Health Belief Model and Hypertension Treatment Compliance

Health Belief Model and Hypertension Treatment Compliance The health belief model and compliance with hypertension treatment Running title: Health Belief Model and Compliance in Hypertension Pauline E. Osamor and Olanike A. Ojelabi Pauline E. Osamor,  Institute of Child Health, College of Medicine, University of Ibadan, Nigeria, Olanike A. Ojelabi,  Worcester State University, Urban Studies Department, Worcester, MA 01605, USA Author contributions: Osamor PE, contributed to the conception and design of the study; all authors contributed to the writing and critical revision of the manuscript. Biostatistics statement: The study was designed, analysed and data interpreted by the authors. Data available in this manuscript did NOT involve a biostatistician. Conflict-of-interest statement: The author reports no conflicts of interest in this work. Data sharing statement: No additional data are available Abstract AIM: To explore the use of the Health Belief Model (HBM) in evaluating care seeking and treatment compliance among hypertensive adults in south-west, Nigeria. METHODS: A community-based cross-sectional study was conducted using a semi-structured questionnaire to obtain information from 440 hypertensive adults in an urban, low-socio-economic community, situated in south west Nigeria. Focus Group Discussions (FGDs) were conducted with a subset of the population. The relationship between treatment compliance and responses to questions that captured various components of the HBM was investigated using chi-square tests. Content analysis was used to analyze data from the FGD sessions and to provide context to the survey responses. Data entry and management was carried out using the Statistical Package for Social Sciences (SPSS) version 11.0. RESULTS: The components of the HBM reflecting Perceived Susceptibility components were significantly associated with treatment compliance. On the other hand, HBM Perceived Seriousness components were not significantly associated with compliance. The main HBM Perceived Benefit of Taking Action component that was prominent was the belief that hypertension could be cured by treatment, a theme that emerged from both the survey and the FGD. CONCLUSION: Use of the HBM as a framework is helpful in identifying perceptions and behaviors associated with hypertension treatment compliance. Key words: Health belief model; Compliance; Hypertension; Community-based; Nigeria Core tip: Hypertension is a major health problem in developing and developed countries, and treatment compliance for such chronic conditions is often poor. In this study, the Health Belief Model (HBM) was used to evaluate care seeking and treatment compliance among hypertensive adults. HBM proved to be a valuable framework to develop and modify public health interventions and also serves to improve treatment compliance and reduce the risk of complications. Osamor PE, Ojelabi OA. The health belief model and compliance with hypertension treatment. World J Hypertension 2017; INTRODUCTION Hypertension, otherwise known as high blood pressure, is a leading cause of cardiovascular disease (CVD) worldwide[1]. The proportion of the global burden of disease attributable to hypertension has significantly increased from about 4.5 percent (nearly 1 billion adults) in 2000 to 7 percent in 2010[2-9]. This makes hypertension a major global public health challenge and the single most important cause of morbidity and mortality globally. The prevalence of hypertension in Nigeria may form a substantial proportion of the total burden in Africa. This is because of the large population of the country currently estimated to be over 170 million[3,6,10]. In Nigeria, hypertension is the commonest non-communicable disease with over 4.3 million Nigerians above the age of 15 classified as being hypertensive using the erstwhile national guidelines (systolic BP > 160 mmHg and diastolic BP > 90 mmHg)[12-15]. Treatment of hypertension rests on a combination of lifestyle interventions and use of antihypertensive medication. However, poor compliance with treatment is often common in hypertension. Studies of treatment compliance have explored the role of various factors, including demographic and socio-behavioral features of patients, the type and source of therapeutic regimen, and the patient-provider relationship[16]. Yet, a common framework for evaluating such factors is often lacking. One such framework is the Health Belief Model (HBM),which has shown utility in evaluating compliance with antihypertensive medications[17-20]. Health Belief Model The Health Belief Model (HBM) is an intrapersonal health behavior and psychological model. This model has been commonly applied to studying and promoting the uptake of health services and adoption of health behaviors[21]. Recently, a National Institutes of Health publication, Theory at a Glance, A Guide for Health Promotion Practices proposed that the HBM may be useful in the examination of inaction or noncompliance of persons with or at risk for heart disease and stroke[24], suggesting a natural fit for this study. The HBM is a value-expectancy model [17]. It attempts to explain and predict health behaviors by focusing on the attitudes and belief patterns of individuals and groups. The modelconsists of six dimensions: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and modifying factors. While the HBM has been criticized for overemphasizing the logical order and rationality of ones health behaviors[28], it is considered to be one of the most influential models in the history of health promotion practice[29], and has shown usefulness in predicting health behaviors among population with or at risk for developing cardiovascular disease. With respect to care-seeking and treatment compliance, a hypertensive patients