Category: Uncategorized

Introduction

Tourism is economically significant to countries since it earns them foreign exchange. Consequently, various countries invest in developing activities and infrastructure, making them attractive tourist destinations. Relevant authorities engage in destination planning to manage the visitor economy for tourists. A Destination Management Plan (DMP) is a business plan developed for building and managing the visitor economy in a tourist destination. Liverpool in England is one of the cities with a clear DMP that sets its vision and development plans for tourists visiting it. The city is popularly known as the city of The Beatles, culture, and sports making it attractive to tourists. The DMP is significant since it allows the metropolis to identify investment areas and ensure that their investment is appropriately used. Given its significance, DMP is an ongoing process and involves four critical areas of informing, planning, developing, and communicating the information to essential visitors. Liverpools DMP is significant for development planning, but the city can adopt various changes to ensure that it achieves its DMPs primary objectives.

Destination Profile

Liverpool is one of Englands largest cities in Northwest England in the Merseyside metropolitan. The citys origin dates to 1207, when King John issued letters patent that established a new borough: Livpul. The citys name evolved into different spellings like Leuerepul, Lyuerpole, Lytherpole, Litherpoole and eventually, Liverpool (Thompson, 2020). The citys inhabitants are renowned for fantastic literature, arts, maritime culture, and poetry. Consequently, it upholds significance in British music and literature. Furthermore, the city was hailed a city of culture in 2008 alongside Norways Stavanger (Thompson 2020). The various activities carried out in the city make it a suitable tourism destination.

The city has a wide range of tourist attraction sites suitable for international and local tourism. The city is popularly known as the city of Beatles, the Liverpool Football Club, and their famous Anfield stadium (Ramshaw, 2019). The heart of Merseyside lies in the east of the Mersey estuary that is three miles from the sea. Moreover, Liverpool has many historic buildings, gardens, parks, museums, and recreational facilities (Ebejer, 2021). The citys Walker Art Gallery and the Philharmonic are among the best concert halls in Europe (Ramshaw, 2019). The Merseyside Maritime Museum is also one of the greatest attractions in the city (Ebejer, 2021). Therefore, Liverpool is endowed with attractive sites ranging from the natural Merseyside estuary to man-made buildings like the Philharmonic Hall making it an excellent tourism profile.

Tourists visit different places for various reasons, including their natural scenery among others. A destination profile provides the tourists and stakeholders with an overview of a place and can be used to improve the places attractiveness (Bassols & Leicht, 2021). Therefore, the profile refers to the place smartness contributing to its tourism attraction. Although tourism is based on historical sites and developments, high-tech inventions have revolutionized the industry (Jiang et al., 2022). Smart tourism involves innovations and is reliant on four core information and communication technologies: the internet of things, mobile communication, cloud computing, and artificially intelligent inventions (Erdem & Seker, 2022). Various tourism companies and stakeholders integrate the smart-technology in marketing the industry and providing hospitality services (Stylos et al., 2021). For instance, many tourist destinations have websites and mobile applications where tourists can access the services like booking entrances, hotels, transport services, and paying for similar services on time (Wang et al., 2021). Therefore, the tourism future is based on technological development and its extensive application at all tourism sector levels.

6A Dimensions

Evaluating a destinations smartness is a multifaceted task that explores the available sites, services, and technology integration. The 6As analysis framework is a broadly accepted model that helps understand a destination profile (Font et al., 2021). The 6As for tourism destinations are attractions, accessibility, ancillary services, activities, amenities, and available packages (Kuninggar et al., 2021). Liverpool is a smart tourism destination characterized by high innovation levels and facilitation using higher technology interfaces (Barron, 2021). The 6As dimensional analysis is significant since it allows the tourism stakeholders to explore all the levels of tourism for sustainability.

Liverpools 6A Dimensions

• Attractions. Liverpool is popularly known for its tourists inherently magnificent natural and artificial sites. A tourist attraction is a place of interest visited by tourists for recreation, amusement, or leisure activities (Babaev et al., 2019). The sites serve various purposes like cultural value, historical significance, or natural beauty to the surrounding community (Choi & Choi, 2019). Man-made tourist attraction sites include skyscrapers, historic buildings, and ancient structures like the pyramids of Giza (van der Linden, 2021). Meanwhile, natural tourist sites include sandy beaches, deserts, and wild animals (Mishra & Kukreti, 2022). The various features in the chosen destination help meet the tourists expectations.
• Accessibility. Accessibility is crucial for tourism since it enables people to participate in and enjoy tourism experiences (Qiao et al., 2021). Accessible tourism is an ongoing endeavour to ensure tourist destinations, products, and services are reachable to all people regardless of their physical or cognitive limitations (Tlili et al., 2021). Therefore, convenience is relative among the tourists since different people have access needs whether or not related to a physical condition (Qiao et al., 2021). When determining the approachability of a tourist destination, various factors must be considered: barrier-free destinations, transport networks, high-quality services, activities and exhibits, and tourism information (Tlili et al., 2021). Various countries have put in place measures to ensure easy access for all. The various tourist attraction sites in Liverpool are located at different locations but connected with excellent infrastructure. The city is significant with its road, rail, and ferry networks, a well-known dock system, and an international airport (Devile & Kastenholz, 2018). However, the citys transport system is majorly centred on rail and road transport. The citys public transport is controlled and run by Merseytravel, while local authorities primarily manage the road networks (Boyle et al., 2020). The cars and trains in the city are accessible to everyone, including the physically challenged. Furthermore, the Liverpool Airport facilitates international travel among its visitors. The city is accessible due to rails and roads offering local transportation and an international airport crucial for international tourists.
• Ancillary Services. The primary tourism amenities need a secondary support system for enhanced service delivery. Ancillary services refer to organizations that do not have a particular or direct role in travel and tourism but related products and services (Pencarelli, 2020). Insurance companies offering holiday insurance, foreign exchange bureaus, restaurants, and car parks are examples of ancillary service providers (Camilleri, 2018). The tourism ancillary organizations offer services that make tourism and travel completely. Although tourism is a major source of income for governments, the ancillary organizations may earn a higher income than the government from a particular tourist (Pencarelli, 2020). Many companies have specialized in providing ancillary services to tourists. Liverpool is endowed with a variety of tourism ancillary service providers. The UK government has seriously taken the hospitality industry. Consequently, colleges and universities offer courses that are related to tourism. For instance, hotel management, business management, and hospitality management (The University of Liverpool, 2022). The courses equip the learners with the necessary skills to provide excellent services in the hospitality industry. Liverpools local government has favourable business legislation that allows the formation of private travel agencies and restaurants. The foreign exchange bureaus in the city allow the tourists to exchange their foreign money with local currency for effective logistical activities. Moreover, the different tourist sites have qualified tour guides who have graduated in hospital and other relevant fields in tourism. Therefore, a conducive legal environment and qualified professionals boost ancillary services provision in Liverpool.
• Activities. Tourism activities include social and cultural activities that attract tourists to various destinations. Liverpool is full of activities that attract local and international visitors. The city is the home of Liverpool Football Club, one of the most prestigious football clubs in the English Premier League. Since the club attracts local and international fans, many people visit the city to witness the clubs matches (Kennedy, 2018). Many visitors come to the city to carry out activities like going underground with the remarkable Williamson Tunnels, taking the ferry across the famous River Mersey, and listening to music at the popular Cavern club. The city is also an educational destination attracting scholars to the University of Liverpool to explore various study areas and learn British music history. The recreational and educational activities in Liverpool make it a unique tourism destination.
• Amenities. Tourism amenities involve tourism-related services and properties like hotels, accommodations, and catering. The amenities, unlike ancillary services, are directly or indirectly related to tourism. Liverpool is home to luxurious hotels like the Titanic Hotel, DoubleTree by Hilton hotels, and Hotel Pullman Liverpool. The hotels provide quality accommodation and catering services to the tourists visiting the city. The transport system serves as a tourism amenity since it facilitates the movement of visitors from one place to another. Liverpool has well-developed and convenient transport and communication systems that allow hospitality companies to communicate with their clients. The availability of hotels and reliable transport system makes Liverpool an attractive tourism destination.
• Available Packages. Many tour operators offer hospitality services in Liverpool at different costs. A tour package comprises transport and accommodation advertised and sold together by tour vendors (Halkiopoulos & Koumparelis, 2020). The package may consist of other services like a tour guide, rental cars, outings, and various activities that are attractive to the visitors (Smith et al., 2019). The cost and type of tour packages available in Liverpool vary from one vendor to another. For instance, accommodation packages in luxurious hotels and air tickets are expensive. The tour operators have reliable communication systems and websites where potential visitors can access the package information and compare it with other available options.

Strategic Destination Planning and Management (SDM)

What is it

Destination management is crucial since it allows tourism stakeholders to identify the visitors needs and create a cordial environment. A destination management plan (DMP) is a document that captures the process, vision, tourism aspects, and approach is taken to manage a tourism destination strategically. The management can be described as a process that leads, influence, and coordinate all tourism destination aspects contributing to visitors experience (Soulard et al.,2018). Meanwhile, a destination plan defines the stakeholders vision and identity an appropriate approach that meets the visitors needs (Alseiari et al.,2019). An effective DMP captures the entire tourism experience, including environment, cultural integrity, built heritage, aesthetics, and overall trends (Soulard et al., 2018). Therefore, strategic tourism and management provide tourism stakeholders with tools to identify and produce sustainable and competitive tourism.

Various approaches can be adopted when developing a strategic SDM. The theories help the stakeholders identify visitors needs and associate them with the destinations unique environment. Moreover, the approaches help create new destination entities that make tourism more competitive. The umbrella approach helps develop existing destinations and implement an umbrella organization (Camilleri, 2018). The approach enables task sharing and coordination by keeping strong brands alive. The centralization approach facilitates the survival of the strongest brand and leads to the concentration of resources (Camilleri, 2018). Furthermore, the motivation theory identifies destination drivers among the visitors about the destinations environment (Camilleri, 2018). SDM presents various benefits to organizations but also has some negatives.

What are the Positives and Negatives?

SDM Positives

• Roles Identification. SDM involves identifying visitors needs, destination developments, and tourism aspects. Moreover, the planning involves intense research and data collection, contributing to effective planning. Different stakeholders are assigned particular roles that contribute to the development of the industry. For instance, learning institutions are tasked with revising their curricula to offer quality hospitality education, and the hotel industry is tasked with providing quality and affordable accommodation to visitors, among others. Role identification and allocation through SDM improve service quality by enhancing specialization among the stakeholders.
• Competitive Edge Establishment. SDM involves the identification of loopholes contributing to the failure in the industry. Moreover, depending on the approach taken during SDM, tourism brands are strengthened through collaboration and coordination (Soulard et al., 2018). Consequently, the strong brands offer global standard services and become competitive in the industry. SDM creates a visitor-friendly environment by eliminating all the obstacles and meeting visitors unique needs (Camilleri, 2018). The improvement of existing destinations helps attract more visitors whose needs are met. For instance, establishing hotels that embrace Chinese and Italian cuisine attracts Chinese and Italian visitors to the destination. Therefore, SDM establishes a competitive edge by identifying visitors needs and meeting them by improving existing amenities.
• Ensuring Tourism Sustainability. Tourism sustainability ensures the enjoyment of the industrys benefits over time. SDM suggests a mechanism that can be put in place to ensure that the destination remains relevant and attractive over time. Sustainability measures include preserving and maintaining existing attraction sites and amenities (Soulard et al., 2018). Moreover, the development of related amenities that preserves the destinations culture makes tourism sustainable. For instance, developing more music museums and art galleries in a destination that embraces literature, art, and music attracts more visitors over time.
• Spreading the Benefits of Tourism. Tourism is a multifaceted sector that involves various stakeholders. SDM ensures that different roles, visitors needs, and possible improvement areas are identified. Consequently, new opportunities are created to economically and socially benefit the distentions inhabitants (Camilleri, 2018). Hospitality scholarships and scholarships for tourism research result from effective SDM. Furthermore, SDM encourages sharing tourism benefits by ensuring that the local businesses at attractive sites and amenities prosper.

SDM Negatives

• Business Poaching. SDM exposes a tourism destinations areas of success that competitors can imitate in the market. The approach involves intensive research that collects opinions from inhabitants and potential visitors. The collected information is analyzed and used to deliberate on the existing challenges (Camilleri, 2018). Then new methods adopted can be reported and available for public access. The competitors can adopt a similar approach to improve on their weak areas. Furthermore, SDM involves the identification of market opportunities that competitors may imitate. Although SDM leads to new opportunities, the opportunities are at risk of poaching the opportunities.
• Lack of Creativity. Developing an effective SDM involves the encouragement of a central management system. The system encourages coordination and collaboration among stakeholders. Consequently, the approach eliminates business diversity among stakeholders who are encouraged to specialize in their areas of expertise. Diversity in business enhances creativity, which is crucial in business. However, the SDM approach through role division discourages creativity and innovation. Furthermore, the research process may not involve all the crucial stakeholders for the business, inhibiting creativity. While SDM leads to new opportunities, it discourages creativity among the stakeholders.
• Loss of Small Business. SDM may take an umbrella approach that only encourages the survival of the strongest brands. The surviving brands may enjoy government support at local and national levels (Camilleri, 2018). Meanwhile, the weakest brands lack support from necessary authorities leading to their failure in the industry. Furthermore, strong brands may enjoy more resources and benefits than weak and small brands (Halkiopoulos & Koumparelis, 2020). Consequently, the industry may become unequal and biased encouraging monopoly and death of small businesses.

SDM and Liverpool

SDM Limitations

SDM is a strategic process that demands in-depth research and critical thinking when formulating solutions. However, the approach may be limited to research scope, lack of knowledge among the locals, and control of the tourism activities by a central government (Fyall & Garrod, 2019). Tourism involves local and international visitors who must be consulted when developing a destination management plan (DMP). However, the process may be unsuccessful in collecting opinions from every visitor representing every country.

Furthermore, the local inhabitants and those involved in SDM may lack knowledge of the tourist attractions and amenities. The knowledge required includes thorough history and understanding of the causes of failure in a particular area of research (Fyall & Garrod, 2019). Furthermore, countries like the UK have their tourism activities controlled by national agencies like VisitBritain. Therefore, SDM is limited to the capacity of a local authority in tourism. Lack of knowledge, limited research scope, and control of tourism activities at the national level are barriers to SDM.

Why Liverpool Should Be Mindful About the Limitations

Liverpool tourism sector is under VisitBritain agency that markets the industry abroad. Furthermore, the city cannot collect feedback from every tourist who visits the city. Therefore, the city should be mindful of the various limitations of SDM since they may lead to inaccurate data collection and misleading plans. Getting feedback from people without the tourist attraction sites may distort the objectives of DMP. Moreover, making plans beyond the metropolitan scope may lead to slow implementation due to the bureaucracy at the national levels. Therefore, Liverpool should be careful about the limitations to avoid inaccurate conclusions and slow implementation of the recommendations in DMP.

Successful International Destinations

SDM has been adopted by various countries leading to their success in tourism. The successful countries have attracted many tourists due to their improved services and increased competitive edge. France, Spain, and China top the list of most visited tourism destinations (Mariani et al., 2021). The countries have enhanced tourism sustainability through SDM, attracting many visitors each year. The increased number of visitors leads to increased foreign income. Some countries have adopted SDM but failed to attract tourists. The failed countries have not failed altogether but in some attraction sites. Germanys Spreepark and Russias Mirny Diamond Mine have failed in attracting tourists despite the adoption of SDM by the countries. Although SDM can lead to success in a tourist destination, sometimes it does not guarantee the success of particular tourism destinations.

External Environment

The external environment plays a crucial role in tourism since it determines successes and failures in the industry. Natural disasters, wars, pandemics, and economic crises negatively affect tourism. The factors can be categorized into political, social, economic, and technological developments (Wang et al., 2020). Various countries have adopted strategies and mechanisms to counter external negative influences. Meanwhile, the countries have embraced the positive influences and taken them to their advantage. While the positive external influences increase the profitability of the tourism industry among countries, the negative influences significantly contribute to losses among the countries.

