP and CA. With this assumption, FDA could then argue that the accident was caused by the QP and CA’s negligence in highlighting and rectifying safety issues during construction. FDA could state that their ride was certified by the QP and CA, assuring FDA that the ride was acceptable and followed all safety aspects. In addition, if FDA was certified through a document of approval signed by the QP and CA, FDA could use this certification as evidence in court to back up their case. This is due to the fact that it would be unfair for FDA to take up the liability if we were to consider that FDA followed all of BCA’s ACRA requirements and sought necessary approval by the QP and CA for the ride. However, the possibility of the scenario above is rather small as it is most likely that at the point of construction, all safety limits proposed by the FDA met the safety requirements of BCA and that the QP and CA properly checked and certified the ride. As the QP and CA’s duties were only restricted to the period of construction, it was the FDA’s responsibility to ensure that the day-to-day operations of the ride were well within the safety limits and that regular maintenance was conducted on the ride. In addition, considering that the accident took place two years after the construction, it would be unfair to attribute blame onto BCA, as the ride would have undergone much wear and tear and weathering. Furthermore, BCA does not have proper control over FDA’s maintenance of safety standards beyond the initial construction phase of the ride. Also, as BCA is a statutory body in ensuring that operators of amusement rides complies with the safety regulations, it would be unreasonable to expect them to be responsible for all safeties of all rides at every point in time. In addition, its role does not extend to ensuring that the ride’s safety features are continuously maintained. As such, it is extremely difficult to hold BCA liable for the accident to any degree, because the onus lies on the FDA to ensure the constant safety of the rides beyond the construction phase. Our Final Evaluation In conclusion, it is highly likely that the court would rule out that FDA was negligent in verifying the safety of the ride, and hold FDA liable for McCarthy’s losses. Assuming McCarthy’s weight was within the true weight limit of the ride, and the braking system of the ride did malfunction on that day, it is most likely that FDA will be held liable as the onus of verifying the efficiency of the brakes is solely on FDA. Should the braking system have been working well that day, but McCarthy’s weight was not within the true weight limit of the ride, it is also most likely that FDA will be held liable in this case as the court can then rule that FDA was negligent in determining the true safety limits of the ride. In saying this, we are assuming that McCarthy was not negligent himself in adhering to any of the safety procedures (e. g. wearing safety harness etc. ). Hence we can assume that there was no contributory negligence on the part of McCarthy. This, in turn, is also not likely as it was not stated in the facts of the case. We can also assume that BCA will also not be held liable to any extent at all, as the onus of ensuring the day-to-day safety of the ride system is on FDA. In a nutshell, from our points of evaluation, we can conclude that the the court will most likely rule that FDA was negligent, be it in verifying the physical safety of the system, or verifying the true safety limits of the system. In committing an act of negligence, the FDA’s exemption clause will be rendered invalid, by virtue of section 2(1) of the UCTA. On these grounds alone, FDA will likely hold liability for McCarthy’s injuries. In addition, FDA’s negligence can also be ruled out to be in breach of the implied duty of care. On these separate grounds alone, it is also likely that FDA can hold liability for McCarthy’s injuries. As such, we can conclude that the likely legal outcome will be that FDA will be held liable for McCarthy’s recoverable losses. If ruled in McCarthy’s favor, it is likely that operations of the ride will be suspended until all investigations and modifications to the ride have been made and verified to be safe. By section 30 of ARSA, FDA â€Å"shall be liable on conviction to a fine not exceeding $10,000 or to imprisonment for a term not exceeding 12 months or to both†. FDA would also be held liable for all costs with regards to McCarthy’s personal injury.

Womens Health Education On Anemia And Its Dangers

