Category: Literature Review

Abstract :

Human services is an imperative perspective in regular daily existence, with quality and reasonable consideration being basic for a populace’s prosperity and future. All things considered, related expenses for medicinal administrations keep on rising. One perspective adding to expanded expenses in social insurance is waste and misrepresentation. Specifically, with the quickly rising old populace in the United States, programs like Medicare are liable to high misfortunes because of extortion. In this manner, extortion location approaches are basic in reducing these misfortunes. All things considered, numerous investigations utilizing Medicare information don’t give adequate insights about information preparation as well as coordination making it conceivably increasingly hard to comprehend the exploratory outcomes and testing to imitate the trials. In this paper, we present a flow look into utilizing Medicare information to identify misrepresentation, concentrating on information preparation and additionally mixing, and surveying any holes in the given information-related subtleties. We at that point present exchanges on imperative subtleties to search for when handling and combining diverse Medicare datasets demonstrating open doors for future work.

Introduction

Human services has and propagates to be a fundamental segment in individuals’ lives. The human body is a compound structure. Consequently, it is basic to have expert doctors fit the bill to analyze and treat infections in various pieces of the body. This instigates a few kinds of treatment methodologies that doctors do for patients in various fortes. The point of the wellbeing business is to effectively fill in however many patients as would be prudent. Yet, with each treatment, there is a cost related to each administration. Doctors, street pharmacists, and restorative staff must be paid for their time and ability including different medicinal comforts. Regularly these costs are not reasonable to the patients. Along these lines, protection plans are utilized to apportion costs over all patients in the human services framework and pay for the imperative individuals and hardware. Similarly, as with any protection framework, there is a probability of abuse or misrepresentation exercises.

Human services misrepresentation is progressively perceived as one of genuine social concerns. Human services extortion is an issue for the administration and there is a requirement for increasingly powerful recognition strategies. To distinguish human services extortion requires extraordinary measures of endeavors with broad therapeutic information.

Customarily, social insurance misrepresentation recognition incredibly relies upon the experience of area specialists, which is wrong enough, costly, and tedious. Manual discovery of human services extortion includes a couple of evaluators who physically audit and distinguish the suspicious therapeutic protection claims which requires much exertion. Be that as it may, the cutting-edge advances of AI and information mining strategies prompted increasingly effective and computerized discovery of human services fakes. There has been a developing enthusiasm for digging medicinal services information for misrepresentation discovery in the ongoing years. This paper surveys the different methodologies utilized for identifying the fake exercises in Health protection guarantee information.

Literature review

The Centers for Medicare and Medicaid Services (CMS) discharges social insurance information which is utilized by a large portion of the specialists for human services extortion location.

Srinivasan et al. [19] proposed an oddity discovery strategy by applying Rule-based Data Mining, an unsupervised method, on the protection claims information obtained from Medicare information. Applications for investigating medical coverage claims influence enormous information to recognize misrepresentation, misuse, waste, and blunders that were contrived. Medicinal protection guarantee peculiarities were identified utilizing these applications that benefit private well-being safety net providers distinguish shrouded cost invades that exchange preparing frameworks can’t recognize.

Branting et al. utilized Healthcare information sourced from Medicare and Medicaid and connected directed methods alongside diagram investigation and choice tree [9]. They proposed a way to deal with assessing medicinal services extortion chance that applies arranged calculations to charts obtained from open-source datasets.

Ko et al. explicitly thought to be just a single field, Urology, while utilizing 2012 CMS information [21]. The creators endeavor to decide on expected reserve funds from an institutionalized administration use by dissecting changeability among Urologists inside the field’s administration use and installment.

Medicare data processing and integration

Since our essential intrigue is how Medicare information was prepared and blended, we center this segment around works, barring our momentum inquiry about, the utilization of Medicare information sources (Part B, Part D, and DMEPOS) and additionally, the LEIE database to recognize extortion or other atypical supplier exercises. We detail how the information was taken care of, the converging of datasets, and talk about any holes in the exploration concerning information handling. The holes in these works make it hard to reproduce the info information and replicate the investigations. All things considered, these impediments present open doors for future research.

A. Does Medical School Training Relate to Practice? Proof from Big Data

In a paper by Feldman et al. [16], the creators break down medicinal services data to recognize contrasts in the quantity of methodology performed, normal charges, and normal installments for doctors dependent on their therapeutic schools. Their investigation does exclude the use of AI techniques, yet rather utilizes distinct measurements. The creators give some data in regards to information handling utilizing the accompanying datasets from 2012: CMS Physician Compare and CMS Medicare Part B. Moreover, just U.S. restorative schools, from the Physician Compare dataset, are incorporated and data concerning school areas are filled in, as required, for geographic examination. They include or update postal districts for every medicinal school utilizing sources, for example, paper articles and school declarations. On the off chance that a school has no postal division or is never again dynamic, the creators utilize the postal division for the city of the outdated school. Data from the 2012 Association of American Medical Colleges Tuition and Student Fees Reports [6] is utilized for medicinal school educational cost costs. Other than the incorporation of the extra therapeutic school data, there is no other discourse on purifying or preparing the Physician Compare or Part B information. The creators incorporate and total the information as follows:

• Link the Physician Compare and Part B datasets by coordinating one-of-a-kind NPI values.
• Group the information by restorative school name and method code and accumulate over doctors.

Each occasion in the last blended dataset demonstrates the code, for the technique performed, and therapeutic school 10 name with comparing strategy cost and check information(line_srvc_cnt,average_submitted_chrg_amt,andaverage_Medicare_payment_amt), just as school educational cost and area. With this dataset, the creators could conceivably recognize deceitful doctors or banner doctors right off the bat in their professions who are in danger of future misrepresentation. The investigation is restricted by just utilizing one year of information and is missing misrepresentation approval, which should be possible by including known false doctors from the LEIE database.

B. Doctor Medicare extortion: qualities and results

Pande et al. [23] utilize graphic insights and information investigation to discover examples and make suggestions on Medicare-related extortion, such as utilizing prescient models for cases misrepresentation location. The creators mean to give answers to who submits Medicare misrepresentation and what occurs after they get captured. Their essential information source is the LEIE dated October 6, 2011. From this information, the creators use prohibited suppliers dependent on subsection 1128(a)(1) just, demonstrating a conviction for Medicare or Medicaid misrepresentation. In the wake of choosing those people with a Medical Degree (MD), they wound up with 795 doctors for their investigation. They did exclude any specialist of osteopathic drug (DO) degrees which may have restricted the potential number of doctors in their examination. The creators don’t give subtleties on rejection timespans or whether waiver or restoration dates were thought about. Any extra information sources that may have been utilized by the creators in their investigation are not examined

C. Diagram Analytics for Healthcare Fraud Risk Estimation

In an examination by Branting et al. [8], the creators present a strategy for pinpointing false conduct by deciding the extortion hazard through the use of diagram calculations and identifying deceitful suppliers utilizing these chart-based highlights and a choice tree student. For their examination, they used CMS Medicare Part B (2012 to 2014) and Part D (2013) information, just as the LEIE database for misrepresentation names. The creators play out the accompanying information-handling steps:

• Link the three datasets by coordinating NPI values.
• Additional connecting done utilizing fluffy string coordinating on supplier names and other personality-related criteria, for example, necessitating that a coordinating arrangement of suppliers have the addresses in a similar state.
• Generate a chart incorporating the supplier, medicine, and methodology information sources used to speak to supplier exercises and practices, with hubs to incorporate NPI and HCPCS and edges showing practices, areas, and so on. Given these means for handling and coordinating the information, the creators express that just 10-15% of the suppliers in the LEIE without an NPI could be unquestionably coordinated.

D. Recognition of Fraudulent Claims Using Hierarchical Cluster Analysis

Khurjekar et al. [18] propose a two-advance unsupervised way to deal with distinguishing misrepresentation utilizing residuals from a multivariate relapse show. They distinguish suspicious cases dependent on a lingering edge of $500 and apply grouping to these residuals to discover extortion dependent by and large bunch separations. They utilize 2012 Medicare Part B information just with the accompanying highlights: hcpcs_code, line_srvc_cnt, bene_day_srvc_cnt, and avg_medicare_payment_amt (reaction variable). The creators don’t talk about information handling, so the supposition is that they essentially utilized the 2012 dataset as is and subset the previously mentioned highlights for investigation. Also, another restriction of their work is that exclusive 285 Medicare claims were utilized in their examination, however, no clarification of this confinement is displayed.

E. Fluctuation in Medicare Utilization and Payment Among Urologists

In a work by Ko et al. [19], the creators center around examining the changeability among urologists utilizing administration usage, for example, the quantity of office visits, and installment to decide the evaluated investment funds from an institutionalized administration use. All the more explicitly, they utilize straight relapse to show these connections and take a gander at anticipated installment esteems versus genuine Medicare installment adds up to contrast urologists and their companions. The creators utilize the 2012 Medicare Part B information and channel for urologist supplier types as it were. This prompted a dataset which comprised of 8,792 urologists. Also, the number of patient visits as shown by HCPCS codes for new patient visits (99201, 99202, 99203, 99204, and 99205) and return visits (99211, 99212, 99213, 99214, and 99215) was totaled for every urologist. As with [18], the work by Ko et al. has little exchange on information preparation and it is accepted that Medicare information was utilized in its present condition.