Positive Influences

Various factors like technological advancements, new legislations, and an improved global economy positively influence tourism. Technological advancements lead to improved communication within the system. For instance, the 5G network and artificial intelligence development can lead to enhanced communication among stakeholders and improved innovation within the tourism sector (Khan et al., 2021). New legislation like the United Nations legislation on environmental sustainability boosts the countrys culture of environmental conservation (Murshed et al., 2021). Many tourists are attracted to environmentally sustainable countries leading to job creation and improved economy of the country.

Furthermore, recognition as a cultural heritage by the United Nations greatly increases the number of annual visitors. Meanwhile, an improved global economy improves UKs currency value and service provision within the tourism sector. Liverpools DMPs primary objectives are to improve engagement and communication with sector businesses and stakeholders, share best practices, and inspire innovation across the sector (Liverpool LEP, 2014). Therefore, an improved global economy, new favourable legislation, and technological advancements positively influence the achievement of Liverpools DMP objectives.

Negative Influences

Natural disasters, civil wars, and pandemics like COVID-19 negatively influence tourism. Natural disasters like drought and hurricanes make a tourism destination unsafe for visitors. Moreover, wars destabilize a countrys political and economic growth leading to mismanagement of tourism activities (Murshed et al., 2021). Consequently, tourists fail to visit the country since it is unsafe and without clear economic plans for the sector. The global economy is significant to the tourism sector since it enhances the marketing and currency value of the countries. Therefore, issues like inflation that negatively affect the global economy are hazardous to tourism. Negative influences negatively affect the achievement of Liverpool DMPs primary objectives.

COVID-19 Case

The onset of COVID-19 negatively impacted the tourism sector in many countries like Britain. Countries worldwide applied travel restrictions by closing their borders and local zoning areas that had increased virus cases. The travel restrictions included the suspension of air travel and the temporary closure of airports (Duro et al., 2021). The global economy was affected since many economic activities failed to take place. Consequently, many services and industrial activities that are ancillary to tourism were suspended (Duro et al., 2021). Furthermore, the local and international travel restrictions negatively impacted hospitality industries, and some were permanently closed due to a lack of sufficient funds for sustainability. The COVID-19 pandemic negatively affected the tourism industry leading to a decline in profitability of the industry.

Responding to the Influences

Liverpool may develop strategic mechanisms to respond to the negative and positive influences in the external environment. Embracing technological advancements and actively participating in the global market will financially boost the sector. Moreover, taking part in formulating favourable international legislation and ratifying the same will positively boost the sector. Meanwhile, Liverpool can develop an emergency response strategy to unprecedented pandemics like COVID-19. The response may include setting aside an emergency tourism fund that can be used to subsidize tourism-related services in the wake of unprecedented natural events. A strategic mechanism can help Liverpool embrace positive influences and overcome negative influences in the external environment.

Liverpools Existing DMP

Vision Statement and Covid 19 Response

The existing DMP vision focuses on improving the destinations competitive edge globally. The city aims to create jobs and increase the sectors revenue at the local level. Moreover, the city aims to be featured among the top five cities for domestic and international visitors in the UK (Liverpool LEP, 2014). The city aims to remain sustainable in culture, music, and sport globally, given its recognition as a World Heritage Site (Liverpool LEP, 2014). The city is still on track to achieve its vision after the COVID-19 impact since the UK is rapidly recovering its economic status amid the post- COVID-19 economic crisis. However, the achievement of the vision may take a longer period than planned, given the recovery time taken by the countrys economy.

Strategic Aims and Long-Term Targets

The existing DMPs longer-term targets focus on the sectors marketing, infrastructural improvement, and cooperation among the stakeholders. Creating an integrated marketing agency, promoting wider economic assets, and ensuring that the existing assets meet the visitors needs are effective and SMART (Liverpool LEP, 2014). The SMART targets and aims are very specific by stating the particular areas of improvement. However, the targets of helping the businesses in the Visitor Economy and aligning transport and Visitor Economy policy and market opportunities are not SMART (Liverpool LEP, 2014). The targets are not specific by failing to address the specific sectors of the Visitor Economy that will be affected. Despite the post- COVID-19 crises, the SMART targets are achievable and can be measured over time.

Conclusion

Tourism is beneficial to a countrys economy and should be treated like any other lucrative sector. The City of Liverpool is renowned for its British music culture and is the home of the famous Liverpool Football Club. As a tourism destination, the city has a well-planned DMP that aims at improving the sectors economy. The DMP focuses on fostering cooperation and job creation in the tourism industry. Although the city is vulnerable to the economic crisis caused by the Covid 19 pandemic, the set targets and objectives within the DMP are achievable. Therefore, Liverpools DMP will help boost tourism through infrastructural development and improvement and job creation.

Recommendations

Liverpools existing DMP has achievable objectives that need strategic planning. Liverpool can set timelines to measure the sectors performance concerning the DMPs objectives. Setting the timelines will allow the city to identify areas of strength and emphasize them and areas of failure and improve on them. The sector stakeholders should be involved in implementing the DMP through consultations. Getting the stakeholders opinions will help Liverpool identify primary focus areas and improve those specific areas. Furthermore, opinion and data collection from the visitors should be a continuous process to keep track of the sectors performance and identify the changes with time.

References

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Introduction

The previous chapter provided a detailed review of literature to help explore what other scholars have found in relation to this topic. In this chapter, the focus was to provide a detailed discussion of the methods and strategies used to collect and analyze primary data. Robinson and Werblow (2013) explain that the fundamental objective of every researcher is to provide new information by addressing the knowledge gap in a given field of study. That objective can only be realized by conducting primary research. An investigation that focuses on this topic needs proper collection and analysis of primary data to understand the phenomenon.

Chapter 3 starts by defining the purpose of the study to help emphasize reasons why this research was necessary. It then provides research questions that guided the process of primary data collection. The research design used in the study and reasons why it was appropriate were discussed. The chapter also focuses on the sampling strategy and sample size used, and the procedure used in selecting the participants.

Data obtained from the participants was collected with the help of questionnaires. The chapter discusses the design of the questionnaire, and how it was used to collect data from respondents. The chapter concludes by explaining the ethical considerations and the chapter summary. A detailed plan of the paper provides an effective outline of the steps necessary to conduct the research. It was necessary to re-state the research question that guided the study.

Purpose of the Study

The methodology section is important because it defines the steps taken to collect, analyze, interpret, and present primary data collected from sampled respondents. Percy et al. (2015) explain that when writing the methodology section, it was important to understand the purpose of the study. Restating the purpose of the study in this chapter guides a researcher to select appropriate design and data collection strategies that would help in achieving research objectives.

The purpose of the study was to identify the perceptions of single African-American mothers relationships with their adolescent sons. It was expected that findings of this study would help inform policies relating to parenting in the American society. The study would help in preventing juvenile delinquency and increasing academic success of adolescents in the society. The study would help design interventions for these families to improve mother-son relationships (Barajas, 2011; Roberts, 2011; Robinson & Werblow, 2013). According to Benner, Boyle, and Sadler (2016), the experience of single African-American females of being parents to their adolescent sons is changing.

This study is important to the community in general because it addresses challenges faced by a section of the society and defines ways in which these single African-American mothers can overcome parenthood challenges when raising adolescent sons. Practitioners of psychology will find this document resourceful when counseling single African-American mothers who are having problems parenting their adolescent son. The document explains to these experts the possible causes of such problems in a family setting and what can be done to address them. Scholars who will be interested in furthering research in this field will find the document critical in providing a basis for their study.

Research Question

How do single African-American Mothers experience their relationship with their adolescents Sons?

Research Design

The qualitative design for the proposed study was a generic qualitative study (Kahlke, 2014; Percy et al., 2015). The approach was suitable for the problem to be investigated because the generic qualitative methodology can be used to understand the experiences and perceptions of external phenomena, which are African-American mothers experiences of their relationships with their sons (Kahlke, 2014; Percy et al., 2015).

As for the research model, inductive analysis, a component of generic qualitative inquiry, was used (Bendassolli, 2013; Percy et al., 2015). The data was used by the researcher in the analysis process, during which repeating patterns were found in the participants responses (Percy et al., 2015). From these patterns, themes emerged, which were then synthesized to answer the studys research question (Percy et al., 2015).

The data collection methods comprised of semi-structured interviews, which consisted of open-ended questions. The strategy allowed for follow-up questions to keep participants focused on identifying their experiences (Dworkin, 2012; Irvine, Drew, & Sainsbury, 2013; Qu & Dumay, 2011; Rabionet, 2011). According to Percy et al. (2015), semi-structured interviews are appropriate for data collection in a generic qualitative study (Percy et al., 2015). It was considered an appropriate way of determining the perceptions of single African-American mothers relationships with their adolescent sons.

Identifying the appropriate research philosophy was critical to ensure the correct assumptions are made when collecting and analyzing data. According to Fusch and Ness (2015), before selecting the appropriate research approach and research design used in a study, it was important to start by defining the research philosophy that guided the major assumptions of the study. Doody and Noonan (2013) explained that a research philosophy refers to the beliefs the researcher has about how data on a phenomenon should be gathered, interpreted, and used. A researcher can opt to use positivism, realism, pragmatism, or interpretivism, based on the nature of the study. For the current study, interpretivism was selected as the most appropriate philosophy.

Interpretivism

Interpretivist, also known as interpretivism, is a popular philosophy in social sciences research. Interpretivism holds that access to reality is only through social constructions, such as language, consciousness, shared meanings, and instruments (AlYahmady & Alabri, 2013, p. 184). When investigating a phenomenon in a society, limiting ones self to an observer who does not integrate and engage participants, can limit the ability to collect data accurately.

It may lead to cases where one makes wrong assumptions because of the lack of physical interaction. Limiting oneself to the role of an observer may explain why it allows a researcher to engage the participants directly, ask for clarifications from them when necessary, and ensure that an issue is understood as much as possible. The role of an observer is used in studies of phenomenology, social constructivism, and hermeneutics (Woolfolk, 1992).

When embracing this philosophy, a researcher is expected to take the qualitative approach of research design because of the need to identify how and why a phenomenon occurred in the manner it did. In this case, the goal was to identify the experiences of single African-American female parents of adolescent sons. It was possible to identify the experiences of these single mothers based on different factors, using qualitative methods.

It was also possible to identify any variations that emerged based on their experiences caused by their varying socio-economic status in the society. The generic qualitative approach was the most appropriate research philosophy selected for the study. The next step was to select the appropriate research approach.

Inductive approach

The inductive approach was selected as the appropriate research approach for this study. The inductive approach is commonly used in social sciences. Unlike deductive research, inductive reasoning does not require the formulation of the hypothesis (Yanow & Schwartz-Shea, 2014). Instead, it starts with the development of research goals and objectives. One is then expected to go to the field and make observations that would help in achieving the goals by answering the research questions. The inductive approach starts with making observations based on the research questions and objectives (AlYahmady & Alabri, 2013).

One is then expected to monitor the patterns, before developing a theory or making a conclusion. The inductive approach was selected as the most appropriate approach for this study because it facilitates the use of open-ended questions to conduct an in-depth investigation of the issue at hand as required in a qualitative research as Dörnyei and Ushioda (2013) note.

Target Population and Sample

Population

In this section, the focus was to conduct a brief discussion of the population of African- American single mothers. Various factors discussed in the previous chapter have led to the increase in the number of Africa-American single mothers. Although the exact number of African-American single mothers may not be easy to predict, recent statistics show that over 70% of African-American children are raised by single-mothers (Fernandez, Butler, & Eyberg, 2011; Varner & Mandara, 2013). The population is expected to increase in the coming years as these studies show that the institution of marriage is becoming increasingly unstable. In most of the cases of divorce or separation, children are left with their mothers (Varner & Mandara, 2013).

Identifying the target population was important to enable the researcher to select an appropriate sample. According to Benner, Boyle, and & Sadler (2016), identifying the experiences of single African-American females when parenting their adolescent sons required engaging the specific target group. Although there are no exact statistics about the number of single African-American mothers in the country, Brannon, Markus, and Taylor (2015) explained that the problem affects millions of people. According to the 2010 U.S. Census (United States Census Bureau, 2010), the population of African-Americans was believed to be more than 42 million. A significant portion of that number included single women with children.

The researcher focused on African-American single mothers who had adolescent sons at the time of the study. It was also important to note that another important factor was the place of residence of the targeted population. The research only focused on single African-American mothers who resided in the U.S., since the socio-economic and political environment in the United States is different from that of other countries. As such, those living out of the country were excluded because factors that influence their experience are different from that of the locals. These factors defined how the sample was selected.

Sample

According to Dworkin (2012), sample sizes for qualitative studies are usually smaller than quantitative methods (Dworkin, 2012). The sample was from a number of participants, which is sufficient for achieving data saturation (Dworkin, 2012; Fusch & Ness, 2015; White, Oelke, & Friesen, 2012). Clinard (2015) stated that when collecting data from a specific group of people, the non-random sampling method was the most appropriate (Ebert et al., 2015). The purposeful sampling method was used, which meant participants were selected according to the inclusion criteria for the study (Palinkas et al., 2015; Suri, 2011).

Purposeful sampling was necessary to ensure the right number of participants was selected for the study. Purposeful sampling allowed the selection of those who were part of the study. The sample population was large enough to provide information needed to understand the issue under investigation while at the same time manageable enough to ensure that data was collected from everyone within the time available for the study.

Purposeful sampling was necessary to ensure that data was collected within the set time. The population for the current study was comprised of single African-American mothers who had one adolescent son, aged 14-19 (Fernandez, Butler, & Eyberg, 2011; Varner & Mandara, 2013). It was necessary to have a range of 80-100 participants in the study. The range was considered adequate to provide information that would guide the conclusion and recommendations made at the end of this study.

The selected age range was chosen because during this period of life, known as adolescence, the child undergoes significant physical, cognitive, emotional and social development, and parents often find it difficult to adapt to this change and adjust their parenting methods (Hahn et al., 2012; Varner & Mandara, 2013). Adolescence makes the relationships between the mother and her son in this period difficult, and understanding these difficulties is important if methods to facilitate these relationships are to be developed in the future. In addition, it was necessary to select single mothers who had at least one son. These mothers must have lived with their sons, so their relationship would be sufficiently close, and to reduce heterogeneity of the sample. Inclusion criteria were:

1. Single African-American mothers aged 27-55.
2. Reside in the U.S.
3. Resided with at least one adolescent son aged 14-19.

Procedures

According to Guirdham and Guirdham (2017), outlining the procedures used in collecting primary data is one of the ways of demonstrating validity and credibility of the study. Scientific merit is questionable if a study lacks transparency in the methodological procedures. Correct procedures must be followed at every stage of the study, and that was why it was important for the researcher to explain the steps taken to gather information from the sampled respondents (Guirdham & Guirdham, 2017). The whole process started with participants selection to the last stage of data analysis.

Participant Selection

Selecting the right participants, as described above, was critical in this study. It was necessary to develop the appropriate procedures to conduct participant interviews. The researcher posted flyers in parks, recreation centers, church bulletins, and Facebook posts. The contact number for the researcher was provided on the flyer. Once potential participants contacted the researcher, a detailed explanation of the relevance of the study was provided, and why these specific parents were chosen. It was also necessary to ensure that participants were protected. As explained above, purposeful sampling was used to identify participants in this study. The procedure involved selecting specific individuals who meet the inclusion criteria.