Womens Health Education On Anemia And Its Dangers Anemia is a common global public health problem (GPHP) affecting both developing and developed countries with major consequences for human health as well as social and economic development. It occurs at all stages of the life cycle, but is more prevalent in pregnant women and young children in both rich and poor countries. In 2002, iron deficiency anemia (IDA) was considered to be among the most important contributing factors to the global burden of disease (1). Anemia is one of the most common factors complicating pregnancy worldwide specially in the development countries, and Palestine is one among of those countries .In Gaza strip ,an overall prevalence of anemia is more than 35% among pregnant women .most studies have demonstrated adverse effects of anemia to both pregnant women and their offsprings mainly in developing countries due to several factors. The more etiologic factor for anemia among pregnancy being iron and folic acid deficiency(2-4) Anemia is the result of a wide variety of causes that can be isolated, but more often coexist. Globally, the most significant contributor to the onset of anemia is iron deficiency so that IDA and anemia are often used synonymously, and the prevalence of anemia has often been used as a proxy for IDA. It is generally assumed that 50% of the cases of anemia are due to iron deficiency (5), but the proportion may vary among population groups and in different areas according to the local conditions. The main risk factors for IDA include a low intake of iron, poor absorption of iron from diets high in phytate or phenolic compounds, and period of life when iron requirements are especially high (i.e. growth and pregnancy). Among the other causes of anemia, heavy blood loss as a result of menstruation, or parasite infections such as hookworms and ascaris can decrease blood haemoglobin (Hb) concentrations level. Acute and chronic infections, including malaria, HIV, tuberculosis, and cancer can also lower blood Hb concentrations level. The existence of other micronutrient deficiencies, including vitamins A and B12, folate, riboflavin, and copper can increase the risk of anemia. Furthermore, the impact of haemoglobinopathies on anemia prevalence needs to be within some population. Anemia is an indicator of both poor nutrition and poor health. The most dramatic health effects of anemia, i.e., increased risk of maternal and child mortality due to severe anemia (6-8). To tackle the problem of iron deficiency and anemia, WHO recommended the adoption of a multidisciplinary approach tailored to specific circumstances including increased iron intake, public health measures and food versification. Consistent with this strategy, UNRWA implemented a programme for prevention and treatment of iron deficiency anemia. comprising medicinal iron supplementation, fortification of wheat flour distributed to the target groups benefiting from the Agencys regular and emergency food aid programmes, and expanding the use of modern contraceptive methods (3,4). In addition, the negative consequences of IDA on cognitive and physical development of children, and on physical performance particularly work productivity in adults are of major concern (5). Previous studies have shown a very high prevalence of anemia among Palestinian refugees specially among antenatal mothers(3). Hence , it is essential that in Palestine, especially in Gaza strip the women should be aware of anemia to reduce the complication during pregnancy. Objectives of the study 1-To assess the level of awareness and public knowledge of anemia among the Palestinian refugee pregnant women in Gaza strip. 2-To assess if there is a difference between women with and without health education session. 3-To develop a baseline data regarding awareness of anemia among pregnant women for further studies. Scope of the study The study aims to assess the level of public knowledge and awareness of anemia among pregnant women who attended UNRWA health care centers(HCCs) for antenatal care in the middle district of Gaza strip by collecting the information from 164 women from four UNRWA health care centers in Gaza. Hypothesis 1-The Palestinian refugee pregnant women were awareness and had a knowledge of anemia at a medium level . 2-There is a difference between women with and without health education session regarding anemia . Benefits of the study 1-To know the knowledge and awareness regarding anemia among pregnant women living in Gaza strip and who are attending UNRWA health care centers (HCCs) for antenatal care and follow-up. 2-To know if attending health education sessions about anemia affects the knowledge and awareness of women by assessing the women with and without health education sessions about anemia in Gaza strip. Literature review studies To conduct the study, the researcher has reviewed related studies and reports about anemia status among pregnant women attending UNRWA health care centers for antenatal care in Gaza strip. Nutritional survey conducted by UNRWA in (1961,1978 and 1984) Nutrition surveys conducted among the Palestine refugees in 1961, 