F. Learning Discovery from Massive Healthcare Claims Data

Chandola et al. [9] present a general inclusion paper utilizing diverse AI strategies for extortion discovery to incorporate informal community examination, content mining, and worldly investigation. In addition, the creators examine regular treatment profiles dependent on the systems performed. These profiles show the ordinary movement of doctors which are utilized to contrast against different suppliers with decide conceivable concerns or maltreatment in methods. The creators use claims information for 48 million U.S. recipients, yet it is hazy regarding whether this is Medicare, explicitly Part D, or Medicaid information. There is little talk on the underlying information sources. Another dataset is made out of supplier enlistment data which was acquired from a few private associations. To have misrepresentation marks, they utilize a rundown of avoided suppliers from the Texas Office of Inspector General’s rejection database. In this exploratory investigation, the creators give insignificant discourse on the information and no data concerning information handling or joining. This absence of detail as to the information makes it hard to create reproducible outcomes.

Types of frauds in healthcare

Human services extortion has diverse fake practices that change the event. It is a particular subject for each nation. There are diverse kinds of misrepresentation that happen in the social insurance industry. The sorts of fakes can be characterized based on which gathering or people are occupied with the extortion [4], [5]:

Misrepresentation by Service Providers

• Service suppliers may charge for the therapeutic administrations that are not performed;
• Service suppliers may charge for each phase of a therapeutic strategy as though it were a different treatment; likewise called Unbundling
• Service suppliers may charge for more costly restorative administrations than the one performed;
• Just to produce protection installments, specialist co-ops may perform superfluous restorative administrations;
• Just to get protection the specialist organizations may distort non-secured medicines as therapeutically fundamental secured medications;
• To approve the therapeutic methods that are not required, specialist co-ops may distort patients’ findings or potential treatment accounts;
• Fraud by Insurance endorsers:
• For getting a lower premium rate, records of business/qualification can be adulterated;
• Subscribers may document claims for restorative administrations that are not gotten; – To wrongfully guarantee the protection benefits, endorsers may utilize other people’s inclusion or protection card.
• Frauds by Insurance bearers: – Fake repayments;
• Misrepresenting advantage/administration articulations. Trick frauds:•
• In such cheats more than one gathering is included; for instance, false movement may incorporate a patient and a specialist or insurance agency.

Conclusion and future work

Human services misrepresentation keeps on being a risk to our economy and general prosperity. Specifically, the older who use Medicare assets are progressively helpless to the impacts of misrepresentation with the expanding old populace and Medicare costs that keep on rising. To give compelling extortion location, the Medicare information utilized in research thinks about must be talked about in a manner that gives enough detail on information handling or potentially mix to all the more likely comprehend the outcomes and to empower reproducible research. In this paper, we present an ebb and flow investigation on Medicare misrepresentation examination and identification with an accentuation on information preparing or potentially joining. Our commitment incorporates outlining holes and exercises learned in related examinations, which can direct specialists in leading future research here. The emphasis is on Medicare Part B, Part D, and DMEPOS claims information, just as the LEIE database, since these portray therapeutic methodology, medications, and hardware utilized by suppliers. We found that the ebb and flow look is inadequate in dialog on the two information handling and incorporation (where it applies), along these lines making it hard to comprehend what datasets are utilized and how they are utilized to deliver misrepresentation recognition results. Additionally, this absence of detail makes it hard to duplicate these examinations. We distinguish the holes in these examinations and give some dialog on some imperative information preparing issues, for example, missing qualities and ascription and information sifting utilizing given banners. The LEIE mapping process is likewise talked about to incorporate admonitions like the coordinating of dates. Our examination shows that there are lack of flow investigation. These holes, in any case, give abundant chances for future work.

The Medicare for All bill would primarily aid the uninsured American population. Medical bills and health insurance are extremely expensive in the U.S. As a result of these high costs, people miss out on care. Health policy analyst Thomas Waldrop writes, “Uninsured people are much more likely to postpone seeking care or skip needed care due to cost.” Avoiding care is a dangerous practice, but some people who don’t have insurance are forced to avoid care. The majority of these people do not have insurance because they can’t afford it and do not qualify for Medicaid. The result of not having insurance is being forced to pay expensive medical bills out of pocket, or choosing to avoid care altogether. Lots of Americans simply cannot afford healthcare. Christopher Ingraham, a writer and statistical researcher for the Washington Post, highlights the issues associated with our current healthcare system: “Fully one-quarter of [Americans] have put off needed care because of cost. More than 8 million Americans have started a crowdfunding campaign to pay for medical care.” Abstaining from care is an extremely dangerous practice and has led to preventable deaths. Furthermore, a large number of Americans have to rely on donations from strangers to pay for their medical expenses, showing how desperate these Americans are for care.

In addition to there being a high amount of residents who are unable to receive care, there is also a lack of equality when it comes to health insurance. As of 2020 data, 16.7 percent of Hispanic people don’t have insurance, compared to 5.2 percent of white people (U.S. Department 7). This inequality is very detrimental to minority communities, as it causes members in these communities to have a lower average life expectancy. The Centers for Disease Control, the United States federal health agency, found that African Americans’ average life expectancy is 75.5 years, compared to 78.9 years for white Americans. While not having access to health insurance is not the only factor causing this disparity, it is a contributing factor. Inequitable access to healthcare for minorities leads to lower life spans, which is a large problem that needs to be addressed.

Senator Bernie Sanders is striving to create more equality and better access to affordable healthcare. To achieve these goals, Sanders proposed the bill ‘Medicare for All’ in April 2019. To uninsured Americans, this bill will provide them with many benefits. First of all, they would be given access to healthcare. According to CNN writers, “In Sanders’ proposal, everyone who is a U.S. resident, including undocumented immigrants, gets coverage” (Wolf et al.). As a result of everyone gaining access to healthcare, more people will be able to get healthcare whenever they need it, not just when they can afford it. Furthermore, the bill claims to cause no discrimination and provide care to everyone. “No person shall, based on race, color, national origin, age, disability, or sex, including sex stereotyping, gender identity, sexual orientation, and pregnancy and related medical conditions (including termination of pregnancy), be excluded from participation in [this act]” (United States, Congress, Senate, 104). The bill promises to provide healthcare to all people, which in turn may help address the inequalities in our current healthcare system. To further the idea that everybody will receive care, the Medicare for All bill would be similar to private insurance companies as they will not charge more or deny coverage to people with pre-existing conditions. The bill also says that they will not discriminate against people based on demographics. All Americans will be enrolled, which will likely lead to more evenly distributed healthcare among all Americans.

Furthermore, all residents will be given access to any facility they choose and for cheap prices. As Mr. Sanders says, “You go to any doctor that you want, you will go to any hospital that you want…you’re not paying any more premiums, you’re not paying any more copayments, you’re not paying any more deductibles” (qtd in Herzlinger). Mr. Sanders promises to give everyone access to any facility they choose, meaning everyone will get the same quality of care. People also will not have to pay many of the fees associated with a traditional, private insurance plan. This will likely encourage more people to visit the doctor, as they will not have to pay as much in fees every time they go to a medical facility. As a result of this increase in doctor visits, Americans will presumably be healthier. Lower payments to doctors and access to any facility are not all of the benefits that Medicare for All would provide. Medicare for All would also cover a substantial amount of services, even more than private insurers. According to Margot Sanger-Katz, a New York Times writer, this act will cover most things that private insurances cover and more services, like hearing aids, eyeglasses, and long-term care for people with disabilities. Uninsured Americans will get many benefits under Medicare for All, including comprehensive healthcare coverage and even services that are typically not included by private insurers. They not only will receive insurance, but the insurance provided will be comprehensive. Overall, currently, uninsured Americans will receive access to substantial health insurance coverage, as well as access to all facilities, meaning this bill would be extremely beneficial to them.

While Medicare for All will provide insurance to many uninsured Americans, the effects the bill will have on the currently insured population as well as insurance companies will be harmful. Currently, many private health insurance companies offer health insurance to Americans. However, these companies may lose a lot of money if not go bankrupt if the Medicare for All bill is enacted. This is because “Sanders would make it illegal to sell private health insurance that covers the benefits offered by Medicare for All” (Wolf et al.). Mr. Sanders will severely limit what the insurance companies can cover, as coverages that duplicate the ones listed in the Medicare for All bill are prohibited. This will mean that these companies can only cover the few things that the Medicare for All plan won’t cover. Furthermore, author Karen Pollitz, a former researcher for Georgetown and employee at the United States Department of Health and Human Services, writes that “because Medicare-for-all covered benefits would be comprehensive, the market for insurance to cover supplemental benefits likely would largely be limited to nursing home care” (Pollitz et al.). Pollitz and other researchers predict that private insurance companies would only be able to cover nursing home care, as almost all other coverages would be monopolized by the U.S. government. Private health insurance companies will have a very small list of services that they are allowed to cover, like nursing home care or cosmetic surgeries. All of these coverages that private insurers are allowed to cover are not necessary, as necessary services will be covered by Medicare for All. As a result of this bill, these private insurers would lose the ability to cover a lot of services.