Protection of Participants

The proposed study was designed to comply with the ethical standards for a psychological study, in particular, with the Code of Ethics of APA (Hanson & Kerkhoff, 2011; Wester, 2011). Neither the participants nor the researcher was subjected to risks, since the interviews were conducted in a setting provided by the researcher (Fraga, 2016). The participants were interviewed using the semi-structured interview approach (Doody & Noonan, 2013; Rowley, 2012), and participants were informed they had the option to refuse to answer questions that made them feel uncomfortable (Hanson & Kerkhoff, 2011; Wester, 2011). To protect the participants, the researcher did not reveal any personal information to third parties.

An informed consent was obtained from each of the participants prior to involving them in the research. The participants were advised that participation is voluntary, that they may skip any question or topic they do not wish to discuss, and that they may stop an interview at any time. During the data collection process, the participants were assigned ID numbers that allowed for identification. Third parties may transcribe the audio recordings of the interviews, but no information about the participants was revealed to them, and a signed confidentiality agreement was obtained stating they cannot provide this data to anyone else.

After the data was collected and transcribed, participants were requested to review the transcripts, and make any revisions they deemed necessary. Data was only used to answer the research question of the proposed study. The data was used against study participants or anyone else. It was utilized solely for scientific purposes, and not for any other goals.

According to Lewis (2015), it was critical to ensure that participants were protected, especially when collecting data on a controversial topic. The topic being investigated in this study may not be emotive, but it is one that a section of the society may not want to talk about because of the emotional pain and financial burden associated with it (Cokley, Awosogba, & Taylor, 2014). It was necessary to ensure that the participants were protected.

Protection of the participants was done at different stages. First, the participants were fully informed about the purpose of the study and the reasons why they were selected to participate. They were informed they had the option to withdraw from the study at any time if they felt it was necessary to do so. As Lewis (2015) advised, the selection of the participants was done on a voluntary basis.

The voluntary nature of the study ensured that no one who felt threatened took part in the investigation. The next step was to protect the identity of the participants. Some of the participants stated they could only take part in the study if they were assured that their identity would be confidential. Rovai, Baker, and Ponton (2013) explained that sometimes-single parents were victimized because of their status, thus each participant was assigned a unique code.

This approach meant that it was impossible for anyone who accessed the raw data to identify the participants (Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015). Participants were informed about the mechanisms when assigning them the specific codes. The above steps were taken to ensure that the identity of the participants remained confidential.

Data Collection

The actual process of data collection can be a very rigorous process. As Tricco et al. (2016) observed, primary data helped to identify gaps in the phenomenon. As previously, described, primary data was obtained from interviews of single African-American females parenting adolescent sons. The qualitative data (Bazeley, 2012; Jackson & Mazzei, 2013) was collected from participants during personal interviews, which were conducted either in-person or by telephone.

In-person interviews were conducted in a private room in a public organization (such as a local public library, school, or university) that was booked in advance. Yilmaz (2013) believed that a face-to-face interview is one of the best ways of collecting data, especially in a qualitative study. The physical interaction also creates a bond between the researcher and the respondents, making it easy to gather the needed information (Vaismoradi, Turunen, & Bondas, 2013).

For respondents unable to attend an in-person interview, telephone interviews were conducted. Bendassolli (2013) provided a rationale for telephone interviews, which included parents limited scheduling availability and lack of transportation. As such, it was easier to interview them by telephone as opposed to conducting a face-to-face interview.

Prior to starting the interview, participants were provided with informed consent forms. Once the signed consent form was returned to the researcher, the interviews began. Each participant was assigned an alphanumeric designation (i.e., P1, P2, etc., for participant 1, participant 2, and so on) to maintain their confidentiality throughout the study. Participants were also informed their participation was voluntary, and the interview could be stopped at any time, and questions that made them uncomfortable did not have to be answered.

At the beginning of each interview, each participant was requested to provide responses to the questions, but to feel free to add anything the participants wished to add or believed was important. Semi-structured interviews questions consisted of open-ended questions that kept participants focused on identifying their experiences (Dworkin, 2012; Irvine, Drew, & Sainsbury, 2013; Qu & Dumay, 2011; Rabionet, 2011). The researcher made field notes during and after the interview. At the conclusion of the interview ended, the audio recording was stopped, and the participant was given the $10 gift card. The following steps were used to collect the data:

1. Advertisements, listing the researchers contact information, were posted on Facebook and in public places seeking participants.
2. Once contact was established with participants, the researcher made phone calls to parents explaining the purpose of the study and requested their participation.
3. The date, time, and location of the interview was established.
4. Prior to the interview, the purpose of the study was provided and informed consent forms were provided to participants.
5. Once the signed, informed consent was presented to the researcher, the interview began.
6. The approved demographic questionnaire was provided to participants.
7. The interview was conducted using semi-structured interview questions.

The interviews lasted approximately one hour. After each interview was over, the recording device was turned off, and the data collection procedure for each participant was concluded. The researcher thanked the participant for the interview. The researcher made impression notes about the interview.

The audio recordings were transcribed by the researcher. Each participant was emailed the transcripts of their interview, with the request to review it and return it with comments or revisions. No participants submitted revisions. All the data was saved onto a USB flash device. The recordings and the researchers notes were placed in a locked safe.

After the seven-year retention period, the information was destroyed by shredding and according to _ University, data was permanently and irreversibly destroyed or sanitized. A device that has been sanitized has no usable residual data. Physical destruction is considered the most secure method of destroying data. Other means of destroying data include reformatting the media or using special software to scrub the media. The National Institutes of Standards and Technology has issued guidance on data sanitation that described best practices for clearing, purging and destroying data for a vast array of media and was used for this study (_ University, 2017). All data was kept in a locked file cabinet located in the home office of the researcher until the end of the seven-year retention period.

Data Analysis

After collecting data from the participants, the next step was to analyze and interpret the data. Qualitative analysis of data was considered most appropriate when identifying the experiences of single African-American female parents of adolescent sons (Boeren, 2018). Identifying the experiences of participants was critical to determine emerging themes (Creswell, 2012). When done properly, themes emerged to answer the research question.

According to Percy et al. (2015), thematic analysis is appropriate for a generic qualitative study. Data analysis was conducted using the method of coding to identify themes in the transcribed data (AlYahmady & Alabri, 2013; Campbell, Quincy, Osserman, & Pedersen, 2013; Chenail, 2012; de Casterle, Gastmans, Bryon, & Denier, 2012; Percy et al., 2015; Pierre & Jackson, 2014; Smith & Firth, 2011). The thematic analysis was inductive and data-driven (Percy et al., 2015). To conduct it, the following steps were taken (Percy et al., 2015):

1. All the transcribed data was read several times.
2. The researcher then listened to the recording of each interview. Significant words and phrases were highlighted.
3. The significant words and phrases were assigned codes, i.e. very brief descriptions of the contents (Percy et al., 2015).
4. The parts of data that were similar were clustered, so that it was possible to find patterns. Each pattern was assigned a brief code. The codes were relevant to the field of psychology (Percy et al., 2015).
5. The patterns were reviewed and themes were found in the data. The patterns, codes, themes were arranged into clusters (Campbell et al., 2013; Percy et al., 2015). Direct quotes from participants were placed near the corresponding patterns.
6. The same procedures were repeated for the data obtained from each participant.
7. The patterns were clustered and synthesized into themes. Descriptors were assigned to themes using terminology relevant to the field of psychology (Percy et al., 2015).
8. The themes were arranged into a matrix, and the corresponding patterns that supported the themes were also included (Percy et al., 2015). Codes or descriptors were also utilized for every data cluster in the matrix (Percy et al., 2015).
9. For every theme in the matrix, a narrative description was written and presented in Chapter Four.
10. The same procedures were repeated for each participant in the study. After the data analysis process was complete, the themes and patterns that emerged from the data were combined and presented in a narrative summary (Percy et al., 2015).

Instruments

Instrument of Data Collection

Data was collected from the participants using semi-structured interviews. The interview instrument included 10 interview questions. When conducting the literature review, gaps in the existing knowledge were identified, which helped in developing the studys research question. The interview questions were crafted for the purpose of answering the research question. A detailed explanation of the structure of the instrument used in collecting data was provided in the section below.

Structure of the instrument

The instrument used in collecting data was comprised of various sections. Palinkas et al. (2015) explain that an instrument used in collecting data should also capture specific details about participants. The first section of the instrument focused on the demographic background of participants. The demographic questionnaire captured the age, gender, and nationality of the participants.

The second part of the instrument focused on the academic qualifications of the participants. Yilmaz (2013) explained that highly-educated and experienced people are more likely to get well-paying jobs that those who lack similar qualifications. It defined their financial capacity as they struggled to raise their adolescent sons in the U.S. (Kitche & Ball, 2014). The last section of the questionnaire focused on specific issues related to the experiences of single African-American females when parenting their adolescent sons.

The Role of the Researcher

The role of the researcher was critical in the study due to the fact that credibility, dependability and transferability of the study depended upon the researcher (Patton, 2002). The credibility of the scholar is said to be a factor in the credibility of a study (Patton, 2002, p. 584). To ensure the transferability of a study, it is paramount the researcher does not extrapolate the data without its careful analysis and without considering ones own biases (Patton, 2002, p. 584). Finally, the dependability of a study required careful planning of the steps taken during the study, their accurate execution, and precise description in the final work to ensure other scholars can replicate the study (Patton, 2002).

The role of the researcher in this case involves data collection, analysis, and interpretation in an objective manner. It was critical to ensure the researcher remained objective throughout the data collection and analysis phase. Although the researcher engaged participants, it was essential to recognize and minimize potential researcher bias that may have influenced the outcome of the study. Nuri, Demirok, and Direktör (2017) explained that sometimes a researcher may use personal knowledge, which sometimes is based on misconceptions and prejudice, to make conclusions. As such, it was crucial to remain as objective as possible, as advised by Palinkas et al. (2015).

The participants words were not addressed, and only neutral clarifying follow-up questions were asked, when necessary. To ensure the data collection procedure remained neutral, the researcher refrained from asking additional questions related to socioeconomic status and participants education unless the questions were included in the list of guiding questions for the interview. The researcher also made a list of possible preconceptions and referred to the list prior to asking follow-up questions.

During the data analysis process, the researcher withheld judgment. It was critical to only make conclusions based on the data (Percy et al., 2015). The technique of generating and assessing rival conclusions was used (Patton, 2002). Also, the researcher made a list of personal and professional biases (such as being black, being a female, and having experience of working as a mental health counselor) to avoid biases of the researcher (Patton, 2002).

To avoid these biases, the researcher was keen on identifying common stereotypical words and phrases such as those identified above. Varner and Mandara (2013) argue that a researcher should always avoid sentiments such as blacks are always drug addicts or Hispanics are drug peddlers. Working as a health counselor has given the researcher experience that makes it easy to identify possible bias in ones statement. I can listen and reflect upon a statement and then determine if it is influenced by perception that an individual has towards a given group of people.

Guiding Interview Questions

According to Nestor and Schutt (2014), when collecting primary data, it is critical to have guiding interview questions. As Zan and Donegan-Ritter (2014) observed, such questions were meant to standardize the interview process. It ensured that participants answered similar questions to make the analysis process simple. The guiding, semi-structured interview questions were developed based on the research purpose and objectives. They were designed in a way that made it possible to achieve the primary goal of the study.

It was crucial to draft interview questions that would help in collecting data from the respondents, that would answer the research question. Irvine, Drew, and Sainsbury (2013) explained that when questions are developed effectively, they help in concentrating the focus of the study and eliminated cases where irrelevant information was gathered from the respondents. It was necessary to draft interview questions to identify experiences necessary for the study. The following are the semi-structured interview questions that were used in collecting data:

1. Tell me about your relationships with your adolescent son.
2. What do you feel influences your relationship with your adolescent son?
3. What comes to mind when you think of a mother/adolescent son relationship?
4. Describe in detail what it is like to experience a relationship with your adolescent son.
5. What do you do to maintain a relationship with your adolescent son?
6. What feelings come to mind when you think about your relationship with your adolescent son?

Introduction

The Green Movement

The concept of going green is based on the process of altering approaches towards the consumption and utilization of resources to ensure a more environmentally friendly method of using and consuming resources (Boss, 2010). The basis behind this is the assumption that since the Earth is a closed off ecosystem with a finite amount of resources if nothing is done to conserve and ensure these resources stay replenishable in the long run there may come a time when the Earth will no longer be able to support human civilization (Boss, 2010).

Such an assumption is not without merit, as the human population continues to expand so too does the demand for resources increase. Unfortunately, resources that command the highest demand (wood, freshwater, and food) are only replenishable to a certain extent while others have a set amount (oil, gas, and certain chemicals) and cannot be replenished at all. Advocates of environmental conservation such as former U.S. vice president Al Gore continue to reiterate the need to change the current rate and method of consumption to better utilize resources to ensure that they will continue to remain there for future generations (Reynoso & Heusinger, 2010).

It must be noted though that the concept of going green is not a recent trend rather it has been going since the early 1970s through the creation of various recycling programs and centers (Griskevicius et al., 2010). Despite this, it has only been within the past decade that the concept of environmental conservation has entered into popular culture. Advocates such as Al Gore, Nichol Richie, Lance Bass, and various other pop culture icons were among the primary reasons why environmental conservation became popularized with younger generations today.

While going green through resource conservation is financially beneficial for most companies many attempts the change over to create an effective means of product positioning with the general public (Boss, 2010). Various studies have shown that due to the growing trend in environmental conservation many consumers would be willing to spend money on products that indicate that they were created through environmentally beneficial practices rather than products that do not have such a distinction (Beil, 2009).

This has given rise to the concept of corporate green washing where corporations indicate that their products were created through environmentally conservative methods but follow ordinary resource wasting procedures (Beil, 2009). Even with such disreputable practices currently being done enough industries do see the benefits that going green has for both their operational capacity and their ability to appeal to consumers and as a result, many choose to change their operational models to account for added environmentally beneficial practices (Cater and Lowman, 1994). It must be questioned though whether going green contributes to consumer patronage of a particular hotel chain or are customers influenced more by other factors about consumer behavior?

Literature Review

State of the hotel industry in Singapore

The 2008 financial crisis deeply affected various hotel chains around the world due to the sudden decline in consumer spending and international travel which was the primary source of revenue for various hotels since international guests made up the bulk of their clients. An examination of Singapores hotel industry at the time reveals that while the Singaporean economy suffered a significant financial blow due to its orientation as an exported oriented country its hotel industry did not suffer as significant a loss as compared to its other counterparts around the world.

It must be noted that the 2008/09 financial crisis primarily affected the U.S. and European markets due to the U.S. housing crisis and the subsequent sub-prime investment fallout however markets in South East Asia, primarily within the A.S.E.A.N (Association of South East Asian Nations) were not as deeply affected due to tight fiscal and monetary policies adopted by their central banks which did not invest heavily into U.S. sub-prime backed securities.

As it turns out the 2008/09 recession did not have as large an impact on arriving visitors into Singapore because Americans and Europeans only made up 18% of the visitor arrivals coming into the country. Visitors from ASEAN member countries make up almost half of Singapores visitor source markets as well as various South and southeast Asian nations.

As can be seen in the graph there was a definite drop in the number of visitors from countries deeply tied into the state of the U.S. economy. Countries such as China, Taiwan, South Korea, and India are locations for various outsourced U.S. production facilities; a sudden decline in U.S. consumer spending would have a definite backlash on their economies as well since the U.S. is their biggest customer.

On the other hand, there is a significant increase in the number of visitors from various ASEAN countries which shows how the financial crisis did not deeply affect the various economies in the region. While this graph does not represent the entirety of Singapores visitor base that their hotel industry relies upon, it is an accurate enough representation of the type of visitors that enter the country on a daily basis.

Research into the records of the Singapore department of statistics has resulted in the following graph on the 2009 market share of visitors going into the country. As can be seen, visitors from the U.S. and U.K. make up only 8.7% of the total amount of visitors going into the country with the lions share of visitors coming mostly from ASEAN countries, China, Hong Kong, India, and Australia. This might be due to the fact that Singapore acts as a financial center within the Asian region and deals primarily with Asian business interests.