ability to see a physician and comply to medical treatment regimen is a function of a various factors. These include patients personal knowledge, benefit and perceptions, modifying factors, and cues to action[30]. Therefore, the goal of this study is to explore the use of the HBM as a framework for evaluating care-seeking and treatment compliance in hypertension in south-west Nigeria. Rationale Uncontrolled hypertension is caused by non-adherence to the antihypertensive medication, patients understanding their drug regimens and the necessity to adhere to this regimen will help to improve their adherence, thus help prevent the complications of hypertension that are debilitating and if not prevented can increase the burden of a disease that is already on the increase[31]. Knowledge and beliefs about hypertension have been frequently examined in efforts to better understand the disparities in blood pressure control[33,34]. Relatively few studies, however, have attempted to identify individual factors associated with the adoption of hypertension control behaviors using a health behavior model as the theoretical framework. Thus, this study aims to explore the use of the HBM- an intrapersonal health behavior and psychological model in evaluating care seeking and treatment compliance among hypertensive adults in south west Nigeria. MATERIALS AND METHODS This community-based cross-sectional study was carried out in an urban, low-socio-economic community in Nigeria. Most of the residents belong to the Yoruba ethnic group and the dominant religion is Islam. The health facilities in the community include an outreach clinic run by the Department of Preventive Medicine and Primary Care of the University of Ibadan, four private clinics and a small dental clinic. Other sources of health care in the community include Patent Medicine Vendors (PMVs) and three traditional healing homes. The study site was selected for three specific reasons: Firstly, the community has been the site of previous research studies where people were screened and therefore know of their hypertension status. Secondly, a community study approach (instead of a clinic-based approach) was chosen because selecting participants from a clinic or hospital will only select those who are attending clinic or complying, thereby introducing a selection bias and thirdly, the commun ity has a variety of sources of healthcare located within the community, implying that residents have options when seeking healthcare. The study is a community-based cross-sectional study which enrolled hypertensive adults (age 25 years and above) in the community. It utilized both the survey and Focus Group Discussion (FGD) to collect primary data from the respondents. The participants for this study were selected from a list of known hypertensive adults residing in the community that was developed from a previous hypertension study[35] and updated for the present study during home visits. Four hundred and forty (440) hypertensive subjects were enrolled using a consecutive sampling method. After obtaining informed consent, subjects were administered a semi-structured questionnaire that had items on several issues, including knowledge on causes, prevention and severity of hypertension, healthcare seeking for hypertension, their beliefs and perception about hypertension and compliance with treatment including keeping clinic follow-up appointments and regularly taking their antihypertensive medications. Eight FGDs were conducted, each with 6-8 discussants. The dimensions of the HBM were operationalized as described in table 1, where each dimension was framed as a series of questions, which were asked in the survey and/or discussed as a topic in the FGD. Data entry and management was carried out using the Statistical Package for Social Sciences (SPSS) version 11.0[36]. Univariate analyses were employed in interpreting socio-demographic characteristics of the respondents, while a bivariate analysis was used in cross tabulating variables. The transcription of the qualitative data was carried out immediately after each FGD session. This was essential since the memory of the interviewer/note taker was still fresh and it was easier to reconcile written notes and the interview transcripts. Content analysis was used to analyze data from FGD sessions. RESULTS Socio-demographic characteristics A total of 440 (including 287 women) respondents were studied. The ages of respondents ranged from 25 to 90 years, with a mean of 60 (SD 12) years. Most (71%) of the respondents were married and 61.4%, Muslims. Slightly over half of the respondents (51.1%) had no formal education. About half (50%) of the respondents were traders, while those who have retired and not working constituted 25.7%. Prevalence of compliance with clinic visits and taking medication The prevalence of self-reported compliance with clinic appointments was 77.5% and that of good compliance with treatment was 50.7% of respondents. 41.5% reported poor treatment compliance at different levels ranging from regularly missing taking their medication to fairly regularly, sometimes and rarely taking their medication. Perceived Susceptibility to hypertension In response to being asked what they understood by the disease hypertension, most respondents defined hypertension as an illness of anxiety and stress (60.9%). Nearly one in twelve (7.3%) said they did not know what hypertension meant. A few of the respondents (4.1%) believed that hypertension means too much blood in the body, thereby causing tension in the blood. Roughly two percent of respondents said hypertension was in everybodys blood. A quote from one of the FGDs is illustrative: Hypertension is in everybodys body and blood. When we exert undue stress on our body, think too much and do a lot of wahala (stressful things), hypertension will start. This