1978 and 1984 revealed that more than 50 per cent of preschool children 0-3 years of age and women in reproductive age suffer from iron deficiency anemia. Nutritional survey conducted among pregnant women by WHO in (1990) In 1990, a nutrition survey was conducted by the WHO Collaborating Center at Centers for Disease Control and Prevention (CDC), Atlanta in four Fields of UNRWAs area of operations, namely Jordan, the Syrian Arab Republic (SAR), Gaza Strip and the West Bank. The survey revealed that the prevalence of iron deficiency anemia among pregnant women ranged between 31.3% in the first trimester to 58.9% in the third trimester Agency-wide, while the prevalence among children 6-36 months of age ranged between 57.8% in the West Bank and 75.3% in SAR. A new intervention strategy for iron supplementation was then introduced in 1991, which was amended in 1995 placing special emphasis on treatment. Nutritional survey conducted among infants ,preschool children and pregnant women by WHO in (1998) In October 1998, the WHO Collaborating Centre at CDC conducted a nutritional survey in Gaza Strip, the results of which revealed that iron-deficiency anemia was still high among high-risk groups, namely infants, preschool children and pregnant women. A study conducted among pregnant women by UNRWA in (1999) In 1999, UNRWA conducted a study to assess the maternal health programme which revealed inter-alia that the prevalence of anemia among pregnant women was 44.7% in Gaza, 35.5% in the West Bank, 32.1% in Jordan, 28.6% in Lebanon and 27% in Syria. In addition, the study showed that the prevalence of anemia progressively increases during the course of pregnancy as well as with parity. Anemia below 9g/dl constituted 1.4% of pregnant women. This suggests that in spite of the interventions that the Agency had, so far, undertaken, iron-deficiency anemia, still represents a major public health problem. A study conducted among pregnant women, nursing mothers and children 6-36 months by UNRWA during (2004) During 2004, UNRWA conducted a follow-up study to assess the prevalence of anemia among pregnant women, nursing mothers and children 6-36 months of age in order to assess the impact of these strategies on the prevalence among pregnant women, nursing mothers and children. The study revealed that the overall prevalence of anemia among pregnant women varied from 35.7% in Gaza, to 29.5% in the West Bank, to 25.5% in Lebanon, to 22.4% in Jordan and 16.2% in Syria. Although, the overall prevalence of anemia among pregnant women in all Fields dropped since the last assessment in 1999, these rates are still considered to be high. The reason for this drop could be attributed to the prophylactic iron supplementation which is provided for all pregnant women upon registration. There is a progressive rise in the prevalence of anemia during the course of pregnancy, which confirms that iron intake during pregnancy, does not meet the increased physiological requirements. Another study conducted among children 6-36 months, pregnant women and nursing mothers by UNRWA in (2004) Another study by UNRWA in 2004 on the prevalence of iron deficiency anemia among children 6 to 36 months of age, pregnant women and nursing mothers, revealed that anemia in Gaza Strip was fairly high (54.7% among children, 35.7% among pregnant women and 45.7% among nursing mothers. The corresponding rates in the West Bank were 34.3% among children, 29.5% among pregnant women and 23.1% among nursing mothers). The high prevalence of anemia for many children may cause permanent negative effects on their physical and mental development. It is worth mentioning that the prevalence of anemia among infants 6 to 12 months of age reached 75% in Gaza(9). CHAPTER 2 BACKGROUND Definition of anemia Anemia is defined as a decrease in the number of red blood cells (RBCs) or in the total hemoglobin levels in the blood due to lack of sufficient iron (10,11).more specifically , it means lack in the concentration of hemoglobin, red blood cell volume, or red blood cell (RBCs) number(12). Normally hemoglobin carries oxygen from the lungs to the body tissues, anemia leads to hypoxia which means lack of oxygen in the blood .There are three main types of anemia which include : 1- Excessive blood loss such as bleeding 2-Excessive blood cell destruction 3-Insufficient red blood cell production within the human body (13). Signs and symptoms of anemia The signs and symptoms of anemia can be related to the anemia itself, or other causes and the women may experience these symptoms differently : In common cases, most women with anemia has a non-specific symptoms such as weakness, or fatigue, general malaise and sometimes poor concentration. In addition, the signs may include abnormal pallor or lack color of the skin, and nail beds upon clinical examination is