Due to a decrease in available coverages dictated by the Medicare for All Bill, private health insurance companies will likely lose money. These companies make money when people buy their insurance. If Medicare for All is enacted these companies will be limited to the coverages they can provide, and presumably will make less money. New York Times writers Reed Abelson and Margot Sanger-Katz write that “The effective takeover of the health insurance industry in the United States would mean a huge hit to the companies’ stocks, although the companies, which have additional lines of business, would most likely survive.” These insurance companies will inevitably make less money, which will cause the shareholders to lose money. In addition to the shareholders being financially harmed by this bill, there are also concerns about what will happen to the employees who work for these companies, as well as the economy in general: “The private health insurance business employs at least half a million people, covers about 250 million Americans, and generates roughly a trillion dollars in revenues. Its companies’ stocks are a staple of the mutual funds that make up millions of Americans’ retirement savings” (Abelson and Sanger-Katz). Over 500,000 people are working in the health insurance industry, and it is assumed that many of them would have to be fired if the Medicare for All bill is enacted. This bill will require much fewer employees as the government will have no competition and fewer administrative needs. Therefore, this bill will eliminate many jobs and likely create only a few in return, causing a devastating effect on health insurance employees. In addition to the number of people who will lose their jobs, many people who hold mutual funds that contain health insurance stocks may lose money. A lot of these insurance stocks are in people’s retirement funds, and a decrease in the stock value may cause people to lose some of their retirement money. People who are invested in the health insurance industry and working in the industry will likely lose money if Medicare for All is enacted.

Already insured Americans also are going to be expected to have to pay more money to contribute to making universal healthcare in the United States a reality. This is because the government will incur lots of expenses to insure the millions of uninsured people, as well as many other expenses associated with transferring millions of Americans from private insurance plans to government-run insurance. To enact Medicare for All, many people will have to pay more money in taxes. Pacific Research researcher, a conservative-leaning think tank, and Wall Street Journal writer Sally Pipes explains the cost for people above the poverty line: “He’s floated a new 4 percent income tax on all households earning over $29,000 a year, a new 7.5 percent payroll tax,” (“No, Bernie, ‘Medicare-for-all’ Won’t Save Money”). Americans who make over $29,000 a year, most of whom can afford health insurance, would have to pay significantly more in taxes. Other projections also predict how the Medicare for All bill will impact Americans who currently are insured. The Committee for a Responsible Federal Budget, a non-profit organization that addresses government spending, ran a study estimating how much taxes will go up for certain income brackets. They estimate that people making over $207,351 will have their federal taxes raised from 35% or 37% to 70%. This is a massive tax increase that is placed on wealthier Americans, they are going to have a vast majority of their paycheck taken by the federal government. These people will have their federal taxes doubled or almost doubled as a result of this bill.

In addition to the people in the top two brackets for income tax, all Americans above the poverty line will have to pay significantly more money in taxes. Marie Fishpaw and Jamie Bryan Hall of the Heritage Foundation, a conservative-leaning think tank, conducted a study to try to determine the cost for Americans to implement Medicare for All. They determined that U.S. residents would have to pay 21.2 cents more in taxes per every dollar they earn than they do currently. This huge tax increase is very difficult to justify, as many Americans currently spend less than that on healthcare. According to the Bureau of labor statistics, a U.S. government agency that monitors the economy and Americans’ spending, Americans spent on average 8.1% of their income for all healthcare expenses (Chalise). This bill will lead the average American to have to pay on average 13.1 percent more of their income to receive healthcare through the government instead of through their private provider. Many other studies found the same conclusion: Medicare for All will be extremely expensive and result in increased taxes, specifically on already insured citizens. Medicare for All would not only cause an increase in taxes but would also greatly hurt health insurance companies’ revenue, as well as severely hurt its shareholders, employees, and recipients of their services.

In addition to the profound effect that Medicare for All will have on already insured Americans, there will also be a large negative impact on the medical care community. If the U.S. switches to a universalized system such as Medicare for All, Americans can expect tremendous increases in wait times for all medical appointments. Other countries such as Canada and Britain, which follow similar models as the Medicare for All plan, both have significant wait time increases. In Britain in 2018, according to the United States Republican Policy Committee, “One in five emergency room patients waited longer than four hours to see a doctor, and 50,000 procedures deemed non-urgent by the government’s National Health Service were simply canceled.” Britain’s long-existing system of providing healthcare to all residents still experiences long wait times. They not only keep emergency room patients waiting which is extremely dangerous, but they also cancel appointments. These wait times and cancellations are directly linked to universalized healthcare because in universalized healthcare systems more people use the medical resources available due to them being free.

These increased wait times are also seen in other universalized healthcare countries, like Canada. In Canada, the wait times are extremely long. The Commonwealth Fund, a company dedicated to healthcare research and studies, found that 56% of Canadians were forced to wait over 4 weeks for an appointment (qtd in Herzlinger). Canada has a very similar healthcare model compared to Sanders’ Medicare for All plan, and if we switch to Medicare for All we can expect much longer wait times for specialists. Author T.R. Reid chronicled his experiences in 2007 trying to get treatment for his shoulder in Canada and highlighted the long wait times. While in Canada, he was told he would have to wait at least 10-12 months for an appointment, and another 6-8 months for surgery (137). Reid was in pain but was not able to get an appointment or receive treatment quickly, as the waiting list was too long. Enactment of the Medicare for All bill could cause patients in pain, like T.R. Reid, to have to wait for care.

In many universal healthcare systems, medical care is free or heavily discounted. As a result, people tend to overuse these services and get appointments or tests done that aren’t necessary. Adam Gaffney, a researcher and instructor at Harvard Medical School, and David Himmelstein, a lecturer at Harvard Medical School, predicted the increase in medical care usage. They estimate that under Medicare for All, ambulance usage will increase by 7-10%, and hospital usage will increase by up to 3%. This increase in the usage of medical facilities and resources will not only be costly but will also contribute to longer wait times. As more people use these services unnecessarily, the wait times will increase and so will the costs on taxpayers who are funding these services.

Not only will there likely be an increase in wait times for medical services, but doctors may also be paid less. Under a universalized healthcare system, doctors and other medical workers tend to have a decrease in salaries. Medicare for All is expected to significantly reduce wages for medicare workers. Sally Pipes researched and studied the Medicare for All bill, and determined that doctors are likely going to be paid 75% or less of what they were originally being paid by private insurance companies (‘Medicare for All Could Mean Doctors for None’). This is a very large reduction in salary, and will inevitably cause medical workers to be upset. When comparing doctor salaries in the U.S. to other countries with universalized healthcare systems, doctors are compensated significantly less than in the U.S. A study by the Commonwealth Fund reported that “American general practitioners earned a little more than $218,000 on average in 2016, compared with $146,000 in Canada and $134,000 in the U.K.” (qtd in Pipes). In countries that follow a similar plan to Medicare for All, in which health insurance is primarily run by the government, there is a significant decrease in doctor salaries. If the United States enacts the Medicare for All plan, there will likely be a significant decrease in doctor salaries, which will consequently lead to fewer doctors in the future.

A decrease in salaries may also discourage potential doctors from becoming doctors and eventually cause a doctor shortage. Under Medicare for All, the amount of people who will become doctors is likely to decrease, which could cause a shortage of doctors. This theory of Medicare for All decreasing the number of doctors available is supported by FTI consulting:

Literature review

Only a few studies have been carried out to determine the associated factors with the outcome of malnutrition and recovery time in adult HIV patients. As the researcher searched, there is no published literature on the time to nutritional recovery from malnutrition in adult HIV patients in Ethiopia.

2.1.1 Median recovery time

Few researchers struggled to determine the median time recovery from malnutrition in HIV patients in their recent study.

A study on Descriptive characteristics and health outcomes of supplementation in HIV patients was done to determine time to recovery from malnutrition and associated factors in Kenya. According to this study, patients gained greater than 20 BMI with a mean time of 100 days(26).

A retrospective cohort study in Kenya and Uganda also shows that Cured patients were discharged from the Nutritional supplementation Program after a median of 3.7 months (IQR 2.2-6.1)(21).

Similarly, a retrospective cohort study done in Ethiopia in a finite Selam hospital also determined the median time to recover from malnutrition. According to this study, participants had a median recovery time of 12 weeks (IQR 9-17 weeks) for moderate acute malnutrition and 25 weeks (IQR 22-31 weeks) for severe acute malnutrition(27).

Another study in Ethiopia concluded that patients who participated in the study recovered after a median time of 68 days (for moderate malnutrition) and 128 days for severe malnutrition(28).

2.1.2 Outcome of malnutrition in adult Hiv Patients

Reducing or eliminating malnutrition has the potential to significantly slow the progression of the disease, decrease its severity, and improve longevity. Early identification and treatment of undernutrition were found to be cost-effective. Additionally, patients who recovered through the addition of supplementary food experienced long-lasting positive effects on their health and nutrition status(28). In order to know the outcome of malnutrition in HIV patients after baseline diagnosis some scholar tried their best.

A study done in sub-Saharan Africa raveled that out of the 1106 patients admitted into the NP and discharged, 524 (47.4%) were considered cured according to the predefined NP exit Criterion (program success). From participants 149 (13.5%) discharged uncured, 250 (22.6%) defaulted from NP care, 132 (11.9%) died, 26 (2.4%) transferred to another programme, and 25 (2.3%) stopped RUTF due to treatment intolerance. The overall program failure rate was 48.0% (531 of 1106); if patients who transferred to another program or who stopped NP were also considered, the program failure rate was 52.6% (582 of 1106(21).

Similarly, a study done in Kenya suggested that 13.1% of clients attained a BMI of greater than 20 according to the criteria for discharge in Kenya. But 22.2% of participants gained a BMI of greater than 18.5 Participants gained an average weight of 2 kg(26).

A randomized control trial study was performed in Senegal in HIV patients in 2016. In this study, one group (case) was supplemented with 100 gm RUTF, and the control group with no supplementation. A study shows that a group with supplementation with 100 gm of RUTF for 3 months was significantly increased body weight; fat-free mass and fat mass(29).

A study done in Ethiopia in partnership with Tift`s University and save children suggested that 84.3% of participants were increased BMI among the intervention group, compared to 54.2% in the comparison group(28).