This will prove to be an important factor to consider since the current environmental conservation movement has different impacts depending on the country in question. For example, the green movement is more prevalent in regions such as the U.S. and Europe as compared to countries in Asia such as India and China. While there is a benefit to going green the fact remains that guests from countries where the concept is fairly new and underused might result in survey results for this study showing a possibly negative outlook towards hotels going green due to the origins of the various consumers.

The situation of Hotels in Singapore

Every hotel has a different guest demographic that they are targeting, various hotel chains cater to different kinds of guest demographics, with some catering to guests seeking affordability while others cater to guests seeking luxury. The main difference lies in what the hotel in question is actually capable of doing, in terms of available resources, operational capacity, and type of services available. Hotel chains such as the Marriott, Hilton, and Shangri-la obviously have higher operational capacities and types of services available as such they cater to a higher class of consumers.

Other smaller hotel chains do not have the same level of operational capacity and types of service available as such they usually cater to consumer demographics that desire affordability and convenience over services and luxury. Such distinctions are important to take note of since how hotels attract customers is directly related to what their level of operations and services are capable of doing. In the case of Singapore, due to its relatively small total land area of 710.2 km2 and its highly developed market-based economy, the city district is more compact as compared to other countries which resulted in various hotel chains being located relatively close to one another.

Due to its distinction as a leading financial center, logistics hub, and port various major hotel chains such as Ascott International, Four Seasons, Hilton and Hyatt International have all set up various hotels within or near the central business district. This presents a rather unique competitive setup due to the fact that each hotel chain can be stated as offering roughly the same level of services, having the same level of operational capacity, and also having the same level of international distinction.

While such a setup is advantageous for consumers it is quite the opposite for the hotel chains present since attempts at price reductions, special offers or extra services can also be done by competitors with the same level of operational capacity and financial resources (Briassoulis and Straaten, 2000). It would be another matter if it was a major international hotel chain competing against smaller locally based hotels but in this situation, it is a case of international hotel chains competing against each other within a small confined location.

What must be understood is that, as a business, hotels try to achieve a certain level of profit in order to stay operational, as such in a situation where competition is high hotel chains concentrated within a certain area must find a way to distinguish themselves from their competition in a manner that is both profitable and results in a greater degree of guest patronage (Briassoulis and Straaten, 2000).

When examining the hotel industry in Singapore another factor that must be taken into consideration is the lasting effects the recent financial crisis will have on how hotels will continue to operate within the country. Even though the number of visitors coming into Singapore was not as heavily affected as compared to other regions the fact remains that there was a significant decrease in the number of people that visited the country which severely reduced the amount of income garnered by hotels from 2008 to 2009. An examination of the business expectations survey from the Singapore Department of Statistics reveals that during the height of the financial crisis the hotel industry was expected to sustain losses of up to -100% due to the lack of sustained international visitors into the country.

While this view may conflict with earlier statements indicating that the number of visitors coming into Singapore was not as heavily affected compared to other countries, this discrepancy can be explained by examining the earlier graph on the changes in the number of visitors coming into the country. As can be seen visitors from China, South Korea Taiwan, Japan, the U.S., U.K., India, and Hong Kong all displayed negative growth rates while visitors from Malaysia, Vietnam, the Philippines, Germany, and Australia all experienced positive growth.

What must be taken into consideration is the fact that many hotels within Singapore position themselves to target particular consumer groups; this is reflected in the type of services offered, operational capacities, type of guest relations, etc. Among the counties listed are China, Taiwan, Hong Kong, and South Korean, all of whom possess the type of clientele the various hotels in Singapore target (i.e. business men and rich tourists).

While there is nothing wrong with the type of service positioning that various hotels in the country are using the fact remains that the financial crisis has revealed an inherent weakness in this type of consumer positioning in that should another financial recession occur, hotels within Singapore will inevitably bear the brunt of this sudden lack of clientele. It must be noted that periods of growth and recession are actually cyclical and that while there may currently be a period of growth occurring there will inevitably be another recession on the way due to the nature of the financial system. Another factor that must be taken into consideration is the fact that the methods of operation of various hotel chains are considered wasteful and actually contribute to operational costs.

While this varies from hotel to hotel wasteful costs such as excessive water and electricity use as well as continuously replacing soap, shampoo, and sheets despite no inherent need actually drives up the cost of operations. Facility maintenance is actually one of the highest operational costs in the balance sheets of most hotels due to an apparent need to please guests which actually facilitates and even encourages wasteful practices that drive up the cost of operations.

Based on this wastefulness and the inevitability of a future recession affecting the number of visitors into Singapore, there is a definite need for various hotel chains within the country to shift to a more sustainable means of staying in business that will help reduce the cost of operations while at the saying time creating an effective means of product positioning that will help them a achieve a more diverse consumer base.

Wastefulness in the Hospitality Industry

Despite differences in their business culture, prices, and methods of operation all of the major international hotel chains within Singapore possess one thing in common and that is the ostentatious use of resources which results in wasteful spending. The reason behind this is simple, hotels want to attract guests through the feeling of luxury they perceive when they use the hotels facilities. This apparent luxury takes the form of resource wastefulness such as the overindulgent use of lighting, water, electricity as well as different types of food being shipped in through various international sources as well with items not meeting specific quality standards being thrown out.

While there is nothing wrong with maintaining high-quality standards at specific establishments there is a problem when such high standards promote an operational culture that encourages wastefulness. As indicated through interviews with various hotel staff members in randomly selected hotels in Singapore (who wish to remain anonymous due to the nature of their comments), wastefulness is actually an inherent part of a hotels S.O.P (standard operating procedure) wherein in order to maintain a certain level of facility quality areas are often times cleaned more than what is actually necessary.

While cleanliness is important to all living environments, cleaning a specific area that does not have a high concentration of guests several times within a given week using various cleansers, dusters and electronic washers make little sense for the hotel staff. Not only that lights are kept on nearly 24 hours a day 7 days a week in various hotel areas that do not have hotel guests or staff at all. Staff members have also observed that the hotel rarely puts up signs informing guests to conserve electricity or water and as a result, this culture of wastefulness has resulted in air conditioning units being left on despite no one using the room, water is allowed to run freely from faucets despite no apparent need to do so and bathroom products such as soaps, shampoos and conditioners are often replaced daily despite them not being used at all.

Other interviews conducted with staff from the hotel kitchen areas indicate a degree of wastefulness when it comes to the food being used in the hotel. It is often seen by the employees that the hotel administration often imports various ingredients rather than rely on locally produced products. While it may be true that certain types of ingredients can only be obtained through imports the fact is such products do not have an as long shelf life as compared to locally procured products that do not have to undergo lengthy shipping arrangements.

Another factor to consider is that in between the time of shipment and the arrival of the products in question there is the potential for the ingredients to inevitably expire on the way to the hotel. Since the policy of most hotels is to only use the highest quality ingredients this results in wastefully short shelf life for various hotel products. Not only are these practices a waste of resources but add to the costs of operations. If hotels in Singapore were to change their operational practices by going green not only would this reduce operational costs but it also has the chance of attracting environmentally consumers who prefer utilizing products and services that do not impact the environment negatively.

What does going green mean for a hotel?

For a hotel to adopt methods of environmental stewardship this means a radical change in the way it utilizes resources namely:

The reduction of hazardous products used in hotel maintenance

The heavy-duty cleansers hotel janitorial departments use are full of hazardous chemicals that, when released into the environment, cause various types of environmental pollution. This is further exacerbated by the fact that on average a single hotel uses thousands of gallons of cleansers within a single year (Gram-Hanssen, 2010). This problem is worsened by the fact that in areas where there is a greater concentration of hotels this means that the environmental impact is that much worse due to the possibility of greater concentrations of chemicals from the various hotels making their way into the surrounding environment (Cummings, 2009).

While there have been no conclusive studies on the possible environmental impact of the concentration of hotels in Singapore it can be assumed that with each of them utilizing thousands of gallons of heavy-duty cleansers the possibility of environmental contamination is pretty high. Another factor to consider is that at times the use of such cleaners is actually detrimental to the health of the janitorial staff that uses them on a daily basis.

Studies investigating the toxicity of chemical cleansers and solvents have shown that long term and continuous exposure to the chemicals found in todays cleansers can actually cause various respiratory ailments to surface as a result of the degree of exposure. Not only that, informal interviews with various international guests in various hotels reveal that some of them are actually mildly allergic to certain types of industrial cleansers and as such, they rarely go back to hotels that use such products on a daily basis.

An environmentally friendly alternative in such a case is to utilize biodegradable cleansers that are non-allergenic and do not cause respiratory ailments. Not only are such cleansers cheaper but they do not cause harm to the environment due to their chemical composition which becomes easily biodegradable (Cummings, 2009). They also contribute to the well-being of guests that stay at the hotel since the harsh chemicals used in industrial grade cleansers are not present in the environmentally friendly biodegradable types.

The use of more energy-efficient equipment such as lights, heating, air conditioning, and construction materials

Hotels, in general, can have rather large and expensive energy requirements; this can range from using a central cooling system as is the case in most hotels or individual air conditioning units in each room. No matter what the case may be, the fact of the matter is the constant use of such units over an extended period of time without some method of conservation can result in high operating costs due to the excessive use of electricity. In fact, interviews with various hotel guests in Singapore reveal that they consider the excessive use of electricity in various parts of the hotel as wasteful and unnecessary expenditure on the part of the hotel.

One recommended method in order to resolve such an issue has been the implementation of energy saving bulbs and air conditioning units that use a relatively lower level of electricity as compared to other similar unit types. Not only does this result in better long-term costs for the hotel but it also contributes to the concept of environmental stewardship. It must be noted though that the primary actor in hotels that causes wasteful energy expenditure is not the devices themselves but the operating style and procedure of the staff and upper management divisions of the hotel.

The standard operating procedure of most hotel chains directly contributes to the inherent wastefulness of electricity in most hotel chains. An examination of various S.O.Ps in the hospitality industry shows that at most, a large percentage of hotels fail to indicate in their S.O.Ps the need to conserve electricity and various other resources. This has resulted in a business culture of wastefulness where lights are left on, cooling units are left running despite it already being cold and Laundromats are run under inefficient operating conditions which increase the cost of operation.

Recycling of various waste products that come as a result of daily hotel operations

The inherent problem with waste disposal in most hotels is that they fail to consider the usefulness of recycling. An interview with the waste disposal staff of several hotels near the Singapore central business district indicates that on average the upper management of various hotel chains concentrates more on where to dispose of accumulated waste rather than how should waste be properly disposed of. Not only that, food accumulated from hotel buffets is regularly thrown away along with other types of products that fail to meet quality standards.

While it is understandable that hotels wish to have a certain degree of quality in their services the disposal of perfectly good food along with the indiscriminate disposal of perfectly recyclable materials shows a failure on the part of the Singaporean hotel industry to properly show a certain level of environmental stewardship. An examination of various waste disposal techniques utilized by other hotels around their world that have gone green shows that on average food that is still perfectly fine yet is about to be thrown away is regularly donated to various charitable institutions to be distributed among the needy.

Not only that these hotels implement certain levels of trash assortment bins for guests in their hotel rooms where guests can throw away their trash according to the designated labels on the garbage bins; recyclable material is often sent to recycling centers which result in less trash being thrown away by the hotel which winds up in landfills. As a result of these practices hotels that have gone green have been able to show that they care about the environment through positive environmental stewardship through proper waste disposal. This shows guests that they care about the environment and as such leave a positive image of the hotel in the mind of the guest which could result in future hotel patronage.

The use of energy-efficient vehicles in hotel operations

On occasion it is seen that various hotels often times employ vehicles in order to pick up important customers at the airport, such use of hotel resources is usually reserved for various wealthy clients and stars alike however most of them are gasoline or diesel-fueled cars. One of the latest innovations in the car industry has been the creation of hybrid cars that utilize both electricity and gasoline (Harris et al., 2002).

Such cars are far from fuel-efficient and utilize fewer resources as compared to various gas-guzzling vehicles (Deal, 2010). A simple switch to a fleet of hybrid cars would save hotels hundreds of thousands of dollars in fuel costs over the course of the cars operation. Other fuel-efficient cars that do not contribute to environmental waste have been the various cars developed that utilize unleaded gasoline (Deal, 2010).

Compared to regular gasoline powered or diesel powered cars unleaded cars actually last longer due to the corrosion from unleaded gasoline having less an effect on fuel lines compared to regular gasoline. Not only that pollution from engines that utilize unleaded gas is far less compared to that of regular gasoline power cars which as a result helps it to be more environmentally friendly as compared to other forms of transportation (Harris et al., 2002).

Conservation of water and other natural resources

On average a single hotel in Singapore can utilize 66,000 gallons of water or more within a single year. This does not include the resources wasted on throwing away less than ideal produce, fruits, and meats that do not adhere to a strict quality standard. An examination of hotel operations reveals that it is not unusual for hotel staff to note guests leaving taps running or seeing a cooling unit being left on even though there is no one in the room to use it (Kind, 2010).

The problem with the environment of luxury in most hotels lies with the fact that it results in a certain degree of resource carelessness on the part of hotel guests which causes them to adopt certain types of wasteful behaviors that they normally would not exhibit. Various studies examining the behavior of guests within hotels show a distinctive pattern of wastefulness, which, when asked about why they did such actions, the guests regularly responded by stating that they were merely getting what their money was worth by staying at the hotel in that they had a right to waste resources as need be (Kind, 2010).

The inherent problem with this situation is that it stems from the very culture of luxury and wastefulness that hotels are trying to portray to clients (Green & Devita, 1975). While there is nothing wrong with luxury itself the fact remains that the sheer amount of wastefulness of hotel guests when combined into a single year, results in a staggering amount of energy and water costs which results in increased operational costs for the hotel (Hall and Lew, 1998).

Some hotels have actually come with ingenious solutions to this dilemma, automatic water and electrical shut off sensors installed in hotel rooms help to decrease the overall level of wasted consumption (Green & Devita, 1975). Once a guest leaves a room these sensors trigger to turn off any non-essential electronic equipment in the room and the water sensors help to conserve water when no one is directly using it. As a result of such practices hotels that implemented the sensor system has been able to save themselves roughly $46,000 a year on operational expenses alone.

The goal of environmental stewardship is to minimize the overall impact that a businesss daily operations have on the natural environment (Griskevicius et al., 2010). On a daily basis, the hospitality industry in Singapore consumes thousands of gallons of water and hundreds of kilowatt-hours more so than any business outside of the manufacturing industry (Griskevicius et al., 2010).

Unfortunately, unlike the manufacturing industry, most of this expenditure is wasted on aspects of hotel operations (lighting, cooling, heating, etc.) that do not directly contribute to beneficial practices but rather are there so as to continue to create the image of luxury most major international hotel chains attempt to show. Under environmental stewardship, hotels attempt to improve how they utilize resources on a daily basis that minimize wastefulness and promote environmentally beneficial practices (Griskevicius et al., 2010). For a hotel to go green means a certain investment cost towards changing operational practices however such changes usually reap benefits beyond the initial cost that they entail (Hall and Lew, 1998).

Understanding Consumer Behavior

The process of segmentation, targeting, and positioning is a three-stage process used to determine what kind of consumers exist, what type of consumer the business is best off catering to, and finally optimizing the method of operations/services of the business in order to take advantage of that chosen segment and distinguish the business from its various competitors. As can be seen in the provided graph the process begins by identifying the different groups of consumers within a particular population set and identifying their various needs or preferences. In the case of this study, this takes the form of identifying the various groups of hotel patrons that come to Singapore on a daily basis (Herremans,2006).