performed . In severe cases of anemia, there may be signs of circulation disturbances such as tachycardia, and cardiac enlargement. There may be signs of heart failure. and restless legs syndrome is more common in those with iron deficiency anemia (IDA) patients . Swelling of both legs, arms, vomiting, chronic heartburn, and bloody stool may appear in rare cases(14). mhtml:file://C:Documents%20and%20SettingsMARWANMy%20DocumentsAnemia%20-%20Wikipedia,%20the%20free%20encyclopedia.mht!http://upload.wikimedia.org/wikipedia/commons/thumb/9/91/Symptoms_of_anemia.png/260px-Symptoms_of_anemia.png Main symptoms that may appear in anemia (14) Diagnosis of anemia In general, In the first time of diagnosis of anemia a simple blood test is ordered by the physician called complete blood counts (CBC ) .Another blood tests can be ordered is examination of a stained blood smear (SBS) by a microscope which could be helpful in the diagnosis of anemia, and sometimes it will be necessary in some countries internationally where automated analysis is not easily accessible. Usually and commonly four blood components are ordered and measured consists of hemoglobin concentration , RBC count, RDW and MCV, allowing others (hematocrit, MCH and MCHC) to be calculated, and to be compared to values according to age and sex. Some counters measurement estimate hematocrit level (Hct) from direct measurements in the same time (15). Table 2.1 WHOs Hemoglobin thresholds used to define anemia (1 g/Dl = 0.6206  mmol/L)(15) Age or gender group Hb threshold (g/dl) Hb threshold (mmol/l) Children (0.5-5.0 yrs) 11,0 6,8 Children (5-12 yrs) 11,5 7,1 Children (12-15 yrs) 12,0 7,4 Women, non-pregnant (>15yrs) 12,0 7,4 Women, pregnant 11,0 6,8 Men (>15yrs) 13,0 8,1 Anemia during pregnancy Anemia in pregnancy is defined as hemoglobin level less than (11g/dl ) or hematocrit level less than (33%) (16). It aggravates the effects of maternal blood loss and infections at childbirth, and is associated with increased maternal mortality and morbidity(17,18). iron deficiency is usually considered as the most common cause of anemia in pregnancy (16). Anemia occurs when the number of red blood cells are very low under the normal level . Red blood cells are very important blood component because they carry oxygen from lungs to all body organs. Without sufficient amount of oxygen, the body cannot work as well as it should. Anemia can affect any individual, but women are at greater risk for this condition. In women, iron and red blood cells are lost when bleeding or hemorrhage occurs from very heavy or long periods (menstruation). Anemia is common among pregnant women because a woman needs to have adequate red blood cells to carry oxygen to women body and to her baby. So its important for women to prevent anemia before, during and after pregnancy. Women will probably be tested for anemia regularly at least twice during pregnancy: during the first prenatal visit and then again between 24 and 28 weeks(19). Anemia is a condition of less red blood cells, or a lack ability of the red blood cells to carry oxygen or iron in the blood. Tissue enzymes dependent on iron in the blood can affect cell function in the body mainly in muscles and nerves .then the fetus is dependent on the mothers blood and anemia can cause problems before and after pregnancy such as preterm birth, poor fetal growth , and low birth weight(20). Main causes of anemia during pregnancy Iron deficiency anemia Women often become anemic during pregnancy because the demand for iron and other vitamins is increased. The mother must increase her production of red blood cells and, in addition, the foetus and placenta need their own supply of iron, which can only be obtained from the mother. In order to have enough red blood cells for the foetus, the body starts to produce more red blood cells and plasma. It has been calculated that the blood volume increases approximately 50 per cent during the pregnancy, although the plasma amount is disproportionately greater. This causes a dilution of the blood, making the hemoglobin concentration fall. This is a normal process, with the hemoglobin concentration at its lowest between weeks 25 and 30. The pregnant woman may need additional iron supplementation, and a blood test called serum ferritin is the best way of monitoring this(21). Illness or Disease Some women may have an illness that causes anemia. Diseases such as sickle cell anemia or thalassemia affect the quality and number of red blood cells the body produces. If you have a disease that causes anemia, talk with your health provider about how to treat anemia(22). Types of anemia in pregnancy There are several types of anemia that may occur during pregnancy: Iron deficiency anemia This is the most common type of anemia during pregnancy. It is known as the lack of iron in the blood, which