In Ethiopia in finite Selam hospital a retrospective cohort, the study was done in 2020 and revealed that 61.2% of malnourished patients recovered. An overall total of 146 of 376 (38.8%) patients did not recover from undernutrition, 58 (15.4%) of whom died(27).

In addition, another retrospective cohort study done in north Tigray in 2014 reported that 62.2% of patients enrolled in to ready to use therapeutic food recovered. According to the predefined RUTF exit criterion, 31 (5.9%) defaulted from the food therapy and 10 (1.9%) died(25).

A cross-sectional study done in Gonder in 2015 also shows the outcome of malnutrition in patients. According to this study, 24% of participants in the study were recovered from malnutrition from all participating patients in the study(30).

Another cross-sectional study on the retention and outcome of nutrition programs in HIV patients was done in Gonder Ethiopia in 2016. This study concluded that 44.2% of the patient`s recovered from malnutrition. The overall default cases were found to be 24.8 %(31).

A case-control study in Amara regional state in Ethiopia shows that around 40.6% of participant’s body mass index was improved( greater than 18.5)(32).

2.1.3 Associated factors of nutritional recovery

Different scholars in different countries including Ethiopia tried to examine predictors of recovery from malnutrition in adult HIV patients. Even though, they have found different associations; socio-demographic variables, the type of malnutrition, comorbid diseases, ART adherence level, WHO clinical stage, and type of facility were considered as associated factors in nutritional recovery(21,26,27,30,33).

2.1.3.1 Socio-demographic factors

Some studies have been done to determine the association between nutritional recovery and socio-demographic factors.

A retrospective cohort study done in sub-Saharan countries suggested that age and gender were the only significantly associated variables. Being female increased nutritional recovery by 57% when we compared to males. Also, the study concluded that as age increases nutritional recovery decreases(21).

Another retrospective cohort study done in Kenya in 2014 concluded that those younger ages had a greater chance of achieving of BMI greater than 20. Sex is also one of the associated factors for gaining a normal BMI after treatment and men`s had a higher chance of gaining a normal BMI compared to females(26).

A study done in north Ethiopia in Tigray revealed that sex and education was significantly associated with the outcome of undernutrition in HIV patients. Females were 2 times higher to recover than males following ready-to-use therapeutic food. Patients who were educated were 1.8 times higher to respond to therapeutic food than that illiterate one (25).

Sex was associated with recovery in HIV patients in a study done in Ethiopia. According to the study, females were 1.5 times more likely than males to recover(28).

Another retrospective study in finite Selam suggested that residence and educational status were independent factors for nutritional recovery for this study. Based on the finding it was found that participants with rural residences had a 47% lower probability of recovery when compared with urban. Also having an educational background increases recovery from malnutrition by 76%(27).

A study in northwest Ethiopia shows that males have a better chance of BMI improvement than females. The odds of BMI improvement of males is nearly 2 times as compared with the chance of BMI improvement of females(32).

A case-control study in Gonder hospital revealed that from participants in the study males were 1.58 times more likely not to recover than females. Another cross-sectional study in this area suggested that age was significantly associated with the outcome of malnutrition in HIV patients. According to the study as age increases, it`s difficult to recover from malnutrition so recovery decreases(30).

2.1.3.2 Type of malnutrition and nutritional recovery

Studies show, as there is a significant association between the type of malnutrition and recovery from malnutrition. Moderate malnutrition and severe malnutrition have different median times besides of proportion of the patient recovery.

For instance, a longitudinal study in a sub-Saharan country revealed that the type of malnutrition was significantly associated with recovery from malnutrition in HIV patients. According to this study, those patients who were severely malnourished patients had 2.2 times less likely to recover when compared to moderately malnourished HIV patients(21).

A retrospective cohort study in North West Ethiopia in 2014 suggested that patients with moderate malnutrition have a better chance of 7 times more to recover from malnutrition than that of severely malnourished patients(32).

In a study was done in Gonder northern Ethiopia, types of, malnutrition at baseline was associated with the outcome of treatment in HIV patients. This study revealed that those participants who are moderately malnourished at baseline were 4 times higher for recovery as compared with those severely malnourished(30).

Types of malnutrition are also predictors in case-control studies in Ethiopia in 2019. According to the study, those who were diagnosed to have SAM at baseline were 4.5 times more likely not to respond to therapeutic food than patients who had a diagnosis of mild malnutrition(34).

A cross-sectional study in Gonder shows that types of malnutrition was significantly associated with the outcome of malnutrition in HIV patients. This study concluded that those patients with SAM has 0.2 less likely to recover from malnutrition compared to those patients with MAM(30).

However, a retrospective cohort study on nutritional recovery and associated factors in adult malnourished HIV patients concluded that types of malnutrition was not associated with recovery from malnutrition(27).

2.1.3.3 Who staging and recovery

Advanced disease in HIV has an association with the outcome of malnutrition in HIV patients. Some studies show this in their findings.WHO staging is significantly associated in some research, which can affect the time to recovery and proportion of recovery from malnutrition in patients living with HIV.

Some study shows evidence of an association between who staging and recovery. For instance, a study done in Ethiopia in finite selam suggested that the probability of nutritional recovery was 62% lower for participants who were WHO clinical stage III or IV at baseline as compared with those who were stage I or II(27).

Also, a case-control study in Gonder suggested that WHO staging were significantly associated with nutritional recovery. So this study revealed that those patients who were in who clinical stage 3 were 3.63 times less likely to not recover from malnutrition when compared to another clinical staging(34).

However, a cross-sectional study on the outcome of treatment in Gonder hospital did not show any association between who staging and nutritional recovery(30).

A retrospective cohort study in Mekelle found that an association between WHO clinical staging and recovery. Participants who were in WHO clinical stage 1 and 2 had four times more likely to recover than patients in WHO stage 3 and 4(25).

2.1.3.4 OTHER clinical-related factors and nutritional recovery

Some clinical-related factors are significantly associated with nutritional recovery in some studies. Even though different factors were associated with recovery in different studies but adherence, CD4 count, and co-morbid conditions like pneumonia, diarrhea, and mouth ulcer were significantly associated with the outcome.

A case-control study in Ethiopia concluded that those patients who adhered to supplementation were 11 times more likely to achieve normal BMI. Also, this study suggested that patients with good adherence to ART had 2 times more chance to regain normal BMI when compared to poor adherence(34).

Another retrospective cohort study in Ethiopia concluded that the probability of nutritional recovery was 86% lower for participants who had poor ART adherence compared with those who had a good adherence level (27).

A case-control study in Gonder suggested that those who had a CD4 count below 100 were 2.3 times less likely to recover than that had a CD4 count above 350(34).

Similarly, another cross-sectional study was done in Gonder concluded that participants who had opportunistic infections like diarrhea, mouth ulceroral thrush, pneumonia, meningitis and CNS toxoplasmosis were less likely to recover as compared with those who are severely malnourished at entry(30).

A study done in Ethiopia suggested that ART status at baseline was significantly associated with recovery from malnutrition. This study concluded that participants who were on ART for less than six months at baseline were 2 times more likely to recover than those who were not on ART at baseline. While there was no significant difference in the likelihood of recovery between those who were on ART for more than six months and those who were not on ART. This study also revealed that a CD4 count between 200 and 350 at baseline was associated with an increased likelihood of recovery 1.7 times compared to a CD4 count of less than 200. There was no significant difference in the recovery of CD4 between those with CD4 counts above 350 versus those with CD4 counts less than 200(28)

This is a short fictional story about life on the planet Venus where it rains continuously day in day out. The sun disappeared five years ago, and the children are anticipating seeing the sun. The nine-year-old children do no really remember how the sun looked like because they were still too young. The scientists had predicted that the sun was going to come out after all those years but only for a brief moment. These children carry out a lot of activities in school that are related to the sun like poems.

Margot is one of the children, but she lived on the planet earth for five years. Therefore she has a lot of memories about the sun. She writes a poem about the sun and tries to explain the sun to the children, but they mock her instead. She refuses to participate in any activity that does not involve the sun; she sits staring at the window. She appears depressed, and rumors have it that her parents intend to send her back to Earth. The other children are upset with her because she is different. They seized and overpowered her then locked her in a closet. The teacher came back, and the children exited through the tunnel leaving Margot behind. Soon afterward the sun appears, and the children run around enjoying the sun.

Then one of the girls starts crying, in her hand, there is a significant raindrop. The sun disappears, and the rain falls harder. The children stop for a while reflecting on how they had enjoyed the past hour. They re-enter the tunnel heading back to their class. One of the children cries out recalling that Margot was still in the closet. She had been in the closet the entire time that the sun was out. Embarrassed, they let her out, and she slowly emerges from the cabinet.

In the last answer, a short fictional story by Isaac Asimov, Murray Templeton who is an atheist physicist dies of a heart attack. The human mind then finds itself existing as an electromagnetic nexus. He meets the Voice, a being of infinite knowledge who has similar characteristics to God. The human brain decides that such an existence is pointless and vain so it looks for ways to destroy itself. The nearly omnipotent being explained to him that such an attempt would be futile as the omnipotent being would reinstate him as a new. The story attempts to account for the essence of God and how he relates to man.

In Ponies a short story by Kij Johnson, Barbara has a pony with wings and a horn just like every other girl but to be friends with the other girls, she has to give up something. She has to cut off the wings of her pony. The story creates a metaphor about children who go to great lengths to fit in with the rest. People who would do something they do not want to do because that is what other people want.