statement clearly articulates the notion that everyone is predisposed to hypertension but the condition only becomes apparent or manifests itself when the person experiences a lot of stress. This could either mean that everyone is predisposed to having hypertension or that hypertension is hereditary. Perceived Severity of hypertension A large proportion 89.8% of the respondents knew that hypertension could lead to other serious health problems or complications. Only 1.1% did not affirm that it will lead to serious problem, while 9.1% did not know if hypertension could lead to other health problems. Other health problems that could result from hypertension mentioned by respondents include: stroke (47.5%); death (25.5%); severe headache (5.2%) and heart attack (5.0%). In the FGD sessions conducted, respondents were asked if they perceived hypertension to be a serious health problem. The general response was that hypertension is a serious health problem. One of the FGD discussants summed it this way: Hypertension is a very serious sickness. It is not sickness we should take lightly. It can lead to quick death. One of my younger brothers who worked in the bank had hypertension. He suffered attacked from hypertension while in the office and before they got to the hospital, he died. Hypertension kills fast. But it has drugs that can control it and if one is not taking the drugs regularly, it will cause serious problem. A fifty-two years old woman used her personal experience to buttress the magnitude of hypertension. She stated that: This sickness they call hypertension is a very serious sickness. I was not taking any drugs because I did not have money to buy it and I was not worried because I was not feeling sick. In 2003, I was sick just for a week and before I knew what was happening I could not walk or move my body. I was rushed to the hospital and they told me my blood pressure was very high. I was in the hospital for almost a month and my children spent a lot of money. I am better now, but am still using walking stick because the hypertension made my body stiff. I am taking my medication always now so that I do not die quickly because it can kill. The general perception of the respondents and focus group discussants on the complications from hypertension is that hypertension itself is a very serious health problem and that any complications arising from it could be very severe. Perceived benefit of treatment compliance Nearly three quarters (73.2%) of the respondents believed that hypertension could be cured with treatment. Most (72.0%) of the respondents reported that it is not good to wait until one feels sick before taking antihypertensive medication and the reason given by a large proportion (30%) of these respondents is that taking medication regularly will prevent reoccurrence of hypertension. Despite the fact that respondents believe they needed to take medication as prescribed (and not only when they are sick), only a relatively small proportion (a little above 50%) of the respondents did take their medication as prescribed. Perceived barriers to complying with treatment Among the respondents, 41.5% had poor compliance at different levels ranging from regularly missing taking their medication to fairly regularly, sometimes and rarely taking their medication. Of these respondents who were non-compliant with their medication, 11.4% said they felt better and therefore had no need to continue taking their medication. Only 0.5% said they were tired of taking drugs, while 6.8% stopped because of lack of funds to purchase drugs. Other factors included side effects of drugs (6.1%), forgetfulness (8.4%), busy schedule and limited medication (3.6%). A major theme from the survey and FGDs is that respondents were apprehensive of the long term effects from antihypertensive medication and the possibility of being stuck with it for the rest of ones life or the medication causing other illness or complications. Negative feelings were elicited in some cases, as antihypertensive drugs were perceived as being damaging or not good for the body. The FGDs highlighted fac tors that hindered good compliance to treatment despite the general acceptance of the necessity to take antihypertensive medications. One of the discussant said: I do not take my medicine every day. People do not always follow what doctor say. It is not only for hypertension, even for other sickness. If they say take medicine for five days, once we feel better by thethird day, the person will stop. Even the doctors themselves, will they swallow medicine every day? A discussant in another session stated: Let me tell you the truth it is not easy to be taking drugs every day. Sometimes, we forget especially when you are rushing to go out. Sometimes we do not have the money to buy it. Another respondent added details about what often happens as a result of the financial obstacles: That is what we have all been trying to say. Money is the major problem. In the hospital, they will ask you to pay for ordinary card, before you see the doctor. When they write drugs for you there is no money to buy all. If you do not have money and you go to a private hospital, they will not even attend to you. That is why some people prefer to just go to chemist and buy what they can afford and some others prefer traditional medicine because you do not have to drink it every day and it is less expensive. Cues to action An important source of cues to action includes the individuals cultural conditioning of available treatment options. In this study family and friends were a major source of cues to action. Overall, 19.3% of respondents reported that family members were very concerned about their hypertension while 74.8% said family members were extremely concerned about their hypertension. Also, 20.2% and 73.2% respectively reported that