is essential to produce hemoglobin the part of blood that carries oxygen from the lungs to tissues and many organs in the body. Good nutrition system to the women before becoming pregnant is very important to help build up these stores and prevent iron deficiency anemia during pregnancy period. Blood loss Blood loss at delivery and after delivery (postpartum) can also cause anemia. The average blood loss with a vaginal birth is about 500 milliliters, and about 1,000 milliliters with a cesarean delivery. Sufficient iron stores can help a woman replace lost red blood cells during delivery. Vitamin B12 deficiency Vitamin B12 is essential in forming red blood cells (RBCs) and in protein synthesis. Women who eat no animal products (vegans) are commonly most likely to develop vitamin B12 deficiency. Including animal foods in the diet such as meats, milk, eggs, and poultry can prevent vitamin B12 deficiency. Very severe vegans usually need supplemental vitamin B12 which usually administered by injection during pregnancy. Folic acid deficiency Folic acid, is a B-vitamin that works with iron to help with cell development and growth. Folic acid deficiency in pregnancy is most commonly associated with iron deficiency since both folic acid and iron are found in the same types of nutrition. Several Studies revealed that folic acid is necessary for women during pregnancy ,this maybe because folic acid help reduce the risk of having congenital baby with certain birth defects of the brain and spinal cord if taken by the women before conception and in early pregnancy (20). Symptoms of anemia during pregnancy Women with anemia during pregnancy may not have obvious symptoms unless the cell counts are very low. The following are the most common symptoms of anemia that may occur in pregnancy. However, each woman may experience symptoms differently. Symptoms may include: pale skin, ,nails, lips, palms of hands labored breathing underside of the eyelids vertigo or dizziness fatigue rapid heartbeat (tachycardia) The symptoms of anemia may similar other conditions or medical problems .So you should always consult your physician for a diagnosis and treatment(20). Diagnosing of anemia during pregnancy Depending on clinical symptoms, anemia is usually discovered during antenatal screening specially in the first visit of pregnant women to the antenatal care clinics for antenatal care and follow up. Normally ,Blood tests are usually measured on the first visit to antenatal health center, and again during pregnancy . A description of Hemoglobin(Hbs) ,red blood cells (RBCs) and their different components will be included in the blood test result. Possible complications of anemia and iron deficiency anemia during pregnancy There are several possible complications may occur during pregnancy which threats women health such as: Breathing difficulty, palpitations and angina. Severe anemia due to hemorrhage or loss of blood after the delivery. In this condition, the woman may be advised to have a blood transfusion as soon as possible (21). Severe anemia related to any reason may lead to hypoxemia and enhances the occurrence of coronary insufficiency and myocardial ischemia. (23). In women with severe iron deficiency, disturbances in function of epithelial tissue is usually occurred . Atrophy of the lingual papillae in the tongue may occur and show a glossy appearance. Also , angular stomatitis may develop associated with fissures at the corners of the mouth. The occurrance of dysphagia may appear with hard diets. Atrophic gastritis occurs in cases of iron deficiency with progressive lack of stomach enzymes production such as loss of acid secretion, pepsin, and intrinsic factor and development of an antibody to gastric parietal cells. Cold intolerance occurs in some cases with chronic iron deficiency anemia and is characterized by neurologic pain , vasomotor disturbances, or tingling and numbness. In rare conditions, severe iron deficiency anemia is associated with increased intracranial pressure. These symptoms can be treated with iron therapy. Impaired immune function is shown in cases with iron deficiency. Moreover, there are reports revealed that those patients are at high risk to develop infection (23). Treatment for anemia in pregnancy Specific treatment for anemia will be identified prescribed by physician based on: Your pregnancy status Overall health, and medical history Extent of the disease Your tolerance for specific medications, or procedures Expectations for the course of the disease Your opinion or preference Treatment of anemia depends on the type and severity of anemia. In cases of iron deficiency anemia treatment includes iron supplements therapy. Some forms are time-released, while others must be taken several times every day. Having iron supplements with a citrus juice can be help with