These stories use science fiction and fantasy to relay their message. Bradbury made Margot experience bullying showing the resemblance to society today. Margot was different from the rest of the children because of her many experiences in the sun that she misses causing her to be depressed. This emphasizes that individuality due to a person’s knowledge or even opinion encounters discrimination like in the case of Margot. Society should aim to accept individuals and not oppress them because of different views.

Works cited

1. Bradbury, Ray. All Summer in a Day. The magazine of Fantasy and Science Fiction, 1954.
2. Asimov, Isaac. The Last Answer. Analog Science Fiction and Fact, 1980.
3. Johnson, Kij. Ponies. Tor.com, 2010

Introduction

Background

In the recent decades the subsistence of refugee crisis has been on the rise. The problem of asylum seekers has become a major global humanitarian issue. This in turn has led to the issue of refugee asylum and repatriation becoming an issue of public interest and also of major political significance. This has led to major criticism made against local laws, international laws and conventions with regards to the upholding of refugee asylum rights and repatriation. This in advent has led to proliferation of various policies and legislations designed to deal with asylum seekers such as article 14(1) of the Universal Declaration of Human Rights (UDHR), which was adopted in 1948. It guarantees the right to seek and enjoy asylum in other countries. Very few countries can efficiently claim to have a substantive governing administration that is flexible and accommodating to uphold asylum rights.

The objectives of this study is to evaluate on the right of asylum in regards to refugees, similarly to evaluate on the legislative provisions dictating on the right. The study also focuses on the determination of the progress of refugee asylum rights with the dynamic and ever advancing field which sets precedents in determining cases. The study also seeks to extensively evaluate on the repatriation process and how it relates to asylum seekers. This is in advent in scenarios whereby the legal question of suitability of repatriation over grant or expiration of asylum arises. The outcome of the research would be based on the assessment and implementation of the right to asylum and repatriation and their effectiveness.

Statement of the Problem

One major basis posing a tough legal question on both asylum status and repatriation is the principle of non-refoulement. In most cases where host states offer temporary protection it is rather meant to be on a temporary basis. The legal question being posed is when such states and under what circumstances it is acceptable and morally acceptable for host states to return those granted asylum by the state. Another legal question being posed is what circumstances have to exist in the country or origin? Can people be returned to any safe place in their country of origin or must they be able to return to the homes or at least the communities in which they lived prior to flight?

On the matter of handling combatants, what would be the most humanitarian basis of host states when the populations they seek to protect in refugee camps include combatants or war criminals? Is it inhumane not to grant such person’s asylum or would the host country risk the safety of its citizens at the expense of hosting them?

Another tough legal problem is identifying those in need of international protection and those who are not is a problematic issue. For many refugees seeking an asylum status in most cases the line between forced and voluntary international migration is increasingly blurred. In most scenarios their migration is driven by an array of overlapping factors at play relating to looming poverty, inequality, environmental degradation and the effects of climate change, as well as pull factors such as real and perceived economic and educational opportunities in other countries.

The purpose of the study is to gauge the extent of fairness in asylum cases. This is through the dictation of international refugee law statutes similarly to the provisions of humanitarian law and local laws as per given jurisdictions. Another purpose of the study is to showcase precedents set out in cases and also through legal scholars’ determinations on those seeking asylum and repatriation cases eventually. The study is also to showcase the plight of asylum seekers the hardships and hostilities they go through, the loopholes in the laws meant to cater for their quests and the various human rights violations surrounding failure to be granted asylum and also forceful repatriation of refugees. The study also purposely outlines the various laws and guidelines surrounding the field of the right to asylum and repatriation of refugees.

Significance of the Study

The study identifies key areas in the field of asylum and repatriation which contain loopholes preventing the legal enjoyment of the right to asylum and forceful repatriation of refugees from host states without a fair hearing and determination. The study also is meant to give recommendations on the solutions for such loopholes. It also identifies the legal process of acquiring asylum and also dictating the legal process of repatriation and exceptional cases where asylum can be denied and repatriation can be forceful and without the required consent of the victim. The study also showcases the strides made forth in refugee asylum law and repatriation and the precedents set in place for the future determination of such cases.

Literature Review

This book focuses on various factors of asylum seekers such as dimensional protection. Under this it states that the two major justification for more vigilant border controls relates to the financial costa of immigration and the preservation of identity inclusive of the cultural jurisdiction of the state and the security of the national community. In considering the realization of the right to seek and enjoy asylum, advocates of more generous admission policies must seek to overcome these justifications. The book also gives various normative argument towards the enhanced protection of asylum seekers. It gives a view that the universal and individualized approach of the Refugee convention has long been under threat with most states questioning its relevance in the current modern era while others argue on the basis of refugee protection in their regions of origin. In terms of liberalists’ case for permissive entry, they argue that borders are just arbitrary constructs which should be done away with to generally enable entry for all. The book gives a way forward to refugee asylum seekers protection by stating that in order to navigate these contrasting positions we need to distinguish the right to asylum from the broader issues of immigration and migration control. This crucial to fully appreciate humanitarian obligations especially in times of economic restrains when resource arguments are deployed to restrict general immigration.

This book focuses on the African Charter on Hyman and People’s rights based on the protection of the right to seek and obtain asylum. The study builds on the providing of additional dimensions towards the protection of refugees in Africa. The study takes it perspective based on human rights and other applicable laws drawn from the International Covenant on civi and political rights and the Convention Against Torture. The study outlines the background to the evolution of refugee protection. The study also outlines the application of relevant aspects of international law relating to the African charter. The major basis of this aspect as shown in the book is to showcase the basics of the system of law in various states and the obligation of such states to incorporate and implement the charter in their national laws. It also establishes the relationship between human rights and refugees especially asylum seekers in order to establish the basis for the application of human rights in the context of refugee protection. The book also gives a glimpse on the procedures by which refugees may exercise the right of individual protection before the court or the African commission. In addition to this it shows cases procedural and practical difficulties that should be tackled and borne in mind when doing so.

The book poses the question that if not now when are we going to revise the existing laws for the protection of the mounting number of refugees, asylum seekers and displaced persons? The study states that one common and most obvious thread leading to this mass exodus is the fact that there exists total disinterest on the part of both states and international regulatory bodies in producing any efforts to give reason to the causes of such causes or to give the refugees more desirable conditions in their country of origin. The author also states that another common thread is the fact that the only applicable legal regime basically the Convention on the status of refugees and the related 1967 protocol are rather inadequate to deal with both the quantity and quality of asylum seekers. It also gives rise to the basic question of the status of the principle supporting closed borders and relative policies dealing with exclusion and conditional admittance into state territories. It is also for a fact that the result of increasing number of asylum seekers prompts government of the receiving countries to do all in their power legally or not, to repel asylum seekers before they reach their borders.

The book also brings out to light the use of the so-called ‘Safe Third Country’ agreement which permits the use of unprecedented policies and means to return an asylum seeker from one country to the other.

The books form its basis on the fact that permanent resettlement is a rare solution to refugee crises. Repatriation of a refugees back to their country of origin is no longer an option but an imperative. This forms the only alternative to the consequences of protracted displacement. The book raises questions such as: What can refugees ultimately expect after returning to their former states of origin? What are the conditions of a legitimate and just return process? Who is obliged to ensure that such conditions are met? The book also majorly focuses on the responsibility’s states of origin bear towards their repatriating citizens and articulating a minimum account of a just return process. The author in her own opinion claims that the goal of a just return process must be to put returnees back on equal footing with their non- displaced co nationals by renewing a new relationship of rights and duties between the state and its returning citizens. It is argued that remedies such as property restitution, compensation and truth commissions play a critical role in creating the conditions of a just return as it is through such redress that the state of origin may re-establish its legitimacy by acknowledging and trying to make strides to make good on the duties it failed to upholding by forcing its citizens into exile.

The Right to Asylum

The growth of totalitarian states has increased adversely the frequency within which governments are requested to provide refuge. This has led to fresh emerging considerations of whether the right to asylum is an automatic right vested in an individual or faith-based matter vested in the government of the refuge state. The right to asylum is contained in Article 14 of the United Nations Universal declaration of human rights which states that everyone has the right to seek and enjoy in other countries asylum from persecution. This right may not be invoked in the case of prosecutions genuinely arising from non-political crimes or from acts contrary to the purposes and principles. Legal practitioners and critics put forth an argument that entry and residence for an asylum seeker cannot be denied however courts and other related tribunals have in the past discredited this belief and cast a doubt on whether there is a true existence of a right.

Hohfield a legal scholar in 1913 laid down a definitive answer towards the right stating that right is to be understood in relation to its mural correlative, a duty. A right exists if a duty is placed on another that can be enforced by the holder of the former. In relation to the traditional scenarios, it was evident that a refugee’s right to asylum was dependent on the existent obligations if any of the state of refuge and its power of enforcement. This consequently meant that an individual trying to enter a sovereign State of which he/she is not a national in practice, can be denied entry because the State would be under no duty to grant admission. In some scenarios whereby the refugee is granted entry it would be a matter of grace and the individual would be the holder of a mere revocable privilege which is nevertheless unenforceable against the refuge State. The stated scenarios were the traditional processes towards the refugee attainment of asylum. With the recent review in policies regarding the right to asylum, a qualified refugee has the right to enter a State in search of asylum and such a State would be under an obligatory duty to grant asylum.

The traditional approach to the right to refugee asylum

In the olden times there was no right to asylum. The state of refugee exercised complete discretion as to whether to grant a refugee ana asylum status or to decline. With regards to the approach used during the olden context a refugee could not file a complaint if he/she was a deserving case. In advent, such a refugee was repatriated back to face persecution. The traditional approach is based on the principle of State sovereignty. It is grounded on the fact that a country can exercise their sovereign right by denying one entry.