family members were very helpful or extremely helpful in reminding them about taking their medication. Regarding support from friends, 26.4% of respondents reported that friends were very concerned about their hypertension while 28.9% said friends were extremely concerned about their hypertension. Out of the 440 respondents, 91 and 150 (20.7% and 34.1%) respectively reported that friends were very helpful or extremely helpful in reminding them about taking their medication (Figure 1). DISCUSSION Hypertension is a condition of sustained high blood pressure which can only be confirmed after blood pressure measurements that meet the criteria for the condition. The cause of hypertension is not known in most cases[1] hence the term essential hypertension. In the present study, hypertension is perceived primarily as an illness of anxiety and stress. This finding is consistent with a previous study of hypertension in Nigeria[38] which revealed that over 60% of their respondents irrespective of the educational background believe that psychosocial stress is the main cause of hypertension. Similarly, Koslowsky et al[39] found that stress and tension were most commonly stated as causes of hypertension. Majority (more 90%) in this study believe hypertension is a serious condition and two-thirds (66%) believe that hypertension can be prevented. Contrary to findings and reports from previous studies[38,40,41], nearly three-quarters (73%) of respondents in the present study believe that hy pertension is curable. Almost half of the respondents claim good compliance with respect to drug treatment and 86% claim good compliance with keeping their doctors appointment. Reasons for compliance to treatment include fear of the complications of hypertension and the desire to control blood pressure. Benson and Britten[42] reported that patients comply with medication regimen for a variety of reasons including perceived benefits of medication; fear of complications associated with hypertension and feeling better on medication. The latter reason is contrary to the generally held belief among physicians that hypertension is a largely asymptomatic disease[43]. One central theme that runs through the data in this study is the issue of socio-economic status of the respondents. This suggests the importance of considering other variables that can help form individuals perception including health care costs and some sort of lay consultation that takes place before they resolve to take a recommended health action[27]. Financial hardship is a barrier which should not be ignored as it is a contributory factor to noncompliance. This finding corroborates the observed association between poor compliance, ignorance and lack of funds for purchase of drugs[44]. Failure of patients to keep scheduled appointments is an important obstacle to the provision of effective healthcare. By missing appointments, individuals deprive themselves of professional services. Interestingly, 77.5% of the respondents in this study claim they comply with keeping their follow up clinic appointments every time. Several studies have investigated HBM and appointment-keeping for chronic disease management. Nelson et al[20] and also Landers et al[45] found HBM variables to be unrelated to keeping clinic appointments for hypertension. Social support networks are important in the long-term management of chronic conditions such as hypertension, which require a radical and life-long change in the lifestyle of the affected person. In this study, those who had support from friends or family members (concerned about their illness, giving reminders about medication) showed better treatment compliance than those who did not, although this difference was greatest for those that had the support of friends. This is an important finding and is consistent with what has been reported for multiple chronic diseases in several parts of the world[46]. A summary of the major findings in this study in the context of interpreting compliance using the significant components of the HBM shown in Figure 1 suggests that HBM Perceived Susceptibility components tested were significant predictors of compliance. On the other hand, HBM Perceived Seriousness components were not significantly associated with compliance. The main HBM Perceived Benefit of Taking Action component that was prominent in this study is the belief that hypertension can be cured. This is a recurring theme in all the components of the study (survey and FGD) and most respondents believed that taking the medication for some time led to a cure and one could stop taking medication. This finding agrees with studies of Kamran et al[47], which showed a relationship between HBM constructs and treatment compliance. The constructs that were significantly showing relationship in their study were perceived susceptibility, perceived benefit of using the medicine and perceived barrier to treatment. This has major personal and public health implications because hypertension can only be controlled (not cured) and stopping medication can lead to complications. More importantly, it highlights the discrepancy between healthcare providers and their patients in the perceived goal of treatment since the former are working towards control while the latter believe compliance can lead to cure. Most of the HBM Barriers to Taking Action components emerged during the FGD sessions. These barriers are practical issues that loom large and prevent the patients from making optimum use of the hospitals and medications that are available. In other words, the option of a university teaching hospital is available but is not accessible because of costs and inconvenience. Similarly, known medications that work well in hypertension are available but the costs are too high for the patients to comply with the prescriptions as written. It