The reason behind this is rather simple, just as consumers in the auto market have varied tastes i.e. some preferring speed to luxuries or roominess and safety over external appearance the hospitality industry also has various consumer segments that desire different things out of the various hotels i.e. comfort and luxury over price and affordability and vice versa (Herremans,2006). It must be understood that a business cannot be all things to all people since only a limited number of operational procedures can be implemented at any one time. As such businesses tend to specialize in meeting the needs of specific consumer groups due to the higher rate of profitability rather than a generalized approach towards company operations.

In the Singapore hospitality industry, for instance, prices vary between hotels and motels due to the fact that they cater to different kinds of consumer bases. Basically, marketing approaches utilizing market segmentation follow 3 distinct concepts namely: the undifferentiated strategy, the differentiated strategy, and the concentrated strategy. Under the concept of the undifferentiated strategy hotel guests (the consumers in question for this particular study) are categorized under a single demographic by the hotel industry (which is the company not attempting to satisfy any particular group but rather all groups in general).

For the hospitality industry, this can be seen in cases where hotels in a particular area are pretty standard with all competitors having the same methods of operation, prices, and offerings. With the concentrated strategy, hotels can be seen focusing on a particular guest demographic within the greater populace of visitors arriving into Singapore, this results in other potential consumers being allowed to be taken up by other hotels/competitors. This can be seen in cases where various airlines (i.e. Southwest Airlines) focus on consumers looking for cheaper ticket prices and are willing to go on flights without the customary in-flight meal and various other amenities.

In the case of the hospitality industry, this can be seen in the operational strategies of various motels who forego the segment of consumers looking for long term stays in favor of consumers that are looking to stay for either a few hours or one day (Henderson, 2004). Lastly, the differentiated strategy focuses on flexibility in the companys methods of operations employing both the undifferentiated and differentiated strategies.

This can be seen in operational strategies employed by various hotels today where rooms are priced differently according to the needs of the customer and their budget (i.e. budget rooms compared to luxury suites). In the case of hotels going green segmentation and targeting can be seen as playing an important role in identifying consumers within a given market and targeting which consumer to focus on (environmentally conscious travelers).

Concept of Product Positioning

As s

In the first part, this chapter undertakes a literature review on the Heritage Visitor Attractions (HVAs) in Malta. In this part, a review is done on the attractiveness of Malta as far as tourism and heritage are concerned.

The second part of the chapter deals with the question of online strategies that have been employed in the marketing and promotion of HVAs in Malta.

The third and last part seeks to determine the relation between the literature available on the online marketing of HVAs and the implementation of the ideas in the literature.

Take the general overview first and then go into the specifics regarding Malta HVAs  these should come at the very end of the literature review as this is your project area.

Significance and scope of the research

Very few studies have been undertaken on online marketing strategies of Maltas Heritage Tourist/Visitor Attractions. The majority of these studies concentrated on the impact of marketing on Maltas heritage visitor attractions. Amongst them is Farrugias (2006) study that gave an overview of the influence of sustainable tourism marketing on Maltas Heritage Visitor Sites. Her study aimed to identify ways in which tourism marketing of Maltese heritage sites could be achieved. The outcome of her study showed several emergent factors that could lead to a successful tourism market in Malta. The majority of factors emphasized on enhancing the marketing strategies to incorporate communication, networking, and partnerships with the heritage organizations and the visitors, both local and international (Karpati, 2008). With local visitors, this would encourage a sense of ownership which would also promote the protection of the heritage sites for their own benefit and that of others. However, this study did not indicate how these factors are to be incorporated in marketing (Sweeney & Sweeney, 2008).

Online marketing can be instrumental in ensuring communication, networking and partnership (Sweeney & Sweeney, 2008). This research will aim to assess the online marketing of Maltas heritage visitor attractions.

Literature

Smith (2005) undertook a study aimed at evaluating the effectiveness of the use of the internet in the promotion of tourism activities. His study was carried out by studying the use of a website by tourists and other visitors in California. The study found out that the website influenced the decision that the prospective tourists made.

Another researcher, Bramwell (2006) undertook a study that was aimed at reviewing how advertising has changed from its traditional form and how it has slowly been phased out by viral marketing in terms of capacity, dynamism, and attractiveness. The study found out that viral marketing was widely used in promoting many products.

Winter (2009) carried out a study where he sought to identify or to find out what characteristics in a tourism website are most valuable to a tourist. This research was carried out by carrying out a random sampling of tourists arriving at Hong Kong International Airport. The findings indicated that tourists were most concerned with the information to do with hotel reservation and room charges.

Another study was done by Beler, Borda, Bowenand Filippini-Fantoni (2004). Its aim was to identify and present the challenges that came about from the traditional advertising. It also aimed at finding the reasons as to why online advertising was ideal in completing the role of advertising through the web.

Prideaux and Kininmont (1999) sought to determine the effect that the spoken word, through the internet has on each of the decision making stages, which include awareness, interest, organizing as well as the actual decision making (Briggs, 2001). The study found out that users have an attachment to a service where they can easily interact. This interaction is through media such as through emails. Secondly, the study found out that demographic characteristics tend to influence the choices made by the users. Others who have undertaken research include Brannen (2004). His study was carried out with an aim of finding out the extent of internet use among tourists around the world.

Hanson (2000) carried out a similar study albeit in Jordan. His study sought to identify and establish what degree has online marketing and promotion being done in Jordan. The study was carried out by sampling 160 managers in the Jordanian tourism sector. Further, the study sought to identify the role that is played by online tourism promotion as far as Jordan was concerned. This study was carried out by sampling the opinions of different tourists. The findings of the study indicated that, online promotion and marketing of tourism are instrumental aspects in enhancing the competitiveness of the companies. This was especially those that embraced these aspects, as well as those countries that sold their heritage sites wholesomely. Beasley and Conway (2012) asserted that, for a country to continue drawing visitors to its Heritage sites, sustained online marketing campaigns are critical. This will ensure that many people around the globe are aware of the sites, and they are also talking about them. If the HVAs in a country are well marketed through the creation of awareness, tourists will want to visit. The other part that the study emphasizes as salient is about the information that the sector will provide. The study found out that stakeholders such as hotels and tour companies should ensure that they provide relevant information as much as possible.

HVAs in Malta

Heritage Visitor Attractions are a crucial element of tourist products that determine the choices that visitors/tourists make to visit a certain destination over the other (Hall & Zeppel 1990; Leask & Yeoman, 2002). It is the most important component amongst the three basic components of tourist products. One of the most important sectors in the tourism industry is the tourism industry is the Heritage Visitor Attractions (HVAs). This sector has set its eyes on the development of the tourism industry through the development of the most comprehensive marketing strategies at the centre of the Mediterranean is Malta. Interestingly, heritage tourism in Malta dates back as many as seven thousand years ago. Some of the prehistoric sites in Malta have already been given World Heritage Status (UNESCO, 2012).

Given the significance of tourism to the Maltese economy, there is a dire need for the promotion and marketing of the tourism sector both at the local and international market. Maltas tourism policy that has been developed for 2012-2016 talks of improving the accessibility of their tourism products (World Tourist Attractions 2011; UNESCO, 2012). This is to be done by ensuring that the marketing of Maltas tourism products is not only robust, but also effective. Maltas policy recognizes the changes in the international trends. It thus recommends that the country energizes its marketing efforts through the use of technology such as the internet. The policy adds that the countrys plan is to shift from traditional advertising to online advertising (Goeldner & Ritchie, 2009; Pfister & Tierney, 2009). This is shown by the fact that, in the year 2007, Malta had allocated a marginal 3% of its online advertising budget. The policy notes that as of 2011, the budget had increased significantly to stand at 24% and is expected to continue increasing (Shaffer, 2009; Heritage Malta 2005).

Filippini-Fantoni, McDaid and Cock (2011) undertook a research to determine how tourists in the U.S source for information on the choice of travel services. The study indicated that most of the tourists (39 percent) preferred sourcing this information online. The study also found out that 27 per cent of travellers made their choice after influence from the traditional media. Also, 32.7 per cent said that they were influenced by the online media. For those tourists between the ages of 18-24, social media were found to be the most influential in their choices. However, in Europe, Buhalis (2003) found out that the commonly sought information online is on the choice of destination. Gubrium and Silverman (2008) and Keene (2011) established that 69 per cent of internet users would make a decision on where to visit depending on the information they would find on the internet. In the year 2010, 53% of all holiday trips made from Europe were booked on the internet. This was an improvement of 5 percentage points when compared to the previous year (Forbes 2011).

There is also some variable literature from the studies that have been conducted by the Malta Tourism Authority (MTA). In a study done to determine the choice of holiday de4stination, the finding was that more and more people are now being influenced by the internet. For example, in 2007, 17.9 per cent of those sampled said that the internet as the media that have the largest influence on their choice. All these studies concur that online marketing is an idea whose time has come.

Most of this marketing and promotion has been done online as well as through the media. Online marketing in tourism has reaped huge benefits (Feilden & Jokilehto 1998; McElroy & Olazarri 1997). Online marketing has now become one of the most popular ways for stakeholders in the tourism industry to promote their services. This is because consumers are increasingly relying on the internet for information (Egger & Buhalis 2008). Given this fact, there are high possibilities that a consumer will find information on different products and services and will then be interested in buying them. Further, there has been a rise in the number and use of social networks. These platforms are also used by tourists to give information on the places they have visited many travellers and visitors. In general, most tourists find the internet as the most preferred resource and convenient source of information. In this case, it is easy to use, access and use, as well as time and cost efficient (Leask, 2010; Poria, Biran, & Reichel 2009).

Research conducted in mid 2012 showed that 63.5 per cent of all the people living in Europe were internet users. This accounted for 21.6 per cent of the total population in the world (Miniwatts Marketing Group, 2012). Other than providing information on destinations, the internet is also a platform where consumers can enquire about prices of flights, as well as the cost of accommodation before they can proceed with the booking. Despite its small geographical size, Malta has sites that attract tourists from all corners of the globe. Malta has also succeeded in the use of the internet to market its tourism. The number of internet users in the tourism industry has been on the increase. In 2010, they had increased to 59.2 per cent. This is according to a survey by Maltas National Statistics Office (2011) on the use of the internet in homes and enterprises in 2010, 55.8 per cent of the internet users related to travel arrangements. Hotel accommodation came in third amongst the objects commonly sought online by 29.8%, which was a rise of 4% when compared with the 2009 statistics (Heritage Malta, 2012).

Tunbridge (2008) noted that there has been a paradigm shift in the last 15 years in so far as online promotion of HVAs is concerned. United Nations World Tourism Organization (UNWTO) has in a report given some of the advantages that accrue to HVAs that embrace online marketing. Firstly, online marketing allows the user, in this context the tourist, to achieve a higher level of interaction and communication is more enhanced (Brynjolfsson & Smith 2001; Deighton, 1996; Graham, Ashworth and Tunbridge, 2000). Secondly, online marketing ensures that information is spread out to large geographical markets in a cost and time effective manner (Baye and Morgan 2001; Baye, Gatti, Kattuman & Morgan 2009). Thirdly, it is instrumental in enabling countries to enhance their HVAs brands especially through research and monitoring (ComScore, Inc. 2009; Li and Leckenby 2004). Fourthly, the interaction between the tourist and the business is normally two ways say though emails or comments that are responded to promptly. Fifthly, online marketing is a platform where potential clients can be reached one on one while at the same time reaching many other potential clients (Gobo 2004; Bryon & Russo 2003; Beazley, Bowen, Liu, and McDaid, 2010).

Although there is minimal literature on online marketing of tourism in Malta, other researchers have sought to find out the marketing strategies in tourism that Malta has used. Dholakia, Dholakia, Fritz, & Mundorf (2002) are a group of researchers who have undertaken research on the marketing strategies that Malta uses in its tourism sector.

Marketing of destinations that are most preferred by visitors is very essential in the tourism industry (Fyall & Garrod, 2005; Garrod & Wanhill, 2012). Online marketing has inspired the growth of the tourism industry by enhancing consumers exploration of attractive destinations back from the comforts of their homes. This helps potential visitors to reach informed decisions prior to their visitations. In addition, the internet has enabled visitors to scrutinise HVAs, check weather conditions, as well as communicate with other visitors around the world regarding their experience of a chosen destination (Smith 2009). Online marketing is the promotion of tourist products or services using the internet. There are various forms of promoting tourist products or services through the internet. These include company websites, social media networks, mobile phones and many other platforms of interactive media. Therefore, online marketing of heritage visitor attractions is a successful online communication with the potential visitors. In this case, it convinces them that they are being offered tourist products or services that they require or those that will be beneficial (Gimme 2009).

The Malta Tourism Authority embraced the use of internet in marketing tourism products. This was in the mid 1990s when the country launched its first online marketing strategies. By this time, the internet was in its infancy and was not well established globally. Over the years, online marketing of Maltas HVAs relied mainly on the visitmalta.com website. It now features a corporate site as well as other special interest online niches. With the introduction of Web 2.0, social networking took centre stage in online marketing in tourism and other sectors. In this respect, MTA developed its official pages on the most renowned Web 2.0 sites including social media networks like Facebook and Twitter, YouTube, Flickr, blogs, and video sharing websites among others (Debattista 201; Leask and Fyall 2006b). These social networks are more influential to young travellers between the ages of 18 and 24 (Debattista, 2011).

Moreover, MTA established multi-lingual e-newsletters that are sent to the ever-growing consumers database every 2 months. This is meant to keep in touch and enlighten them about the HVAs events and aspects which may be of interest. Furthermore, MTA launched applications for mobile phones and iPads, Apple iPhone Smartphone and Apple iPads tablets. One of the applications is a mobile destination guide written in English, Italian and German, whereas the other focuses on Maltas cultural offers. MTA also initiated a text to speech feature on the visitmalta.com site to enable consumers with reading problems or visual impairments to access information in the form of speech. Maltas tourism industry started redesigning the visitmalta.com portal in 2011 to accommodate these technologies like the geographical information system because of rapid changes in technology (Debattista 2011).

The attractiveness of a heritage site is very important in the marketing of any tourist destination. The stakeholders in any tourism sector also influence how marketable that sector is. In this case, the stakeholders in a tourism sector are responsible for the management of the sector. Good management practices result in positive results and vice versa. To look at marketing, which is a marketing function, it is also important to look at the stakeholders involved in visitor visitations (Henninger 2003).

Leask (2010) sought to find out the best and most effective management styles of visitor attractions. She defined visitor attraction as the permanent resource whether it is natural or artificial whose primary use is to attract visitors. Ferrell & Hartline (2011) regarded visitor attraction as a permanent establishment that is a destination where the primary reason for visiting is for entertainment, interest, or education. Normally, this is open to members of the public during certain pre-publicized times of the year and one that can attract tourists, as well as local citizens. However, the study made by Leask (2010) noted that there is yet to be a universally accepted definition of a visitor attraction.

The second part of the research deals with the importance of a visitor attraction. There are different motivations for visiting a heritage site. Some of the motivations include education, entertainment, or even nostalgia. There are three that make up an attraction; a tourist/visitor, a great site, and a marker. A marker in this context refers to that information about the site that makes the visitor want to visit. From this definition of the elements of an attraction, the importance of marketing is accentuated since marketing is all about letting the clients know of the goodness of the product. The research found out that a researcher is more likely to visit a site where he or she feels that the needs are best satisfied. Cooper, Fletcher, Gilbert, & Wanhill (1998) noted that studies on tourist attractions have been inadequate as researchers have tended to ignore this area. Other scholars observed that there are a few studies on visitor attractions as most of the academic debate has been limited to the definitions of a visitor attraction (Liu & Bowen, 2011). Other academic researches in these areas have dealt with the location, products offered, and management of tourism, as well as the visitor experience.