According to the author of the book titled ‘Reflections upon the Political Offence in International Practice’ he states that States view the right to asylum as rather permissive. This is with view that the state is the only subject to international law. This in turn meant that f international law. If only a State is subject to international law, then the right to asylum in international law to asylum cannot be claimed by an individual. In the context whereby there are also conventions existent guaranteeing the right to asylum, this does not automatically grant such rights directly to individuals but establishes mutual obligations on States to grant such rights to the individuals. In the event of breach of such obligations no rights is granted to the refugees but the refuge state will be liable to other States partied to the convention.

In the case of Ker vs. Illinois in supporting the above view, it was stated that the right of the Government of Peru to voluntarily give Ker and his conditions an asylum in that country would be quite a different thing from the right to demand and insist upon security in asylum. The view was also restated in the case of Chandler vs. United States in which it was stated that ‘it has long been the practice of States to give asylum but the right belongs to the State to voluntarily offer asylum and not that of the fugitive to insist upon it’.

Interpretation of the right to asylum

The right to seek and to enjoy asylum from persecution in countries of origin can be traced backed to the right of sanctuary during the ancient Greek era, early Christian civilization and imperial Rome. In modern civilization it is recorded and addressed by States in Article 14 of the UDHR. It is based on the principles of State sovereignty whereby the right to grant asylum remains a right of the state. The 1967 convention on the Declaration on Territorial Asylum states that the granting of an asylum is an exercise of the refuge state however reaffirms that the discretion of such States should be interpreted hand in hand with Article 3(1) which states that no person shall be subjected to such measures as rejection at the frontier if he/she has already entered the territory in he/she is in search of asylum. Granting asylum in this sense is a lawful exercise of territorial sovereignty, not to be regarded by any State as an unfriendly act.

Some scholars argue that States do not have a completely free hand in deciding whom to admit with regard to refugees. This was further elaborated the 1951 convention. The 1951 convention reinforced the inclusion of a specific prohibition on refoulement including the state of non- rejection at the frontier. Articles 1 and 33 read together place a duty on States parties to grant, at a minimum, access to asylum procedures for the purpose of refugee status determination. The free access to asylum determination procedures are one of the rights dictated by the 1951 Convention and is an accepted state practice. Without adherence to total asylum procedures, obligations towards non refoulment including the rejection at the frontier the asylum seekers rights could be infringed.

Literature review is done at the beginning of the research project to enable the researcher to identify what is already known about the chosen area of interest so they do not replicate the work that has already been done by other researchers. This required the researcher to read around the immediate topic of the research to broaden their knowledge and understanding of what is missing. It also narrows down the topic and highlights the important parts that should be focused on new research. Literature review has four different stages which are extraction of information, interpretation, analysis and synthesis.

Extracting information requires the researcher to skim and scan for preliminary judgement on the relevance of the information. It also identifies key words to look out for or to use during new research. Interpretation helps the researcher understand what the source is talking about and it also questions the reasons of publication of the presented interpretation. This stage also helps the researcher to identify links between the research topic and the researcher’s purpose.

Analysis

At this stage of literature review, the researchers scrutinise the text to look for any arguments proposed by the authors and they look for valid and reliable evidence that back up those arguments. They also look at their own work and compare it to the one they are analysing to see the differences and similarities . During analysis, the researcher looks at the participants group, the methods used and the objectivity of the data.

Synthesis

Synthesis is a method of developing a different argument or point of view based on the gaps highlighted by the preceding analysis. Once each source in the literature search has been critically analysed, the researcher will have a different perspective on the research topic and will be able to identify more clearly how much more research can bring new knowledge and understanding. This will then give the researcher the opportunity to formulate a hypothesis and allow them to plan their project. A researcher might want to do further research in the Ebola outbreak- there is research that has been done already so it is essential to do literature review to have a deeper understanding of what he or she really want to find out in their research and what has been found already.

Websites allow researchers to access important reports as well as government documents that you wouldn’t normally just find anywhere in libraries or book shops. There is a lot of different useful information on the internet and websites which makes it easy to get a hold of it.

Journals are specialist publications published at regular intervals for specialist groups such as professionals, scientists and other researchers. The publication of research is an important aspect of the research project. Some online journals have to be subscribed to in order to access the information, however, the government funds most of the journals needed for research. There are also E-resources such as online newspapers and eBooks which provide information useful for research.

Social science research uses books, mostly to get information whereas scientific research depends on published journals. Recent textbooks have greater credibility than books published a few years ago as they contain older information. For example, books that have information on policies, they regularly change which means more new books are needed with the updated information. However, when referring to theories, older books have more credibility as they were written by the actual theorist who experienced it at first hand – which means they have more validity and authentic.

Data

In research, the data is almost always presented in the form of graphs, tables and statistics. Tables enable data to be viewed systematically without having to read a lot of text. They are frequently used to present quantitative data but can also be used to conclude qualitative information which makes it easier to check for clarity in responses. graphs and charts are another form of visually representing qualitative data; they make the interpretation of the data easier as it enables large quantities of data to be presented in a manageable format.

Demographic statistics

Demographic statistics gathered by government agencies, local authorities and health trusts are useful for comparison with data collected in the researcher’s project. The Ofice for National Statistics also known as ONS publishes different demographic statistics which are grouped under health, social care and education. They also present comparisons with similar data from earlier researches. Statistical information may be presented in various formats such as tables, graphs and charts. This is easier to see and interpret it. This research method is useful when looking where the money in health and social care is spent, also it can help with identifying how many people are living with undiagnosed illnesses.

In our daily life, troubles always occur, many people always trapped by an abundant problem. But we do not seem to be aware of how others are feeling of being trapped. In the reading ‘Sociological Imagination’ by C. Wright Mills, it introduces what sociological imagination is and how personal trouble is related to the whole society.

In the reading, C. Wright Mills mentions that sociological imagination is a way to engage the world. By using this approach, people need to think sociologically and to relate private troubles to public issues or seeing the general in the particular. It is said that ordinary men do not usually realize that they are having a close connection with the society. People used to relate their circumstances with their own business like their personality, their background. Apart from demonstrating the relationship between society and human beings, the benefits of using sociological imagination are posed. C. wright Mills claims that ‘The sociological imagination enables us to grasp history and biography and the relations between the two within society’, by grabbing the relevance between individuals and society, people are enabled to understand the larger historical scene, changing the individuals’ uneasiness towards obvious troubles and the indifference of public, to the involvement with public issues. As a result, people can not only change their own life but also change the process of history and society. Moreover, the reading has shown how the lives of individuals are being shaped and reshaped by broader social change. There are 4 examples in unemployment, marriage, war and metropolis 4 areas given in the reading, to support the idea. The reading encourages us to think ‘out of box’, to see different problems from different perspectives, to link the private troubles with a great variety of milieux, as well as the social structure.

After reading the ‘Sociological Imagination’, I understand that we can see our society in our everyday lives. This approach is also applicable in Hong Kong, and I would like to illustrate an example of it, which is the problem of elderly poverty.

I have observed that there is a granny whose outfit is worn-out, always come to my parents’ store with a trolley. She is not a customer who will buy something but is a collector who ask for waste boxes, newspapers, and other scrap. No matter when, weekdays or weekends, I can see her trace. But why she has to do this? She may earn a few dollars, or a maximum of $40-$60 a day by selling cardboard boxes to recyclers. This ‘job’ is not only exhausting but also time-consuming, they need to collect so many cardboard as these materials are not very valuable, about $2/kg.

One elderly collecting cardboard to earn money is his/her personal trouble, s/he is so poor that s/he has to do this to make a living. However, it is not the only case in Hong Kong. We can see that the problem of elderly poverty exists in Hong Kong.

In Hong Kong, 1.39 million people are living the poverty line (Government of the Hong Kong Special Administration Region, Hong Kong Poverty Situation Report, 2017) and one out of the three elderly Hongkongers aging 65 years old or above is living in poverty (Ngo, 2015). According to the official figures (HKSAR, Hong Kong Poverty Situation Report, 2017), the poverty rate of elders aged 65 or above is 44.4% (495000), even though there is intervention made by the government, the poverty rate is still very high, about 30.5% while the poverty line is set at a monthly income of $3800.The reasons behind this social phenomenon are mainly the less job opportunity to the elderly, the change of family structure and insufficient support by the government.

Elderly poverty problem aroused by the lack of job opportunities for the old people. Elders are to some extent being discriminated against in the job market. Many employers, especially in the private sector, refuse the elderly’s application by using the excuse that the retirement age is 60 (‘Hong Kong’s job market has no room for the elderly’, 2018). Having the stereotype that the generation gap may affect the office’s harmony and lower the efficiency, may lower the possibility of the elderly being hired even though some of them are talented. Besides the stereotype, the higher the labor insurance may hold the employers back from hiring the seniors because the more responsibility employers need to bear, the more unwillingness they have towards hiring the elderly. Moreover, the limited job opportunities provided to the elders are mostly with low payment, which may not ease the problem of poverty.

For the change of family structure in society, it relates to the problem as well. The formation of the society has been changed from a larger scale of family to a nuclear family because of different factors in the society. This structure leads to many people having one to two children, or even no kids, and worsens the problem of elderly poverty as well. The elderly may not have someone to take care of them, or their lives may not be fully supported by their child because their child may not be able to bear the sole financial burden on their own.