is noteworthy that believing that one can stop taking the medication after some time can also serve as a barrier to compliance because the individual now believes there is no need for more medication. Another major finding from this study is that HBM Cues to Action are extremely important in predicting compliance with hypertension treatment in this community. These cues are centered on patients having family members and/or friends who are concerned about the individuals health and treatment. This finding is important because, as noted by Harrison et al[48] in a meta-analysis, cues are often not included in Health Belief Model studies. Indeed, these authors limited their review to articles to the four major components of the HBM (susceptibility, severity, benefits and costs) because in their words: Cues to action have received so little attention in empirical studies that we excluded this dimension. However, the findings of this study shows that cues are an important dimension in these types of study. While the specific cues that are important may vary between locations, cultures, and environments, they emphasize the social context in which health behavior takes place. As expected, attending clinic regularly is an important predictor of compliance in the present study. It provides an opportunity for multiple cues that can improve compliance, including blood pressure checks, discussing actions to control blood pressure, and reminders to take medication. CONCLUSION Components of the HBM show variation in association with treatment compliance for hypertension in this Nigerian community. The findings provide useful baseline data for future studies of the Health Belief Model in hypertension and other chronic conditions in similar societies. Strength and limitations of the study Strengths of this study include: the use of both survey and FGD methods; inclusion of a large set of variables and focus on the components of the HBM to a non-communicable disease (hypertension) in a developing country context. A potential limitation is that the study did not formally investigate the modifying factors dimension of the HBM. Nonetheless, the findings provide clues to care-seeking and compliance issues, while suggesting potential intervention points (e.g. breaking the cost barrier, including social networks in treatment plans) that could be further studied and tested. Ethical Approval Ethical approval for the study was obtained from the Joint University of Ibadan /University College Hospital Ethical Committee. Acknowledgment The authors are grateful to the study participants and community leaders of Idikan community, Ibadan. The input of Dr. Bernard Owumi and Dr. Patricia Awa Taiwo of the Department of Sociology, University of Ibadan, is hereby acknowledged.    REFERENCES 1Mukhopadhyay, B. Detecting and preventing hypertension in remote areas. Ind. J Med Ethics 2006; 3(4): 124-5 2 Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the global burden of disease study 2010. The Lancet. 2012; 380(9859): 2224-60 [DOI: 10.1016/S0140-6736(12)61766-8] 3 Adeloye D, Basquill C, Aderemi AV, Thompson JY, Obi FA. An estimate of the prevalence of hypertension in Nigeria: a systematic review and meta-analysis. J Hypertens 2015; 33: 230-242 [PMID: 25380154 DOI: 10.1097/HJH.0000000000000413] 4 Beaglehole R, Bonita R, Alleyne G, Horton R, Li L, Lincoln P, et al. UN high-level meeting on non-communicable diseases: addressing four questions. The Lancet 2011; 378: 449-455 [PMID: 21665266 DOI: 10.1016/S0140-6736(11)60879-9] 5 Alwan A, Armstrong T, Bettcher D, Branca F, Chisholm D, et al. Global status report on non-communicable diseases 2010. WHO 2011: Available online: http://www.who.int/nmh/publications/ncd_report_full_en.pdf 6 Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease study 2010. The Lancet 2012; 380(9859):2095-128[DOI: 10.1016/S0140-6736(12)61728-0] 7 Whitworth JA. 2003 World Health Organization (WHO)/ International Society of Hypertension (ISH) statement on management of hypertension. J. Hypertens 2003; 21(11): 1983-92 [PMID: 14597836] 8 Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, et al. The Seventh Report of the Joint National Committee on prevention, detection, evaluation and treatment of high blood pressure: the JNC 7 report. JAMA 2003; 289(19): 2560-72 [PMID: 12748199] 9 Kearney PM, Whelton M, Reynolds K, Muntner P, Whelton PK, He J. Global burden of hypertension: analysis of worldwide data. The Lancet 2005; 365(9455): 217-23 [PMID: 15652604] 10 WHO Regional Committee for Africa. Cardiovascular diseases in the African region: current situation and perspectives-report of the regional director 2005. Maputo, Mozambique: The WHO Regional Office for Africa (AFR/RC55/12). Available online: http://www.afro.who.int/en/fifty-fifth-session.html 11 Mocumbi AO. Lack of focus on cardiovascular disease in sub-Saharan Africa. Cardiovascular Diagnosis and Therapy 2012; 2(1): 74-7 [PMID: 24282699 DOI: 10.3978/j.issn.2223-3652.2012.01.03] 12 Kadiri S. Management of hypertension with special emphasis on Nigeria. Arch Ibadan Med 1999; 1: 19-21 13 Akinkugbe OO. Current epidemiology of hypertension in Nigeria. Arch. Ibadan Med 2003; 1: 3-5 14 Iyalomhe GBS, Omogbai EKI, Ozolua RI. Electrolyte profiles in Nigerian patients with essential hypertension. Afric. J. Biotech 2008; 7(10): 1404-1408 15 Ike SO. Prevalence of hypertension and its complications among medical admissions at the University of Nigeria Teaching Hospital, Enugu, Nigeria (Study 2). Niger J Med 2009; 18(1): 68-72 [PMID: 19485152] 16 Haynes RB, Taylor DW, Sackett DL, (1979). Compliance in health care. Johns Hopkins University Press: Baltimore, MD. 17 Becker MH, Maimon LA. Sociobehavioral determinants of compliance with health and medical care recommendations. Med. Care 1975; 13(1): 10-24 [PMID: 1089182] 18 Rosenstock IM. (1990). The health belief model: explaining health behavior through expec