the absorption into the body. Taking antacids may decrease absorption of iron in the blood. There are side effects may occurs when taking Iron supplements such as nausea and stools become dark greenish or black in color. In addition , Constipation may also occur with iron supplements. Prevention of anemia in pregnancy Anemia can be prevented during pregnancy with following a good pre-pregnancy nutrition system not only helps in preventing anemia, but also helps in building other nutritional stores in the mothers body. Having a healthy and balanced diet with essential products of food during pregnancy helps maintain the iron levels and other necessary nutrients needed for the mother health and growing her baby(20). Women education It is important for the public health officials in the geographical regions in which the iron deficiency is prevalent need to be more aware of the significance of iron deficiency, its effect on work performance and activities, and the importance of giving iron supplements during pregnancy and childhood. Moreover, Addition of iron to basic foodstuffs usually employed to solve this problem (24). CHAPTER 3 Women health in Palestine Womens Health Palestinian women have a fundamental right to enjoy the highest possible levels of health and quality of life. MOH works towards the improvement of their health during all phases of lives with wide participation with other key health providers as UNRWA and NGOs. Indicators value Indicators value % of women of child bearing age of total pop 22.3 Prevalence of anemia among pregnant women in MOH 35.7 Total fertility rate (5.8 in GS and 4.1 in WB) 4.6 T.T. immunization coverage among newly pregnant women in MOH (99.1 in UNRWA) (%) 42.4 Maternal mortality ratio per 100,000 live birth 15.4 % of children received breastfeeding 95.6 % of pregnant women attended antenatal care out of total live births 96.5 Mean duration of breastfeeding (months) 10.9 The number of visits paid per pregnant woman in MOH (7.6 in UNRWA) 5.5 Contraceptive prevalence rate (43 in GS, 55.1 in WB) 50.6 % of deliveries in health institution 97 % of IUDs used of total contraceptive methods 32 % of deliveries in home (0.4 in GS, 5.5 in WB) 3.2 % of pills used of total contraceptive methods 38.7 Prevalence of anemia among nursing mother in UNRWA 45.7 Antenatal care services Antenatal care is an essential part of modern health care; such care is every womans right. Health providers must pay serious attention to the health of the pregnant woman and her fetus. In Palestine there are four health sectors providing maternal care; the MOH, UNRWA, the NGOs and the private doctors. There are 353 MCH clinics in MOH and 53 clinics in UNRWA providing antenatal care. The number of visits paid per pregnant woman was 5.5 in Palestine (6.5 in GS and 4.8 in WB). In UNRWA, it was reported at 7.6 visits per pregnant women in Gaza Strip, the percent of women who paid 7-9 visits was 47.5%. According to DHS in 2005, Data showed that 96.5% of women aged 15-49 years received antenatal care in Palestine. There is direct relationship between education level and receipt of antenatal care; women who did not receive antenatal care were more likely to be less educated more than women who received antenatal care. In addition, access to antenatal care decreased with parity, with fewer women accessing antenatal care for their 4th pregnancy or more. High risk pregnancy services Certain conditions or characteristics, called risk factors, make a pregnancy high risk and woman or baby is more likely to become ill or die than usual. Doctors identify these factors and use a scoring system to determine the degree of risk for a particular woman. Identifying high-risk pregnancies ensures that women who most need special medical care. The high-risk program has been implemented in 26 referral governmental clinics in the Gaza Strip and 18 MCH clinics in UNRWA. The percentage of newly pregnant women visits with high-risk pregnancy was 14% of total newly pregnant women in MOH (17.8% in the GS and 11.6% in the WB). The number of visits paid per high-risk pregnant women was 5.2 visits. In UNRWA, the percentage of newly pregnant women visit at high risk and alert pregnancy was 44% from total antenatal visits of newly pregnant women. Out of the total, 40% paid 3-4 visits and 47.7% paid 7-9 visits. During home visit program in Gaza Strip, the factors associated with high risk pregnancy were as shown in the following table; taking in consideration that one woman may have more than one complication: Table 3.1 factors associated with high risk pregnancy Factors Percent % Anemia 48.8 Multipara 27.5 Primapara 25.4 Previous CS 21.6 Hypertention 16 Diabetes 5.5 Pre-eclamptic 2.1 Others 6 Tetanus toxoid immunization The vaccination for pregnant women is taken based on MOH protocol during the first