Last but not least, the lack of government support. As Hong Kong is a liberal city, it has a free market and the tax rate imposed by the government is not high, at a maximum of 15% (‘GovHK: Tax Rates of Salaries Tax & Personal Assessment’, 2019). Thus, there is limited welfare provided by the government. Take ‘fruit money’, the Old Age Allowance as an example, the elders are given a monthly payment of $2600 (HKSAR, ‘Social Security’), however, this subsidy helps a little and it is not enough for the elderly to ‘survive’.

By applying the approach of sociological imagination, we can see that an elderly being poor may not be his/her personal trouble, it can be related to society. Because of different social factors, the problem of elderly poverty occurs and many senior people have difficulties in maintaining daily life. Thus, in solving or easing the problem, we can not just consider the personal situation, we should consider the structure of a society as well. After reading ‘Sociological Imagination’, I realized that private troubles and public issues can have a tight relation. By using sociological imagination in the daily life, I can be more aware of the relationship between personal experience and the wider society, to face my own trouble and the public issue in a new way other thinking individually. In my opinion, lack of sociological imagination can make one indifferent, however, with this approach, people can make decision with self-awareness, but not being dominated by the social norms. Sociological imagination can make one more considerate too, as it helps one to be more sensitive towards different issues, to think deeply in different things, not just ‘judging a book by its cover’.

Within this essay I will be summarizing what C. Wright Mills means by ‘The Sociological Imagination’ and why it is necessary for individuals to possess it.

Within chapter 1 the author explores the plight of individuals and explains that individual troubles are usually linked to public issues and that often the problems that an individual experiences are derived from structural issues with society. For example, an individual problem in the modern world could be a person’s declining mental health, however when we look more broadly at this we can see that it is more of a public issue given the epidemic of poor mental health. Therefore, we must look at society’s role in causing this, this could be from a number of structural issues such as lack of funding for mental health services and a culture with a focus on overworking to the point of burn out. The sociological imagination therefore must be used to look past the issues of an individual to see the root of society’s problems and therefore how we can improve it as a collective.

Mills believes that individuals are unaware and therefore ‘trapped’ by a poor understanding of how society works as they are caught up in their own lives, rarely looking out with their own social environment to see that their individual accomplishments and failures are often directly linked to changes within society. Individuals therefore cannot grasp the idea that the history of society has an influence on how they live their own lives and that they too must be able to influence society as a result of this link.

For an individual to truly understand the society in which they live Mills believes that they must develop the sociological imagination, which is a method of questioning the way society works and discovering the reason that issues have come to be in the first place. This is done by looking through what could be described as a lens that allows the user to gather information and critically analyze a range of societal influences and therefore gain a deeper understanding of why things happen within society.

To conclude, Mills aims to show that by using the sociological imagination individuals are able to understand that ‘history and biography’ are in fact linked, which therefore allows them to see the connections between seemingly minute personal issues and how the bigger picture in society as a whole has influenced them. It allowed for people to gain a greater understanding of where they sit within society and therefore the role they play in comparison to others.

The present study conducted is partly a replication of a study ‘Gender differences in self-esteem and happiness among University students’ carried out by Malik and Sadia (2013). The findings of the study carried out by Malik and Sadia (2013) were as follows: males had significantly higher levels of self-esteem than females; insignificant differences were found between males and females for happiness; a positive relationship was found between self-esteem and happiness.

Moreover, the purpose of the current study is to explore gender differences between happiness and the relationship between self-esteem and happiness. Happiness is a feeling where an individual feels satisfied with their life and experience and feels more positive emotions in day-to-day life (Kesebir and Diener, 2008). A happy person is always cheerful and satisfied with his or her life (Lucas & Diener, 2000). Three important components are suggested to be facets of happiness: a higher level of life satisfaction, higher levels of positive affect (positive feelings and emotions), and little or no negative affect (negative emotions and feelings) (Myers & Diener, 1995; Hill & Argyle, 2002; Lucas, Diener, & Suh, 1996).

Several studies have found that external factors, such as physical health, income, education, job and close relationships, marital status, gender, and age do not have a lasting effect on happiness or influence happiness (Lyubomirsky, King & Diener, 2005; Diener, Oishi, & Lucas, 2003). In contrast, it is the internal factors, such as self-esteem and personality traits that influence one’s happiness and have an enduring effect on one’s long-term happiness (Lykken & Tellegen, 1996). Thus, happiness comes from inside (internal factors) rather than outside (external factors).

Moreover, a study by Khodarahimi (2013), included 200 Iranian adolescents and 200 young adults, which included males and females. The study found that males had significantly higher levels of happiness than females regardless of age. Several studies suggest that gender is associated with subjective well-being and many studies have found that women have higher levels of happiness compared to men (Wood, Rhades, Whelan, 1989; Koker, 1991; Zweig, 2014). For example, the study, which included 600 Taiwan Chinese people found that women scored significantly higher compared to men on the measures of happiness (Lu, Shih, Lin, Ju, 1997). Similar findings were also reported in other studies of happiness, which suggests that this is true cross-culturally (Shmotkin, 1990; Katja, Paivi, Marja-Terttu, Pekka, 2002; Meliha, 2006).

However, women have been found to score higher on the measures of depression and neuroticism than men (Cheng, Furnham, 2001). For instance, Mirowsky & Ross (1995) found that women experienced 30% more distress than men and often expressed negative emotions freely compared to men. The study by Fujita, Diener, and Sandvik (1991) found that even when women were as happy as men they reported experiencing more depression than men.

Another key element in our study is self-esteem. Self-esteem means having a positive view of oneself and appreciating yourself (own appearance beliefs, views, opinions, emotions, and behavior), so have high self-worth and self-respect (Lyubomirsky, Tkach and DiMatteo, 2006). The study by Redenbach (1991) found that Self-esteem is positively correlated with happiness, success at the workplace, and accomplishments in school and college. Self-esteem also has a positive correlation with health and a better quality of life (Evans, 1997).

Moreover, a high level of self-esteem is associated with higher levels of happiness and lower levels of emotional distress (Brown, Dutton, & Cook, 2001). Individuals who have high self-esteem are confident about themselves, can make new friends, and cope with problems in life, and therefore they are contented (happy) and have a higher level of satisfaction with their lives (Brown & Marshall, 2001; Katz, 1998). In contrast, to these findings, individuals with low self-esteem have negative thoughts for themselves, which causes them to experience negative feelings, such as anxiety and sadness. They are not very sociable and are not open to experiences, so they avoid taking risks in life or trying anything new as they think that they might fail or be unsuccessful (Baumeister, Campbell, Krueger, and Vohs, 2003; Croker & Park, 2004). Thus, self-esteem is vital to happiness.

Many of the studies have reported that males have a high level of self-esteem compared to females. This difference in self-esteem between males and females begins in adolescence and continues during early and middle adulthood and this difference decreases to a lower extent in old age (Kling, Hyde, Showers & Buswell,1999; Zeigler-Hill, & Myers, 2012; Robins, Trzesniewski, Tracy, Gosling & Potter, 2002). However, the studies also report that both genders have similar journeys for self-esteem. So, both genders have high self-esteem during childhood, which decreases during adolescence and then increases again in adulthood before it disappears in old age. (Wagner, Gerstorf, Hoppmann, & Luszcz, 2013; Orth & Robins, 2014; Robins & Trzesniewski, 2005).

Furthermore, research findings suggest that individuals with high self-esteem are mentally happy and healthy, whereas those with low self-esteem are psychologically depressed and miserable (Abdel-Khalek, 2016). Individuals with high self-esteem are more likely to feel positive about themselves, they are better able to cope with challenges in life and negative feedback from people and have positive perceptions about people and the world (believe that everyone values and respects them) (Stavropoulos, Lazaratou, Marini and Dikeos, 2015).

In contrast, individuals who have low self-esteem have a very negative perception of themselves and the world. The study by Mackinnon (2015) found that low self-esteem is associated with depression, feelings of loneliness, shyness, and psychological distress. Thus, self-esteem affects the way individuals feel about themselves and low self-esteem can cause individuals to be unhappy in life. Thus, high self-esteem is vital for the feeling of happiness.

Furthermore, research has found that self-esteem is an important factor for emotional well-being (Baumeister et al, 2003). Research has found that individuals with higher levels of self-esteem experience more feelings of motivation, happiness, and optimism compared to those with lower levels of self-esteem and they also tend to experience less anxiety, depression, and negative moods (Abdel-Khalek, 2016). This implies that self-esteem is a very important factor for mental well-being.

Many other pieces of research had similar findings where self-esteem was positively correlated with satisfaction in life, hope, happiness, and loving relationships (Abdel-Khalek, 2016). Individuals with high self-esteem are more likely to cope with difficult tasks than individuals who have lower levels of self-esteem (Baumeister et al, 2003). Individuals with high self-esteem are stronger to face changes in life compared to low self-esteem (Stavropoulos et al 2015). Thus, a high level of self-esteem gives an ability to cope with challenges, handle unpleasant situations, and manage relationships with love.

High self-esteem has also been found to positively moderate depressive symptoms when one is facing negative life events (Stavropoulos et al 2015). Some studies have also found that individuals with high self-esteem are more persistent compared to low self-esteem individuals when they are facing failure in life (Di Paula and Campbell, 2002). Low self-esteem is also associated with higher levels of aggression, being less competent to cope with difficulties in life, depression, and decreased level of well-being (Stavropoulos et al, 2015).

In the study ‘Gender differences in self-esteem and happiness among University students’ by Malik and Sadia (2013) they used the Rosenberg Self-esteem scale (Rosenberg, 1965) to measure self-esteem in university students and they were successful in finding significant differences in self-esteem between males and females and it was also positively associated happiness, therefore, we will use the same scale in the present study.