Nature and Love in the Poetry of Dafydd ap Gwilym :: Poetry

Nature and Love in the Poetry of Dafydd ap Gwilym Essay is 1550 words in length Dafydd ap Gwilym has been acclaimed as the greatest poet of the Welsh language. As Rachel Bromwhich commented, Dafydd’s life "coincided miraculously in both time and place with an unprecedented opportunity to mate the new with the old" (Brom 112). Perhaps "mate" is a more appropriate choice of words here than Rachel intended. As his poetry depicts, Dafydd tried to mate a great many things in his time; the man is immortalized as a ball of raging hormones. A self-proclaimed "Ovid’s man," Dafydd took pleasure in identifying himself with the authoritative source of courtly love, a fresh trend in Wales during his life (Summer 29). Love, specifically courtly love, was among the new themes Dafydd merged with the traditional themes like nature. Even the ancient topic of nature, under Dafydd’s molding, took on new forms. Dafydd personified elements of nature to be his trusted messengers in poems such as "The Seagull." In the "Holly Grove," nature is subtly described a s a fortress or protector of sorts. Variations of these elements of secret, protected, and secluded love mesh with images of nature throughout Dafydd’s poetry. However, nature seems to be much more than a confidant or mere factor in his search for love; Dafydd’s poems such as "Secret Love" suggest that nature is essential in this endeavor. Though Dafydd’s attempts at love are not limited to the natural realm, poems such as "Trouble in a Tavern" make it evident that only in the natural setting is Dafydd a successful lover. Elements in the poetry of courtly love express the need for a love affair to remain secret. The object of a poet’s love in these poems is typically a married woman, or unattainable by some other means. Andreas Capellanus’s The Rules of Courtly Love captures this element of forbidden love by saying, "marriage (was) no real excuse for not loving" (Cap 115-116). As Patrick Ford wisely pointed out, the need to maintain secrecy in a forbidden affair is not a new idea to modern readers. These elements of courtly love do not escape Dafydd’s poetry. His poem "Secret Love," among others, emphasizes the level of secrecy necessary in maintaining a love affair. Dafydd considers himself a learned lover, who found that "The best form of the words that work / Is to speak love in secrecy" (Sec 1-2).

Liberal Education as a Livingstone

During a time when unemployment is at its lowest since World War II, one would think that finding a job would be easy. However, at this point in time, applicants for jobs are more qualified than ever. The competition for well-paid jobs is stiff, and in order to get ahead people need not only skill in one certain area, but a general intelligence of many subjects as well. A liberal education provides the general knowledge that gives job applicants an extra edge when applying for a job. With a base of knowledge in the liberal arts and a specialization in a certain area, people prove to be beneficial to employers. Throughout this paper, I will use the term â€Å"liberal education† not only in describing subjects like English, history, philosophy etc. , but as Livingstone describes a liberal education: an education which â€Å"aims at producing as perfect and complete a human being as may be. † In using the term â€Å"liberal education† I expect that all graduates of a liberal arts college have an expertise in rhetoric, as the art of speaking and writing well is a key focus in the curriculum. I will also use the â€Å"specialized education† in reference to Livingstone†s definition: an education â€Å"which aims at earning a living or making money†. Undergraduates pursuing a liberal undergraduate education have an advantage over people with a specialized undergraduate education because liberal education provides a greater versatility in terms of a broader base of knowledge so that finding a job and excelling in different areas is easier. Training in art of rhetoric, which today is defined as the art of speaking and writing effectively, is a valuable asset for job hunters. Specialized undergraduate curriculums focus less on rhetoric than liberal arts curriculums. A person with training in rhetoric would be hired over another applicant due to their expertise in communicating ideas effectively through speech and writing. Companies aim to employ intelligent people who can express themselves wisely and eloquently because in nearly every profession, writing well and persuading others to one†s opinion is essential: scientists have to apply for grants in order to fund their research and experiments; businessmen must present proposals and of course, columnists and authors who have not mastered the skill of rhetoric are less likely to find a job and be successful in terms of status and salary. Ability to express oneself clearly and effectively designates to what level one may raise in the corporate ladder, for people with refined writing skills benefit companies to a large extent, while people with less skill in writing have less influence, and therefore less power. People with a liberal education are skilled in multiple areas and therefore can be of more benefit to employers. Rather than a specialized study in one area, a liberal education provides students with a broad range of knowledge that attracts employers. As Virtruvius says, liberal education teaches the student the connection between different disciplines. Knowing and realizing the relationship between subjects, an employee can perform a greater number of tasks and learn new ones more rapidly thus being more valuable to a company. Should a man lose his job due to it becoming extinct or other reasons, a liberal education would provide a better