The research emphasizes that the site is the most important aspect in a visitor attraction. Without the attraction, there will be no tourism or visitor attractions. Given that the site is the most influential factor when it comes to visitor/attraction, the question about the features available in Malta arises. Malta is regarded as a small country. However, it is well known worldwide for its vast HVAs ranging from the archaeological and historical sites to natural sites. Valletta, Maltas historical capital was one of the earliest most renowned HVA sites listed among the Worlds Heritage Sites by the United Nations Educational, Scientific and Cultural Organization-UNESCO (Glow, Kenneth & Baack 2004). It is a thriving visitor attraction that includes various national buildings, monuments, artefacts amongst its HVAs. The Megalithic Complexes of Ggantija, Hagar Qim, Tarxien and Mnajdra, as well as the Hal Saflieni Hypogeum, a subterranean Neolithic structure, are the other great UNESCO World Heritage Sites-WHS in Malta (Leask & Fyall, 2012). WHS are attractions of high profile, and they are usually designated as iconic and unique (Leask & Yeoman, 2002). Most often, they are owned by the government and are very significant in the national tourism industry. In addition, WHS/HVAs have other features, which include quality, authenticity, activity options and drawing power (Leask & Yeoman, 2002).

Maltese HVAs are of high quality as they provide a pleasant and clean environment, smooth tourist oriented procedures and operations, security and friendly hospitality. With reference to authenticity, HVAs should be real, that is, they should produce the distinctive flavour of that destination in a manner that creates and promotes the sense of place. The majority of visitors concentrates on the sites, buildings and facilities offered by the HVAs while making their travel decisions. Besides, it is very important to consider the activities, which keep the visitors busy and entertained (Willems 2007; Rose & Martin 2004).

Well managed HVAs should provide a varied program of activities for their visitors. Lastly, the drawing power is measured by the potential number of visitors visiting a certain destination and their likelihood of visiting the destination again. The WHS is endorsed by high drawing power. WHS/HVAs are the primary visitor attractions, and this is attributed to the fact that they highly influence visitors decisions regarding where to visit. They are often the primary reason behind visitation of a certain destination and they are closely connected to the destinations image as promoted in the marketing strategies. Apart from the WHS mentioned above, Malta has other important heritage tourist attractions like Mdina, Gozo Island, Sun/beaches and numerous Mediterranean hotels for dining and nightlife amongst others. Another important attraction for tourists in Malta is the diving activity in the Mediterranean Sea around the Maltese islands (Leask & Fyall, 2012).

Therefore, it is clear that Malta is well endowed with the first element of a visitor attraction which is attractiveness. The second important element is the marker, which is to do with the marketing of these sites. The marketing theory says states that an effective marketing style is one that helps in the achievement of HVA objectives (Bruce & Creighton 2006). Notably, there is a common agreement that marketing of tourism is helpful in attracting visitors. However, the big and controversial question is on the best marketing mix or strategy for a certain tourism product. However, most scholars in the field agree that collaboration between the various players in the tourism sector is a big step in achieving effective marketing. The collaboration is seen clearly in Maltas national policy where the government is to partner with private establishments in promoting their products online (Demoule 2012; Bonn, Joseph-Matthews, Mo, Hayes, & Cave, 2007).

When the country markets the beaches and the cities, the benefits trickle down to the private establishments such as hotels. These are the establishments that will provide accommodation to the visitors (Hall & McArthur 1997). However, researchers agree that such partnerships will not be easy as the stakeholders may be unwilling to share crucial information. This is especially since some of them are industry competitors. However, over the last 15 years, Malta has had some of the most comprehensive marketing strategies (Handlechner, 2008). The first comprehensive policy on marketing Malta tourism was drafted in 2002. The policy talked of the need to diversify the Market by increasing awareness on other products that were available in Malta. This was apart from the sun, which had traditionally been marketed as the epitome of Maltese heritage. During these times, tourism was only marketed in the coastal areas (Lo 2011; Henninger 2003).

Scholars later emerged challenging the notion that the sun was the epitome of Maltese tourism. This led to the start of the exploitation of the heritage tourist attractions most of which have been described above. It has been asserted that a balance should be struck between the Maltese tourism and HVAs (Kotler 2005). This perhaps is the background of this study. The HVAs promotion has developed in the last 15 years. After the decision was made to market the heritage activities aggressively, stakeholders in the industry have continually sought to ensure that the marketing activities are in tandem with the national policy developed by the MTA. This has been done by ensuring that the human resource and skills are developed to market these products effectively, which explains the success of the online promotions in Malta (Buhalis & Egger 2008; Rossiter & Percy 2005).

As of 2011, Expedia.com, one of the most known global travel websites awarded MTA the Best Partner Innovator award because of its marketing strategies. Indeed, Malta was the first Mediterranean country to receive such an honour due to its efforts in online marketing in the widely diversifying tourism industry. The United Kingdom is one of the most important markets for Maltas tourism. UK tourists were the first to adopt online travel services in Europe (Bennett 2002). As mentioned earlier, Europe possesses a huge percentage of internet users. This prompted Malta to change and adopt online marketing services offered by Expedia.com and other online travel agencies to enhance its tourism sector. The European countries, UK, Italy, Germany and France have been the five potential source markets for Maltas HVAs (Wanhill 2000; King & Parnwell 2011).

During the year 2010, visitors from the UK amounted to 415, 120, Italy 214, 259, Germany 126, 097 and France 86, 475 (Debattista, 2011). Expedia enabled the Malta tourism sector to implement online distribution with its HVAs, which boosted sales. A substantial number of visitors employ the internet in their research about holidays, making travel arrangements, booking and paying. Maltas partnership with Expedia has contributed to major benefits to its tourism industry (Tunbridge 2011). In 2011, Malta was able to offer more accommodation to visitors thus making more profits, even during a period of international crisis (Deidun, Castriota and Arrigo 2011). The average profit rate on a daily basis rose by 5 per cent when compared to that of 2010. Additionally, the number of independent visitors increased steadily by about 46 per cent. This relationship also influenced rapid changes in the Maltese tourism sector such as the opening up of several new routes, the emphasized growth of internet marketing, the establishment of low cost carriers and strategies to lure young, affluent and more adventurous tourists with shorter holidays but more travel experience especially during the off-peak periods (Markwick 1999; Malta 1995).

Low cost carriers led to a substantial increase in the number of visitors to Malta. To ensure progress in online marketing in Malta is maintained and enhanced, Expedia offers education to Maltas tourism industry (Debattista 2011). Back in 2009, the Hotel Juliani in Malta was ranked by Expedia the 11^th best hotel in Europe and 29^th globally. By that time, close to 85,000 hotels in the world had registered with Expedia. The Expedia World Heritage Insider list featured only one percent of hotels. Five Maltese hotels had made it to the list; however, Juliani hotel was the one that ranked with the top hotels. The MTA had proposed to invest ¬800,000 in online marketing in 2009 because of this impact of online marketing in Maltas HVAs (Timesofmalta.com, 2009).

The year 2006 saw the entrance of Izzicarhire.com, an online car rental service in the Maltese tourism market. This company connected several car rental companies with tourists. The company offered a portal to access the suppliers, match rates, as well as make bookings. This was a great boost to Maltas HVAs leading to a convenient and comprehensive service to its visitors. This service is connected with Maltas International Airport (Izzicarhire.com, 2012). Malta has gone a long way to improve accessibility to the islands with its national legacy carrier Air Malta. Major changes and improvements have been incorporated in its online marketing strategies. Recently, this Maltese international carrier launched a new interactive website that targeted mainly tourists. This replaced its old website which had served for 14 years. This site is accessed and followed by millions of visitors annually. It is by far the most visited Maltese sites in Malta and Europe at large (Gubrium, Jaber & Silverman 2007). The enhanced new site offered more features and information pertaining to flights, weather conditions and services such as live destinations and terminal maps. Additionally, the new site increased its traffic with the help of thousands checking both incoming and outgoing flights and surveying of Maltas weather conditions daily. The site has also helped many visitors to plan their travel arrangements mostly for leisure (Brown 1998; Busuttil 2000).

Malta tourism industry stakeholders also introduced a new online media library, viewingmalta.com. In this case, viewers can see up to date photo and video collections of Maltese HVAs. This online library is subdivided into three, Malta Islands, Gozo and Comino. In the Malta Islands sector, images showing the Maltas heritage, culture and diversity are posted. The Malta tourism industry has also worked with tripAdvisor.com, a more comprehensive social network platform in order to connect with visitors and collect information about the strengths and weaknesses of various HVAs in order to improve the overall performance of the Maltese Islands. This is attributed to the fact that understanding visitors preferences, opinions, and perceptions about the HVAs is the starting point of developing an effective online marketing (Fedele 2012).

Borg (2008) noted that online marketing of heritage sites in Malta is not aimed at replacing the traditional marketing but rather it is aimed at complementing the conventional marketing styles. Online marketing has quickly evolved as a platform that can keep up with the fast changing dynamics in the world. This is the reason why Maltas tourism players must incorporate this style of promotion and marketing in their strategy (Huberman & Miles, 2002; Conradi & Wang, 2003). There has also been a tremendous shift in the nature of the market. The change in the nature of the market has resulted in the need to change marketing styles, as well as adopt new styles that are effective. Some of the new promotional styles include all-year promotions. Promotion was previously done during the peak season; however, the Malta Tourism Authority changed the policy to allow promotion to be done all year so as to increase awareness (European Commission, 2010). Given the shift in policy and consideration of the cost of running traditional advertising, online marketing has emerged as quite cheap and able to reach a larger market (Markwick, 1999; Hollinshead, 2000).

The majority of visitors relies on the internet to access information about services at HVAs and frequently seek assistance or suggestions from visitors who have previously visited the destinations (Can-Seng 2002). Recent studies concluded that visitors/tourists prefer to seek recommendations from other tourists who previously visited HVAs prior to choosing or visiting a destination. For this reason, they check more for online comments, opinions and preferences to help them reach a sound decision. Tourists tend to believe and rely on word of mouth recommendations from people of their own status. This may include other tourists rather than advice from experts or stakeholders trying to sell a service. The MTA collects

Introduction

One of the central threats to the clinical well-being of the population continues to be the problem of overweight and obesity and all the disruptive consequences that these conditions lead to. It is well known that obesity causes a multitude of pathological changes in the patients body, including any problems related to impaired metabolism (Blüher, 2019). It is essential to recognize that the problem of obesity has no measurable age, gender, or socioeconomic boundaries, which means this dysfunction can affect any individual; however, it is during adolescence that obesity proves to be extremely dangerous. During puberty, when an adolescents body naturally balances hormones and adjusts metabolic processes, obesity can cause crippling abnormalities. As an adult, such abnormalities can lead to exacerbations of chronic diseases. In addition, if a teenager suffers from being overweight, it can cause psychological trauma and additional eating disorders, especially caused by school bullying and lack of attraction to peers. Thus, there is a tangible need for a clinical intervention for this patient population that can preventively address the problem of obesity among adolescents. This research paper aims to explore not only the possibilities of such an intervention but also to evaluate the benefits and limitations of the proposed recommendations critically. To be specific, the problem of obesity and overweight is being studied for adolescents from Tarrant County, Texas; however, it is assumed that the recommendations generated are true for all adolescents with this problem.

Background Information: Tarrant County, Texas

The problem of obesity, including among adolescents, has been traditionally  but not entirely deservedly  associated with the U.S. population. These stereotypical judgments as a whole are not entirely made up: according to statistics from the CDC (2021), approximately 42.4% of American adults are obese, and this number has risen significantly over the past twenty years. Among Texas adolescent population, a similar prevalence persists. Data reports that as of 2019, approximately one in six students in grades 9-12 in Texas were overweight, with 16.9% of Texas teens diagnosed with obesity (CDC, 2019). These statistics report that obesity and overweight are a highly relevant problem among local youth, which means there is an urgent need to address this problem in a reactive manner.

The choice of Tarrant County as one of the largest counties in the state of Texas was not an accident; instead, the motivation for choosing this geographic area is legitimate. By now, Tarrant County has more than 2,100,000 local residents, a number that has increased linearly over the past decade (Figure 1). Of that number, the government reports that 26.0% of the population is under eighteen years of age and, therefore, teenagers (Census, 2021). This is one of the highest numbers not only in all of Texas but in the United States: in Tarrant County, literally, one in four residents is a teenager.

This section critically needs to explain the underlying causes of obesity that cause many adolescents to become overweight and a number of associated health consequences. The NHS (2019) reports that the main pattern that leads to dramatic fat gain is that the individual moves too little and eats too much. As a result of this low activity, excess calories are not spent on exercise, and the body deposits them as a reserve in fat tissue. Scientific studies link the pandemic prevalence of obesity among adolescents to the widespread use of convenience foods. For example, it has been reported that approximately one in three adolescents in the sample consumes fast food at least once a week; as a result, the availability of fast food and abdominal obesity among adolescents found a strong positive correlation (Mohammadbeigi et al. 2018). Extrapolating these reflections to a map of Tarrant County (Figure 2) shows that fast food outlets are often located near local schools and colleges. Taken together, this data shows that for teens from this county, eating at fast-food chains is not uncommon, leading to obesity and overweight problems among Texas youth.

Clinical Intervention

Clinical intervention for preventive management of obesity is a priority need for communities. This need is driven by a general desire to improve the health of the nation and relieve the burden on the health care system, as being overweight and even more so being obese are reliable predictors of the development of chronic problems in an individual. Studies show that obesity is positively associated with risks of diabetes, hypertension, kidney failure, heart attacks and strokes, dementia, and even some cancers (Blüher, 2019). Furthermore, obesity in adolescents is an additional complicating factor for the more severe course of COVID-19 (Rivera, 2021). Consequently, the disruptive effects of obesity result in shorter life expectancy and decreased overall comfort and safety. However, as reported by Blüher (2019), any interventions used so far have not had long-term benefits because they have failed to address reliably managing obesity problems among adolescent patients. As a consequence, a need is created to develop new preventive prevention systems to address this problem.

As part of the solution being developed, the recommendation for clinical intervention is preventive control of the obesity problem through educational programs distributed, including in adolescent dental clinics and hospital dental departments. Dentistry as a medical field, motivated for the purposes of the solution being developed, makes it possible to identify problems related to obesity at an early stage. In fact, oral health acts here as a mediator between malnutrition  a key predictor of overweight problems  and obesity, leading to destructive consequences in the long term. This transparent link, combined with the comparatively easy detection of oral health problems by professional dentists, creates great potential for preventive management of obesity issues and the prevention of the spread of this diagnosis through a sound educational program. As before, Tarrant County was again not randomly chosen for the purposes of this paper because, as shown in Figure 3, there are quite a few dental offices in the county. This increases the outreach to teens and helps to implement recommendations to curb overweight not locally but throughout Tarrant County.

Many studies in recent years have developed the theme of the relationship between obesity and clinical problems related to the oral cavity. In fact, this correlation should be viewed from two angles. First, systematic poor diet, unbalanced diet, consumption of added sugar, and fast food naturally leads to oral disease; based on this, the dentist can predict the formation of an overweight patient. Second, if the patient is already overweight but has not yet entered the stage of obesity, a positive opportunity for change is created. However, even being overweight has an impact on oral health. For example, studies show that being overweight doubles the likelihood of developing periodontitis, an inflammatory disease of the soft tissues of the gums (Martinez-Herrera et al., 2017). Consequently, both of these perspectives  improper diet and already being overweight  should be considered in the current development.

How Diet Influences Oral Health

The need for a proper diet and balanced nutrition stems from the desire to maintain good oral health. The mouth is the first barrier to the mechanical transformation of food, and saliva enzymes are present to break down large polymeric molecules partially and disinfect passing food fragments. Oral health is affected by a number of factors of the food used, including its hardness, salinity, pH, and the amount of sugar used. Lack of solid foods in the diet leads to dysfunction of the chewing muscles of the jaw, resulting in a reduced dental performance of the patient. Using only plant-based foods (vegetarianism and veganism) has been shown to lead to impaired salivary acidity, cavity formation, and the salivary deficiency (GSD, 2019). Meanwhile, tooth decay is one of the most common problems among adolescent patients, which seems to be related to an excessive acidic diet. By consuming large amounts of carbohydrates, among which added sugar, dental hard tissues become demineralized, resulting in a dramatic decrease in dental tissue pH (ADA, 2021). In turn, the decrease in acidity among the oral cavity catalyzes the development of pathogenic microorganisms that populate the damaged tooth tissue and use nutrients to reproduce (Figure 4). The WHO (2018) reports that approximately 0.5 to 3.5 teeth in twelve-year-olds are subject to carious damage. Meanwhile, dental caries is costly to health care and negatively affects well-being (Moynihan, 2016, p. 149). Thus, innocuously starting dental caries can lead to the development of pulpitis, tooth nerve damage, and premature tooth death.