However, in the present study, we have not used the Oxford Happiness questionnaire (Hills and Argyle, 2002) to measure happiness in our participants as in the study ‘Gender differences in self-esteem and happiness among University students’ insignificant differences were found between male and female for happiness. In the present study, we will use the PANAS scale (Watson, Clark, & Tellegen, 1988), which measures positive affect (positive emotions and feelings) and negative affect (negative emotions and feelings), and the Life satisfaction scale (Diener, Emmons, Larsen & Griffin, 1985). This is because evidence from the studies above implies that an individual who has a high level of satisfaction with their life, and who experiences a greater positive affect (experience positive emotions and feelings) and less negative affect (negative emotions and feelings) will have a high level of happiness as they have a high level of subjective wellbeing.

The hypothesis of the present study is:

• Males will score significantly higher than females on self-esteem. H₀: There will be no significant difference between males’ and females scores on self-esteem. Any difference is due to chance.
• There will be a significant positive relationship between self-esteem and happiness (subjective well-being). H₀: There will be no significant positive relationship between self-esteem and happiness. Any difference is due to chance. This implies that the higher the scores on self-esteem, the higher the scores on life satisfaction. The higher the scores on self-esteem, lower the scores on negative affect (and higher scores on positive affect) on the PANAS scale.
• There will be a significant difference in the level of happiness between males and females. H₀: There will be no significant difference in the level of happiness between males and females. Any difference is due to chance.

Schizophrenia

Schizophrenia is classified to be a severe psychiatric disorder that affects individuals’ social life and personal. The origin of the word itself Schizophrenia— meaning “split mind” in Greek—first appeared in 1908 by the Swiss psychiatrist Eugen Bleuler (Barnet, 2018). This disorder presents itself in three types of symptoms which can be psychotic symptoms, negative symptoms, and cognitive impairment. Psychotic symptoms can present delusions and hallucinations which is the inability to connect with reality. Other symptoms related to this order are, negative symptoms decreased motivation, impaired speech, social withdrawal, and cognitive impairment which is the lack of performance that controls a variety of cognitive functions. ( Owen, Sawa, & Mortensen, 2016). The psychotic symptoms tend to be more frequent and more long-term than the other symptoms. By late adolescence, or even in early adulthood many have experienced their first episode that is followed by a prodromal phase. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM 5), schizophrenia presents itself with the state of psychosis, psychoses features can be associated with schizophrenia but have different types of psychoses associated with bipolar disorder that include psychotic episodes including major depressive disorder also including psychotic episodes ( Owen et al., 2016). Each individual’s diagnosis varies taking into consideration the number of times episodes have been encountered also if there has been any sign of substance abuse and if there were any indications of depression or mania. With some evidence of the progression of the disorder during the early stages in the left hemisphere and the superior temporal structures more than any other part of the cortex ( Vita, Barlati, Peri, Desde, & Sacchetti, 2016). As the disorder progresses into more severe stages with the degree of progression with the frequency occurrence of episodes and including antipsychotics that are prescribed.

This literature review scrutinizes the research that includes treatment in sex differences of schizophrenia itself including symptoms, and treatments. My focus is on the symptoms and treatment plan that impaired individuals with schizophrenia according to a treatment plan that follows according to their sex and the severity of their disorder.

Hallucinations and Delusions

In schizophrenia, there are different levels of severity of the disorder, but a common symptom is the appearance of hallucinations which differ from person to person. Also, different types of hallucinations can be experienced by the five senses. Auditory hallucinations are the most common type within individuals (Smith, 2019). During an auditory hallucination, the person may hear voices, it could be several voices at once which can sound like whispers, or a different person trying to mummer. The voices can often tell the affected person to do commands, and the internal voices can sound unhappy with them (Smith, 2019). During visual hallucinations, individuals experience the presence of objects, figures, people, patterns, and lights that are not physically there. Others have reported being able to see and get in contact with their deceased loved ones. Losing perception is also included (Smith 2019). Also, when experiencing olfactory hallucinations often can cause some trouble without being able to smell many individuals fear for mealtime from the fear being experienced, many of them refrain from eating because they fear their food has been poisoned. (Smith, 2019) Next, in a tactile hallucination individuals experience the feeling of ants crawling which in reality is not happening. Delusions are characterized by DSM 5 “by having a false belief based on incorrect interference about external reality that is firmly sustained despite what almost everyone else believes and despite what makes up incontrovertible and obvious proof or evidence to the contrary (Imperfect Cognitions, 2013)”. During persecutory delusions, the person concludes that harm is coming their way either by an individual group despite the reality that is not happening. In erotomanic delusions, the person comes to the delusion that an individual, or more likely to be a celebrity has fallen in love with them. In somatic delusions, a person can believe they have an illness, or that something is affecting their body by an undiagnosed and rare condition that is not present or detected. When a grandiose delusion is present, a person believes that they have superior abilities or qualities despite not having valid proof (Smith, 2019).

Sex Differences in Schizophrenia

Men have a greater probability than women to be diagnosed with schizophrenia, the ratio 4:1 male to female between the ages of 18 and 25 which is 4 years earlier than females (Gogos, Ney, Seymour, Rheenen, & Felmingham, 2019). Because of the lack of ovarian hormones being produced during menopause, women experience a peak of the disease. Research shows that men with schizophrenia have shown higher brain changes in morphological abnormalities and the amount of white matter than women. Reports show that women experience more negative symptoms in a more critical matter than men (Gogos et al., 2019). Both women and men experience the same amount of major depressive symptoms. During the progression of the disease and the severity of each present stage, men are least affected by the prescribed antipsychotic medication and have been hospitalized more often than women. Men also have a higher rate of being hospitalized which comes with substance abuse or medication men increase social isolation than women and many more men experience social withdrawal. Women have been shown to have better rates of remission and higher rates of recovery than men (Gogos et al., 2019). In studies that were conducted on the brains of males and females, MRI and postmortem studies show that men with schizophrenia show to having larger lateral and third ventricles, and anterior temporal horns than women; and also shows that men have smaller medial temporal volumes, hippocampus and amygdala, Herschel’s gyrus, superior temporal gyrus, and overall smaller frontal and temporal lobe volumes (Kathryn, Richard, & Jill, 2010).

Sex Differences in the Treatment of Schizophrenia

Treatment In Schizophrenia

The ultimate goal in treatment for schizophrenia is to seize the relapse of the frequency of episodes, and symptoms and integrate the person back into their daily routines. Most people with this disorder rarely go back to how their life was before the disorder. There are two types of treatment plans nonpharmacological and pharmacological for long-term outcomes. When going with a nonpharmacological option it is advised to include psychotherapy sessions as well. According to the American Psychiatric Association, antipsychotics except for clozapine (SGAs) are the best medication treatment for schizophrenia. SGAs are the best option for medication over antipsychotics (FGAs) because individuals experience fewer extrapyramidal symptoms ( Patel, Cherian, Gohil, & Atkinson, 2014). Sex differences in essential when wanting a more effective gender-specific pharmacological treatment which can help to predict the proper dose of medication is necessary, control the side effects of the medication, and compliance. Female patients have been shown to have surpassed their treatment plan with 50% higher of being hospitalized ( Patel et al., 2014). Thus, male patients tend to have a higher tolerance to antipsychotics which often requires males to be prescribed a much higher dose than females the reason for the higher dose is the correlation between liver enzymatic clearance. Also, males have higher levels of unhealthy habits such as cigarette smoking, drinking alcohol, and high caffeinated drinks which create a higher rate of enzymes to build up in the liver. For women with high hormone levels cause them to have more side effects such as hyperprolactinemia, hypotension, increased weight gain, and autoimmune complications ( Li, Ma, Wang, Yang, & Wang,2016). Research of sex factors in gender differences involves hormones more specifically gonadal hormones, for example, estrogen in women. A new finding of oxytocin is an important hormone for reproductive function which is beneficial for a therapeutic target for schizophrenia patients ( Li et al., 2016).

Conclusion

Limitations of Existing Research

Research on differences in sex differences demonstrated that women have shown to have better outcomes even when schizophrenia remains present longer in women at a later age ( Urizar, Fond, Urzua, & Boyer, 2018). Most of the studies have shown a greater increase in social adjustment for females compared to males, and they also have better premorbid functioning than males (Thara & Kamath, 2015). Studies have shown that there is no relationship between gender differences in the incidence and prevalence of schizophrenia. Thus, the majority of research states females reported having better clinical outcomes than males in the short-term, where in contrast gender differences tend to disappear over longer periods ( Thara & Kamath, 2015). During the early phase of schizophrenia, gender differences are more present in the prodromal phase and early presentation of psychosis a treatment plan is provided ( Talonen, Vaananen, & Kaltiala-Heino, 2017). Psychotherapy was administered to both men and women to help reduce the frequency of negative symptoms, but only women found this type of therapy to be helpful with their symptoms ( Savil, Orfanos, Bentall, Reininghaus, Wykes, & Priebe, 2017). Future research should have a control group with a specific treatment for each man and woman for each group for example adolescents, early adulthood, or late adulthood. Taking into consideration the sample size and patients taking nonpharmacological and pharmacological treatments. However, each treatment plan comes with different types of medication or extra psychotherapy to be included to fully follow the treatment plan. Having the right knowledge of the severity of schizophrenia can help an individual, not relapse and have better management skills in taking their medication without the substance abuse of their antipsychotics. Also, future research should include outpatient treatment plans and their outcomes to inpatient treatment plans.