antenatal visit. Immunization coverage among newly pregnant women was 42.4% (25.2% in WB and 64.1% in Gs). In UNRWA, out of total (11,100) pregnant women of 20 weeks and over of gestation, the vaccinated pregnant women were 11,005 with a coverage rate of 99.1% (25) . Anemia among women in Palestine WHO define anemia as Hb is less than 11 gm/dl. The percentage of anemic mothers whom visited the governmental MCH for antenatal care was 38.5% (27.2%in the GS and 50% in the WB) .During study conducted in UNRWA in the year 2005, the prevalence rate of anemia among pregnant women was 35.7% and 45.7% among nursing mothers visited UNRWA-PHC centers for antenatal services in the Gaza Strip. During home visits program which are conducted by Womens Health and development Directorate in MOH, Hemoglobin (HB) has been examined for 1,950 visited mothers after delivery in Shifa as 38.5% (27.2%in the GS and 50% in the WB). During home visits program which are conducted by Womens Health and development Directorate in MOH, Hemoglobin (HB) has been examined for 1,950 visited mothers after delivery in Shifa hospital especially those at high-risk pregnancy or who has complication/s during delivery. The results indicated that 61.6% of women were anemic. Out of the total women, HB was diagnosed 10 gm/d l 11 gm/dl among 38.4% of visited women. Ferrous sulfate and folic acid as a tonic is distributed for pregnant women and children under 3 years in MOH and UNRWA centers free of charge (25) . Table 3.2 Prevalence rate of anemia among women visited UNRWA-PHC centers in Gaza Strip, 2005 Pregnant women Nursing mothers Samples HBà ¢Ã¢â€š ¬Ã‚ ¹11gm/dl % Samples HBà ¢Ã¢â€š ¬Ã‚ ¹12gm/dl 920 328 35.7 810 370 CHAPTER 4 METHODOLOGY Study design A cross-sectional study design was conducted during August,2009 in order to assess awareness among pregnant women attending UNRWA health care centers for antenatal care , based on health clinics of UNRWA in Gaza strip. Target population All pregnant women who was registered at UNRWA clinics ,both old and new ,who attended for antenatal care during August,2009 in Gaza strip . Sample size A total of 164 women from UNRWA clinics in the middle region of Gaza strip were selected randomly to participate in the survey taking into account the distribution of population in each area to represent the study population fairly. The sample size was calculated by assuming a 95% confidence interval and sampling error no more than (5%) using Yamane formula (1967:886) as follows: Where n is the sample size N is the population e is the sampling error rate (5%) Instrument of the study The instrument used in this study was questionnaire which created to cover the objectives of the study .the questionnaire included four divisions . 1st division: The question is about socio-demographical data of the women including age, educational level, occupation, number of children, economical status and attending health education session .the questions in this division were closed-ended and open-ended. 2nd division: The questions is about knowledge and awareness of women regarding anemia concept ,nutrition ,iron supplements ,and the tea with meals. The questions included 3 choices (completely agree, partially agree and disagree). 3rd division: The questions about opinions and attitudes of women regarding anemia .It included 3 choices (completely agree, partially agree and disagree). 4th division: The questions about health education session regarding anemia. It included 3 choices (completely agree, partially agree and disagree). Data collection Data was collected using the structured questionnaire as a tool to collect data from the samples of study by individual interview performed by the researcher and with assistant of staff in UNRWA clinics who has the experience in data collection and methodology. data analysis After data collection ,the questionnaires were collected and the data was entered to computer software for processing and analysis. the programme used for analysis is (SPSS) statistical package for social sciences software version 15. Ethical consideration Clearance and permission was obtained from Chief Field Health Section of UNRWA in Gaza strip in order to conduct questionnaires survey among refugees pregnant women who attended UNRWA clinics for antenatal care and follow-up in Gaza strip. In addition, the permission was taken from the head of UNRWA clinics and also oral permission was obtained from the women who participated in the survey. CHAPTER 5 RESULTS The current study aimed to assess the awareness of anemia among pregnant women who attended UNRWA clinics for antenatal care. Table 6.1 Age distribution of pregnant women Percent Frequency Age groups (years) 8.5 % 14 Less than 20 34.8 % 57 20 -25 25 % 41 26-30 31.7 % 52 More than 30 100 % 164 Total Table 1.6 shows that most (34.8%) of parti