Although carious tooth tissue damage is one of the most common causes of oral disease, it would be a mistake to associate the destructive effects of food only with tooth decay. For example, a patients teeth and gums may be susceptible to erosive lesions that result in thinning of dental tissue. Erosive processes differ from caries because, in this case, the dental tissue is only destroyed (as shown in Figure 4), but there is no bacterial contamination of the cavities that have formed. The formation of erosive foci is traditionally associated with an excessively acidic diet: this includes most carbonated lemonades with added sugar. Thus, an improper diet with an excess of chemically unbalanced foods and added sugar leads to several degenerative processes.

Link to Obesity

As a consequence, an ill-balanced diet in adolescents affects not only oral health but also overweight problems. Statistics show that only 1 in 10 overweight teens does not consume fast food, while the preponderance of overweight or obese students consume fast food at least three times a week, as shown in Figure 5. However, the oral cavity is a convenient area for clinical observation because it is possible to predict obesity from the presence of caries and erosions if the childs diet is also examined. This means that during a dental examination, the dentist will always be able to make a preliminary assessment of the type of food that the patient systematically eats and then suggest dietary adjustments based on the fear of obesity. This is the assumption that is the idea behind the clinical intervention being developed.

The possibility of using dental offices as the primary gateway to detect the likelihood of overweight in a Texas adolescent turns out to be highly convenient for current clinical intervention purposes. Common recommendations suggest that adolescents should see a dentist at least twice a year (once every six months), which creates a positive dynamic for monitoring changes in oral health (ADG, 2019). The more red flags a doctor sees in a patients mouth, the more likely it is that teens have a poor diet, which has the potential to affect overweight problems. In this case, the physician has the opportunity to alert the child to the real risks and provide education on proper dietary intake. A competent doctor should clearly understand the psychology of eating disorders and be knowledgeable about aspects of addiction to specific foods. It is unacceptable to ban an adolescent from consuming carbonated lemonades or fast food to fix their diet because, as previously stated, such tactics have been shown to be ineffective in the long run; even if a child gives up these foods for several weeks, they will eventually return to them (Blücher, 2019). Instead, the clinician should suggest alternatives for the specific foods that are most addictive and transform the Texas teenagers diet in a planned but effective manner. This may involve gradually removing one unhealthy food per week from the diet so that it is replaced with a healthy and tasty alternative that the patient will enjoy. Ultimately, any consolidation of change and positive results can only be achieved when the adolescent is self-aware and fully aware of the problem and is willing to see the consequences.

Measuring Outcomes

Because oral diseases that lead to overweight problems are most often treated clinically but almost never left to develop further when supervised by a physician, any carious and erosive dental changes are difficult to observe over time. More specifically, an adolescent patient who comes to the doctor for an examination with complaints of caries is the most likely to receive therapeutic treatment for this caries, which means that further evolution of this problem proves difficult. However, in general, the positive trend remains that in the case of a childs improper diet  and in the absence of the same problems in the family history  degenerative lesions of the oral cavity are more frequent. Consequently, if the number of disease development foci has increased after six months, the child has never been able to transition to a healthy diet, and thus their risk of becoming overweight naturally increases. However, this method is not highly accurate or reliable, as several limitations affect the validity of the measurements at once. First, the presence of hereditary dental problems can be ignored. Second, during initial examinations, the doctor may not have noticed hidden forming cavities that have evolved six months later. Third, the development of tooth and gum degenerative lesions is ambiguous evidence of a teenagers illiterate diet, although there is a connection.

However, if the adolescent is indeed following a new diet and following the lessons learned from the doctor, it may be noticeable during a dental exam. In particular, avoiding junk food and proper oral hygiene leads to less plaque. In addition to a reduction in the number of carious lesions, the intensity of gingivitis is also reduced, as the case studies suggest (Sosiawan et al., 2020). Notably, the level of artificial sugar consumed can be assessed by rapid patient blood tests. Although it may seem an uncommon practice, giving blood for a complete test before a therapeutic intervention has its advantages. First, by doing so, the physician assesses the amount of glucose in the blood, which, in addition to evidence of the consumption of sugary foods, can be a predictor of the development of diabetes. Second, with this screening, the therapist can detect blood inflammation and pathological infections, which has implications for choosing therapy for diseased teeth (Cotter & Dilliard, 2019). Including hidden dental abscesses that are not symptomatic can be detected through laboratory blood testing. Thus, clinical examination of a patients blood in a dental clinic setting makes just as much sense.

Meanwhile, a physician interested in treatment may suggest that the patient keep a personal dietary observation diary in order to keep track of progress. Writing down absolutely all the foods consumed in a calendar can be fraught with the development of eating disorders, so an alternative is suggested: for a limited time (for example, one month), the child records all the unhealthy foods he or she has consumed and indicates their amounts. An example of a fragment of such a diary is shown in Table 1 below: this format may be sufficient to trace the teenagers diet and draw conclusions about the balance of the diet. Even in this case, however, it should be understood that there are limitations. For example, there is a research pattern that subjects under observation tend to change their behavior for a more encouraged one, which distorts the actual results (Purssell et al., 2020). In addition, it is possible that an adolescent may forget to write down foods or lie about precisely what he or she consumed. On the other hand, keeping a diary fosters systematicity and responsibility for ones diet, which can be beneficial in combating obesity. The patient shows this diary to the dentist at each visit. However, if the frequency of visits to the dentist is low, the dentist can telecommunicate with the teen via email or messengers to monitor the dynamics.

Conclusion

To summarize, overweight and obesity are a severe threat to the national health care system. Being overweight in adolescents proves to be a particularly sensitive problem, as it is not only associated with the most critical changes in the patients metabolism but also entails dangerous mental trauma for the emerging personality. Being overweight and obese has been shown to be positively associated with the development of chronic disease, diabetes, kidney and heart disease, and cancer. Consequently, the national medical agenda is interested in preventively addressing obesity among adolescents. This research paper developed the idea of using dental offices as the primary gateway to detect potential obesity among Texas adolescents. The choice of a particular area, Tarrant County, was driven not only by its demographics but also by the infrastructural characteristics of the region, which may cause many local high schools and college students to consume fast food systematically. This affects oral health and leads to overweight problems. The clinical intervention involves the use of treating dentists to screen oral health. Dynamics are measured through regular monitoring of dental and gum health and/or through the use of a food diary to assess the adolescent patients diet. In other words, dentists have an almost unique opportunity to detect the potential development of obesity in a patient through systematic, high-quality, and detailed oral health surveillance.

This intervention is expected to bring about positive changes in the overweight crisis among Texas youth not only in the short term but also in the long term. However, it should be kept in mind that there is no perfect solution to this problem, and therefore each of the recommendations is associated with some risks. For example, oral diseases are ambiguously linked only to an incorrect diet. In addition, it is likely that the patient will refuse to keep a food diary or will not want to write down all the foods. All this together distorts the results of therapy and has a negative impact on clinical intervention. This is why the procedure of educating the adolescent and absolutely acknowledging the need for change should be paramount. Once a teenager is fully aware of his or her oral problems and understands that the cause of these problems  or one of the causes  is an improperly formed diet, and is aware of the consequences of continuing such a diet, it is expected that this will lead to a desire to change his or her eating habits.

References

ADA. (2021). Nutrition and oral health. Department of Scientific Information, Evidence Synthesis & Translation Research, ADA Science & Research Institute, LLC. Web.

ADG. (2019). How to know when your teenager should go to the dentist. Aurora Dental Group. Web.

Almuhanna, M. A., Alsaif, M., Alsaadi, M., & Almajwal, A. (2014). Fast food intake and prevalence of obesity in school children in Riyadh City. Sudanese Journal of Paediatrics, 14(1), 71-80.

Blüher, M. (2019). Obesity: Global epidemiology and pathogenesis. Nature Reviews Endocrinology, 15(5), 288-298. Web.

CDC. (2019). Obesity / weight status. Youth Risk Behavior Surveillance System CDC. Web.

CDC. (2021). Adult obesity facts. U.S. Department of Health & Human Services. Web.

Census. (2021). QuickFacts. Census. Web.

Cotter, J. C., & Dilliard, J. A. (2019). What do lab values mean? DDH. Web.

GSD. (2019). Is a vegan diet bad for your teeth? Golden State Dentistry. Web.

Martinez-Herrera, M., Silvestre-Rangil, J., & Silvestre, F. J. (2017). Association between obesity and periodontal disease. A systematic review of epidemiological studies and controlled clinical trials. Medicina Oral, Patologia Oral y Cirugia Bucal, 22(6), 708-715. Web.

Mohammadbeigi, A., Asgarian, A., Moshir, E., Heidari, H., Afrashteh, S., Khazaei, S., & Ansari, H. (2018). Fast food consumption and overweight/obesity prevalence in students and its association with general and abdominal obesity. Journal of Preventive Medicine and Hygiene, 59(3), 236-240. Web.

Moynihan, P. (2016). Sugars and dental caries: evidence for setting a recommended threshold for intake. Advances in Nutrition, 7(1), 149-156. Web.

NHS. (2019). Causes. NHS. Web.

ODN. (2018). Tarrant County, TX. Open Data Network. Web.

Purssell, E., Drey, N., Chudleigh, J., Creedon, S., & Gould, D. J. (2020). The Hawthorne effect on adherence to hand hygiene in patient care. Journal of Hospital Infection, 106(2), 311-317. Web.

Rivera, E. (2021). North Texas hospitals are seeing more children with COVID. experts say it might get worse. KERA News. Web.

Salat, A. (2020). Initial caries: Management for minimal intervention. Style Italiano. Web.

Sosiawan, A., Krissanti, T. D., Palupi, R., Berniyanti, T., Wening, G. R. S., & Lestari, P. (2020). The relationship of nutritional status and gingivitis in elementary school children. Indian Journal of Public Health Research & Development, 11(3), 2471-2475.

WHO. (2018). Diet and oral health [PDF document]. Web.

Appendix A: Informed Consent

Nutritional Food Choices in Teenagers

Purpose of the Study

You are being asked to participate in a research study about nutrition in teenagers. The purpose of this study is to find out how much knowledge teenagers have in picking food for healthy meal choices. If you agree to participate in this study, you will be asked to answer a few questions regarding your childs demographics and eating habits during the day at the start of the dental screening, then after the screening is over answer the same questions on your childs eating habits after having a discussion during the screening appointment on healthy food choices. The study will take 30 minutes during your dental screening at Dental Health Arlington Texas.

Risks

This is a minimal risk research study. That means that the risks of participating are no more likely or serious than those you encounter in everyday activities. You can withdraw from the study at any time, without any penalty.

Benefits

Participation in this study may directly benefit you by making you aware of the benefits of healthy food choices. More broadly, this study may help researchers learn more about nutrition in teenagers and may help future people with similar interests or issues.

Confidentiality

The researcher will make every effort to ensure that the information you provide as part of this study remains confidential. Your information will be collected through questions and confidentiality is protected by providing a number to participants. This information/data will be securely stored.

This informed consent form will be kept for three (3) years after the study as required by federal law and then it will be destroyed. Your identity will not be revealed in any publications, presentations, or reports resulting from this research study.

Participation

Your participation in this research is completely voluntary. If you agree to participate now and change your mind later, you may withdraw at any time. If you choose to withdraw after we have already collected information about you, we will not use your information in the results of the survey. ________ I agree to be photographed and videoed during screening.

________ I do not want photographed or videoed during screening.

You will not receive any type of payment for participating in this study. There is no cost to you for participating in the study.

Contact

Prior, during, and after your participation you may contact the researcher by email [email protected]. When asking questions about the research study please be sure to reference the researchers name and study title.

For concerns with any part of this study, please contact the Lamar University Institutional Review Board at [email protected].

Signature

You have been informed about the title of the study, the purpose of the study, the study procedures, the benefits of the study, and possible risks. You have been given a copy of this consent form. You have been given the opportunity to ask questions before signing this form.

By signing this form, you voluntarily agree to participate in this study, but you are not waiving any of your legal rights.

_____________________________________

^{Participants Printed Name}

_____________________________________ _____/_____/____

^{Participants Signature}

As part of the research team, I have explained the study title, study purpose, study procedures, benefits of the study, and possible risks involved with the research study.

_____________________________________

^{Research Team Member Printed Name}

_____________________________________ _____/_____/____

^{Research Team Member Signature Date}

Minor(individuals under the age of 18) are not legally able to consent to research. Consent must be provided by the participants parent or legal guardian. If a child is of an age and mental ability that s/he can understand the concept of research and research activity, the childs assent must be sought and documented in addition to the parents.

Minor Assent

By signing below, you agree that the above information has been explained to you and all your current questions have been answered. You understand that you may ask questions about any aspect of this research study during the study and in the future. By signing this form, you agree that your child may participate in this research study.

_________________________________

^{Parents Printed Name}

_________________________________ _________________

^{Parents Signature Date}

PRINT THE CHILDS NAME: ________________

Minors Assent: This research has been explained to me and I agree to participate. _________________________________ _________________

^{Minors Signature Date}

PRINT the Adults Name: ________________ _________________________________ _________________

^{Participants Signature Date}

Consent of Guardian / Representative If you have authority to consent on behalf of the above-named participant, please print your name __________________ and indicate your relationship to the participant: __________________.

_________________________________ _________________

^{Participants Legal Guardian Signature Date}

Appendix B: Clinical Intervention Plan

The purpose of this study is to examine the effectiveness of clinical training programs for adolescents implemented at dental centers in Tarrant County, Texas, to address overweight and obesity. The intervention design is based on a longitudinal approach in which groups of respondents are interviewed before and after the training programs. Thus, two groups of eight adolescents were used for the working sample, each of whom (or their caregivers) signed an informed consent form in advance (Appendix A). The selection of participants for the experiment is strictly voluntary according to the adolescents desire to participate; a promotional flyer (Appendix D) for participation is posted in the central lobby of Dental Health Arlington (DHA).

The first group of eight participants begins at 8 a.m., with half an hour given to each student by a dental professional. During this time, the dentist carefully examines the patients oral health, documents any changes to study the dynamics, and offers some pertinent advice and dietary recommendations. After five hours, a second group is invited to participate, so the

Introduction

Palliative Care is a form of medical care that tries to reduce the disease symptoms instead of providing cure to the disease suffered by the patient (Pathmavathy, 2004). It attempts to mitigate the severity of the symptoms rather than halting the disease itself to boost the quality of life of the patients that are suffering serious diseases. The main goal of palliative care is to relieve such patients of their suffering to ensure they live better lives despite their complex illness (Pathmavathy, 2004).

Buckley (2008) argues that palliative care enables the patients and their families to cope when their patient is experiencing the critical conditions of the disease. It is applied at early stages in the course of illness and is combined with other therapies meant to prolong the life of the patient.

According to Speck (2006) palliative care generally alleviates symptoms of the disease irrespective of whether the other curative methods make progress or not. It could therefore be used to alleviate the side effects of illness, mostly of curative treatments. In the United States, two kinds of palliative care namely general palliative care and hospice care depending on where (location) the services are offered and also the payment systems that each of them uses.