cushion to fall back on because of the diversity of subjects studied. For example, if a court stenographer loses his job due to a new audio technology that records and word-processes court proceedings, he would not have to, in a sense, start over for lack of knowledge in other areas. Utilizing his knowledge in rhetoric, philosophy, history, and other humanities, he could find another job without going back to school. On the other hand, the opposition would report that a liberal education would not benefit many people because a curriculum based on the humanities repels many students. Rather than take courses that disinterest them, students should specialize in subjects they enjoy. One should not waste money on an education that does not focus on one†s interests; an education that does not stimulate the student is a failed education. In order to make the most out of undergraduate years, the students should study what interests them. In rebuttal, a liberal education does not suit every personality or preference. However, in the job market, having a liberal undergraduate education and a specialized graduate education gives people an advantage, for not only are they trained specially in their specific area, but they also have a general knowledge of the liberal arts. Students interested in areas such as technology and sciences should take classes that interest them. However, in addition to the sciences courses, rhetoric classes would prove beneficial even in a scientific line of study. Every occupation entails writing in some way, and sharpening one†s writing skills only reaps more benefits when searching for a job. Many people interested in the sciences and technologies specialize during their undergraduate years, and therefore miss out on training in rhetoric. Specialists who take classes to improve writing are better-prepared and more likely for find a job. Another argument of the opposition: people who start specializing during undergraduate years are better prepared for graduate school. They master and excel in one specific area of study. Whereas, it would take someone with a general undergraduate education a longer time to master a specific area of study because of the attention spent on a broad education during undergraduate years. Instead of spending thousands of dollars on a general education, students could use the four years to specialize in the field that they enjoy. A liberal education may prove beneficial for students who are unsure about their major, but focused students should not waste their time on general education. Students who know what they want to focus on should specialize their education in order to expedite their college time and either start a masters degree or start their careers. It may take longer for a generally trained undergraduate to specialize in a certain area, but then again, if they are trained in understanding the connection between different areas of study, they may be able to pick up different subjects more quickly. There are really two issues here to refute. First, when studying, why is everything such a rush? People are in a hurry to enter the job force rather than to take their time during their schooling. I suppose the answer to the question is money. While people are in school they pay thousands of dollars and receive very little back in comparison. Once they start working they can begin the payback period. Sadly, those who enter the workforce first do win in the sense that they can start paying back their debt, while the people still in school keep accumulating debt. Second, even if people with a liberal arts education enter the workforce at the same time, they are not at a disadvantage in terms of knowledge capability as the previous argument concludes. In fact, liberal arts undergraduates may be at a slight advantage in terms of useful knowledge. For example, two applicants for a job have both had the same graduate education but one (person 1) had been trained in the liberal arts during undergraduate years, and the other (person 2) had specialized earlier. Assuming the two candidates preformed equally in gradate school, which may not be a fair assumption due to person 2†³s past knowledge and previous study, however, for argument†s sake, assume both were successful in graduate school. An employer would choose person 1 because of the liberal arts background on top of the specialized graduate schooling. An employer would know that people with a liberal arts background are not only intelligent in their specific line of study, but also understand the connection between disciplines, and would choose the person with the broad base of education. In discussing liberal arts training, one assumes that every student who graduates has a well-developed knowledge of all the subjects a liberal education offers. However, it is not fair to assume that every student attending a liberal arts undergraduate school explores each subject extensively and excels in every class. Many students take advantage of the time they spend in undergraduate school by partying on weeknights and coming to class so tired that they cannot concentrate on the lesson, or even worse, they skip class all together. This careless behavior towards schooling hurts not only the students† understanding of the material, but their grades as well. It is time that all upperclassmen graduate with honors rather than just slide by. The effect on the community and world would be astounding. Thousands of great minds graduate from college every year and become success stories like Bill Gates. Imagine every college student intellectually on par with the smartest graduate. Our world would be a different place. That is the place to which we should strive, and we have reached out goal when everyone achieves individual excellence.

How Stressful Life Experiences Affect A Child s Emotional...

This annotated bibliography covers six journal, reports and articles associated with the subject of how stressful life experiences can affect a child’s emotional development, what role the schools play in a child’s emotional development and how there is a need for the Department of Education to commission a sector body to develop a framework of core content for initial teacher training (ITT), which should include child and adolescent development. A child’s emotional development is a complex, multifaceted process and one which many interaction partners play a role. To teach effectively, trainee teachers need to understand child development expectations at different stages of development together with issues that can have an impact on the child’s progress. The research literature has accentuated the association between stressful experiences and psychological dysfunction in children and evidence has been found which suggests that there is a need for continuity across Initial teacher training institutes. ITT should be an environment for new teachers to learn from the best teachers, introducing them to essential skills, knowledge and understanding that all teachers require in order to continuously improve the opportunities and outcomes of young people. The authors of this study compared the judgements of trainee teachers with the responses of young children regarding their perceptions of student stress. The study compiled questions such as: Does teaching experience have anShow MoreRelatedHow Does Poverty Affect Education?1036 Words   |  5 PagesBoisvert Taylor Boisvert Mrs. Spoor English 11 April 17, 2017 Poverty Research Paper Research Question: How does poverty affect Education? A child who is raised in a stressful and poverty stricken household environment is more likely to channel their stress into disruptive behavior at school and will be less likely to develop a healthy social and academic life (Bradley and Corwyn, 2002). Many say that laziness is a factor affecting education and success rate, however, it is a proven fact that gettingRead MoreRichard Lazarus and Susan Folkman’s and Stress and Coping Paradigm1542 Words   |  7 PagesDiscuss Richard Lazarus and Susan Folkmanà ¢Ã¢â€š ¬Ã¢â€ž ¢s and stress and coping paradigm and in view of this paradigm explain age and individual difference in the experience and handling of stress 1. Introduction Stress is induced by life events .Lazarus and Flokman in (Cavanaugh and Blanchard à ¢Ã¢â€š ¬Ã¢â‚¬Å"Field (2005) point out stress is defined by the person and that no two people experiences stress the same event in exactly the same way. Each individual has a specific tolerance for stress dependingRead MoreEffects Of Cancer On Children Under The Age Of 15 ( Toro )869 Words   |  4 Pagesneuropsychological effects that coincide with the life saving treatment. This effects can have a lasting impact on children (Rae Sullivan, 2005). Diagnosis and treatment of cancer is stressful. As stated before in order to have a chance of surviving cancer, children are forced to endure painful invasive procedures. In addition to the medical symptoms, they also face physical adverse effects to the treatment like significant body changes like weight and hair loss. The experiences of painful invasive procedures andRead MoreRichard Lazarus and Susan Folkmans and Stress and Coping Paradigm1526 Words   |  7 PagesLazarus and Susan Folkman’s and stress and coping paradigm and in view of this paradigm explain age and individual difference in the experience and handling of stress 1. Introduction Stress is induced by life events .Lazarus and Flokman in (Cavanaugh and Blanchard –Field (2005) point out stress is defined by the person and that no two people experiences stress the same event in exactly the same way. Each individual has a specific tolerance for stress depending on general level ofRead MoreThe Effects Of Stress On Infants And Young Children1711 Words   |  7 Pagesresponse that can have enduring biological, emotional, and behavioral consequences (Lupien et al, 2009). A fetus is sensitive to hormonal and other physiological indicators of stress within the womb and exposure to stress carries on after conception and continues to affect emotional and cognitive functioning of infants and young children. Similar to many other psychological disorders, ADHD has roots early in life. After birth, stress continues to affect infants and young children in comparable waysRead MoreEffects Of Early Childhood Trauma On Relationships1656 Words   |  7 PagesOver 25% of children in the United States will witness or experience a traumatic event before they turn four. Early childhood trauma is the experience of an event by a child that is emotionally painful or distressful. Consequently, exposure to traumatic events in childhood is associated with a wide range of psychosocial and developmental impairments. Nilsson, Holmqvist, Jonson (2011) conducted a study that found trauma related experiences (particularly in childhood) relate to dissociative symptomsRead MoreThe Early Years: The Effects of Nurturance During Childhood on Development1589 Words   |  7 Pagesâ€Å"Although experience may affect human brain structure and function throughout the entire life span, evidence†¦..suggests that early experience may be particularly critical† (Rao et al., 2010). Duri ng the childhood years, adequate nurturance by parents has a large impact on optimal biological and psychological development. This includes neurological, social, emotional, and cognitive growth. Rao et al. (2010) broadly define nurturance as including â€Å"warmth, affection, and acceptance† (p. 1145). LikeRead MoreChild Abuse And Its Effects On Children1132 Words   |  5 PagesIntroduction Child abuse takes many different forms. Including physical, sexual, emotional, or neglect of a children by parents, guardians, or others responsible for a child s welfare. Regardless of the type of abuse, the child’s devolvement is greatly impacted. The child’s risk for emotional, behavioral, academic, social, and physical problems in life increase. According to the Child Maltreatment Report by the Children’s Bureau (1999) the most common form of child abuse in the United States isRead MoreEssay about Connection between Relationships and Emotions606 Words   |  3 Pagesemotions can define their relationship with someone else, emotions can also separate the two people. Relationships can be more meaningful when the people involved are on the same page. Positive emotional connections create stability in relationships. There is a variety of relationships that a person experiences in a lifetime. A relationship is something that connects two or more people emotionally, mentally or physically. Relationships can be with family, friends, a significant other, and co-workersRead MoreChild Neglect Is An Unfortunate Reality For Children1297 Words   |  6 Pageswidely recognized that the first few years of a child’s experiences are essential to his or her personality and behavioral development. The most critical integral aspect in this regard is the child’s relationship with his or her parents in the formative years. However, that is not always the case. Neglect-the maltreatment related to the failure to provide needed, age-appropriate care-has a power capability of comprising a child’s development. Child neglect is an unfortunate reality for children in our