However, the two kinds of palliative care share the same philosophy and are not distinguished in some other place like the UK (Fallon & Hanks, 2006). The United Kingdom and Canada talks of hospice and non-hospice based palliative care depending on the condition of illness being experienced. Hospice based palliative care is meant for those patients in critical conditions while non hospice based palliative care is provided to those with life-limiting illness connected to their diseases. Palliative care is therefore worth reviewing because of its importance in improving the quality of life of patients suffering from complex illnesses (Fallon & Hanks, 2006).

World Health Organization WHO (2010) has noted that palliative care, when it is delivered correctly, provides dying people with appropriate care by providing them with the required education and help. It exists to ensure that there are good policies that govern the dying process. Talking about the end of life is usually difficult for healthcare workers, due to such reasons as the fear of hurting someone by saying that he/she is about to die, the fear of giving out unnecessary information, lack of effective communication, fear of making someone to lose hope among others. Palliative care, therefore, encourages people to think positively as well as discourages the reflections with regards to death. It encourages people to remain hopeful and not to give up. It also gives hopes of peaceful death, pain relieving as well as symptom control (Forman, 2003).

The reason of choosing this topic is to proof the need for implementing palliative care approaches in the authors place of work based on the evidence from different literatures. The main focus of this paper is to undertake a critical review of the literature relating to Palliative Care and a justification of the use of evidence in improving healthcare practice.

Literature Review

The history of palliative care dates back in 1960s and it was aimed at addressing the needs of the patients who were terminally sick together with the needs of their loved ones (Charlton, 2002). Palliative care is meant to increase the comfort of the sick person and that of his family by mitigating the effects of the illness and reducing the distressing symptoms experienced by the patient. It is a form of expert symptom management that ensures that the severity of the illness does not disturb the patient and his family (Fallon & Hanks, 2006). According to Morrow (2010), In addition to expert symptom management, palliative care focuses on clear communication, planning, and coordination of care. Twycross in his book introduction to palliative care (2003) describes palliative care as aggregate active care given to patients with diseases that are capable of limiting their lifespan especially when the disease is still worse despite the prolonged treatment.

According to WHO (2004), palliative care is meant to benefit dying patients like cancer cases by helping relieve pain in the body. There are however other scholars who have a divergent view. According to them palliative care has not been as successful as others have tended to portray. For instance, according to Davies (2004) palliative care can only work effectively when the illness is discovered early so that other modes of treatment and therapies can be initiated. Therefore, according to him, patients who fail to learn of their conditions early in life are not applicable when it comes to palliative care. He argues that as much as this process helps the patients in living a comfortable life while suffering from the disease, it is discriminative because it does not take care of those patients who have been heavily affected by this killer disease. He says that individuals fail to learn of their condition not because of ignorance but also as a result of symptoms that resembles cancer as a disease. Therefore, caring for those who have just suffered from cancer alone should be discouraged because it can accelerate the rate at which cancer cells eat the white blood cells in a patient. This, according to Webb (2005), can be brought about by the fact that such patients may feel discriminated and hence stigmatized.

In addition, Pathmavathy (2004) has contended that palliative care helps in alleviating pain from the patient as well as providing a relief from other related symptoms. However, he has noted that different people have different cultures, and as a result different ways on how they perceive patients suffering from cancer. According to him in the developing countries for example, some communities believe that people suffering from cancer are usually bewitched. As a result such kinds of people are stigmatized and treated as outcasts. Therefore he argues that in such cases palliative care does not relief pain but rather adds suffering to the patients thus making them die fast compared to others who are cared for by their members of the family.

Moreover, Foley (2004) has noted that palliative care uses a holistic approach in the attempts to address the needs of all those people who are suffering from cancer. However, according to Hain (2010), palliative care does not embrace a holistic approach because according to him, the whole idea of just addressing only those patients who have just been diagnosed with cancer makes it less of an effective approach as it neglects other chronic conditions. According to him, such measures would help in improving their state of survival. If this fails to be initiated he argues that all that it has achieved would all be in vain.

Other scholars like Russell (2003) have noted that palliative care is not as perfect as is thought to be. For instance he says that people believe that palliative care gives the victims of cancer a chance to live an active life despite their conditions. However, according to him and other scholars, some of the palliative care given to the patients makes them feel better in the short run but in the long run these patients become weaker and end up dying to conditions associated with palliative care. For instance, radiations meant to cure cancer makes the patients develop a weak body immunity thus becoming vulnerable to attacks by other infections.

Furthermore, William (2008) has also noted that palliative care is a source of misery to the other members of the family who are the care takers of the patients. He says that the cost of acquiring such kind of care is usually like a night mare to many families especially those from marginalized areas particularly in the third world countries. Thus, according to him, palliative care fails to meet its intended function. His recommendation to the various governments in the world is that palliative care centres should be decentralized so that as many people as possible get to access these services and reduce the number of deaths related to cancer.

According to Dickman (2010), palliative care has no intention of accelerating nor postponing the death of a patient but only making it a peaceful death. However, according to Clark (2002), the whole idea of palliative care is to help a patient live longer without experiencing a lot of pain in the affected part. He says that if a cancer patient is left alone without care from the government or the members of the family as well as medical practitioners, he/she is likely to die more quickly. Therefore, the act of providing palliative care according to him is meant to help the patient live longer and as a result postpone his/her death. He says that what Dickman (2010) should have stated is that palliative care is meant to help the patient die without experiencing too much pain that is usually part of the cancer.

Penson (2002) says that not all communities in the world accept patients diagnosed with cancer. Therefore, according to him, the acts of segregating them from the other cancer free population may affect them psychologically as well as spiritually regardless of the care that they may receive in the care centres. He has cited ignorance as the main reason for treating cancer patients in such away. In regard to this he says that it is the duty of the government to try and spread cancer awareness to people so that patients can be treated as any other people and be accepted within the society.

There are many studies conducted in the field of palliative care where most of them support the implementation of the same. However, for this assignment, the author will only critique four studies in the following sections of this paper:

Literature Critique

Belchamber and Gousy (2004) conducted a study on patients perspectives on rehabilitative care in a specialist palliative day care centre. The study had a clear and concise abstract, stating the purpose of the study, the study design, and the outcomes. The purpose of the study was to explore cancer patients perceptions of the rehabilitative care approach, which they experienced in an independent specialist palliative day care centre. The research question shows that the research was aimed to explore patients perceptions of the rehabilitative care approach at a specialist palliative day care centre and consider how the rehabilitative care approach may be improved. The researcher sought to investigate the perceptions of people with cancer of their symptoms, how people with cancer perceive the rehabilitation they receive, and lastly the attitudes or beliefs people with cancer have about the rehabilitation they have received.

The literatures reviewed by the authors are almost old articles and the recent one is 2001 publication. However, there were no secondary sources used and no emphasis on anecdotal evidence. The authors discovered evidence from this literature review which indicates that psychological distress is linked with fatigue, which emerges as the key symptom in people with cancer and has strong influences on levels of pain, nausea and dyspnoea.

The research approach was qualitative as it could describe the form and nature of a particular phenomenon (Belchamber and Gousy, 2004). Open ended questions were used. Out of the five main qualitative methodologies, phenomenology was chosen as a research design as it is the most appropriate to explore the rehabilitative care approach as it aims to uncover the essential structure of a phenomenon by exploring the outward appearance and inward consciousness rooted in the patients memory, image and meaning.

Ethical approval was sought from the local ethics committee and access was obtained from the researchers employer. Following verbal consent, the researcher asked the participants for informed consent before the semi structured interview. And for the sampling, potential participants were required to be experiencing one of the four main symptoms of cancer (pain, dyspnoea, nausea, or fatigue). It was necessary to eliminate from the study people with cancer who had other medical conditions, which would affect the symptoms above. The participants needed to be capable of understanding the study and what is involved, as well as cope with an interview that lasts for one hour.

Data was collected on semi structured one-to-one interview that lasts for one hour. Interviews were recorded and transcribed verbatim. Pseudonyms were applied so that participants could not be identified. Data looks not reliable as it describes a very small number of participants. However, it is valid as the results provide an insight into patients perspectives of a rehabilitative care approach at a specialist palliative day care centre. The results were clear and complete, that was tabulated and then findings were discussed in more detail. Results highlighted patients perceptions of the rehabilitative care approach at a specialist palliative day care centre.

In the discussion, the authors stressed on a number of issues that have emerged as a result of the study, which may have important implications for the care of people with cancer. Patients perspectives of their symptoms, beliefs and attitudes towards the rehabilitative care approach were explored.

The authors concluded with a number of recommendations for future practice. They suggest that further investigation is required in: diversional therapy, aromatherapy, and management of lymphoedema. They recommend the development of an ownership concept and improved collaboration and multidisciplinary networking. The authors note that concerns regarding understanding of palliative care and palliative treatments must be addressed. It is also recommended that better communication between health care provider and patient be improved.

The articles references were accurate and comprehensive but older than ten years of publication. However, the title was clear and indicative of what was studied. Generally, the paper was detailed and well written. Sample was small but provides the means to increase health care professionals awareness and insight into the rehabilitative care approach.

Craft, et al. (2005) conducted a study on knowledge of treatment intent among patients with advanced cancer. The article had a clear and concise abstract. The researchers sought to assess the level of awareness of diagnosis and objectives of treatment among those with suffering from advanced cancer.

Literature reviewed by the authors showed that patients want to be informed about their diagnosis and treatment. The study was longitudinal and authors used a qualitative approach. Data was collected using a survey that was conducted following a written informed consent. The inclusion and exclusion were identified. In the discussion the authors identified that a high number of patients believed that they were getting curative treatment not palliative. The discussion identified the benefits of the results in the counselling sessions when patients are to make decisions for treatment.

The study may be considered to be valid as it gave a clear answer to the research question. However reliability is doubtful as peoples views are changeable from generation to another in regards to knowledge of treatment. The authors concluded by recommending further studies to explore patients knowledge of treatment as populations change over time. However, generally, the article had enough references from different sources.

Winter, et al. (2007) conducted a study titled; imagining the alternatives to life prolonging treatments: elders beliefs about the dying experience. The abstract was clear and concise that stated the purpose of the study, design and summary. The study purpose was to explore the older peoples beliefs about dying and prolonged treatments and what may happen if they chose not to take the prolonging treatment. The research questions were many; what are the patients assumptions about dying, how death is viewed by them, and do they expect a palliative care during the last stages of their life. Authors reviewed articles of ten years publications that explored evidence about the dying process. The research was qualitative in its approach and the authors used a semi structured interview with open ended questions.

The research design was exploratory study and there was no information about the ethical approval. The authors used convenient sampling of forty older people that were recruited through advertisements and they did not meet any of them. Consent was only verbally and not in writing. Data was collected through telephonic interviews conducted by two experts in interviewing older people. The discussion indicates that there is lack of information on palliative care among the older people that suggests focusing on health education. The study may be reliable but it is difficult to validate a qualitative study as the knowledge of people differs. In the conclusion the authors recommended that further studies to be conducted and communication between patients and healthcare workers.

Connell, et al. (2010) conducted a study on the perceptions of the impact of healthcare services provided to palliative care clients and their carers. The abstract of the study is clear and concise and the title accurately describes the study. The study purpose was also clear and research question was defined as well. Literature reviewed was articles of older than ten years. The research was qualitative in its approach with evidence of ethical approval. Sampling was done randomly and by using the inclusion and exclusion criteria.

Data was collected using semi structured interviews. The discussion was relating the findings to the literature review and the research question. Data may not be considered to be reliable as it presents a small number of participants. However, the data can be valid as it provides a clear picture of patients and their carers perceptions. The authors concluded by recommending further studies in the same field but may in a larger sample.

Maltoni, et al. (2005) carried out a study to find out the prognostic factors in advanced cancer patients. The abstract gives a brief and clear summary of the entire study and one gets to grasp the nature of the study, its findings, recommendations, and discussion at a glance. The main objective of their study is clearly stated. The study provides good introduction to the study and sets out a clear understanding of the importance of the study. The methodology used in carrying out the study is also well elaborated and justified. The study gives a step-by-step account of how the study is executed. The presentation of the results is also done elaborately especially by tabulation. The recommendations made by the authors are based on their findings making the study an evidence-based one. The study also offers an elaborate discussion of the findings and recommendations concerning the importance of prognostication especially in patients with advanced cancer. The authors note that ethical considerations during prognosis at end of life are crucial in this process. It can be concluded that this study is reliable and hence believable.

In their study, Hinds, et al. (2001) explore the impact of cancer on decision making by adolescents, their parents, and providers of healthcare services. The abstract provided by the researchers is quite comprehensive. The purpose of the study was primarily to formulate guidelines that will help in the making of decisions in paediatric oncology. The study used three designs for three studies. In the first study, retrospective design was used. The second one employed prospective type of design while cross-sectional design was used in the third study. All the three were descriptive. In the retrospective study design, 39 guardians and 21 healthcare providers were involved, while 52 parents, 10 teenagers, and 22 physicians participated in the second study. For cross-sectional design, 43 parents were interviewed. The data from all participants were collected using six open-ended questions. The analysis of interview data was done using the semantic content analysis technique.

The findings showed that information on the patients health and disease status was one of the most frequently reported factors affecting decision making. Others that were identified include the extent to which the available options of treatment have been tried as well as the confidence in the healthcare service providers. A sense of support and care from the healthcare team was found to influence decision making. The researchers conclude that the overwhelming agreement that exists as far as factors influencing decision making is concerned, then they should be used as the basis for developing evidence-based procedures in palliative care.

Steinhauser, et al. (2000) conducted a study on the factors considered important in palliative care. They focused on key players in the process like patients, family, medical doctors, and other healthcare providers who are usually there at the last moments of a patient. The abstract of the study was clear and concise since it states the objective of the study, design and setting, the participants, major outcomes, and conclusions. They were inspired by the fact that little has been done to provide empirical evidence on key factors at the end of life. The purpose of the study was to establish the most important considerations at the end of life by various stakeholders who must be involved in one way or another in the care of a patient. They used the cross-sectional, stratified random national survey. 340 seriously ill patients, 332 families who bereaved recently, 361 physicians, and 429 diverse healthcare providers including the social workers, nurses, hospice volunteers, and chaplains participated in the study.

The researchers use a 5-point scale to measure 44 attributes of quality that may be regarded important at the end of life. They then compared 9 major attributes in the four groups according to their rankings. It was found that 26 (>70%) of the attributes were considered as being important in all the 4 groups. Some of them included: management of pain and symptoms, readiness for death, satisfaction with treatment, decision making on treatment options, among others. Some (8) of the items were ranked highly by patients but physicians did not consider them as being very important. The results section reveals further findings in a very clear and understandable manner. The study concludes by noting that despite most factors being regarded as being important to quality at the end of life, it is evident that their ratings vary from one person to another depending on their unique roles which explains why their diverse perceptions when it comes to quality. This study is quite good since it examines pertinent issues in palliative care that little effort has been expended on. Given the large number of participants selected for the study, the findings can be generalized.

The success of any treatment depends greatly on the relationship between the patient and the doctor. Rothenbacher, Lutz and Porzsolt (2007) conducted a study to investigate the truth of this statement. They used patients with advanced cancer who are hospitalized for palliative care to establish whether the patients wanted to be involved in decision making about their treatment or not. They also investigated the degree of awareness among the physicians on the patients desire to participate in treatment.

The study involved 59 individuals with terminal cancer in hospital, 89 patients admitted with chronic non-neoplastic disease, and another 115 individuals not admitted in hospital. Standardised questionnaires were used to collect data from the participants including the physicians attending to the admitted patients. The study found that 73% of those with advanced cancer would collaborate with their doctors in decision making. It was also established that the degree of patient involvement in decision as far as treatment is concerned increased with the level of education, employment, and younger age. The study concludes by noting although patients would want to be involved in decision making, their physicians were not aware of this. The study is reliable because of the good number of patients participating in the study as well as the different types of patients. The findings and recommendations are also of acceptable standards.

A study by Smith, et al. (2010) sought to investigate the epidemiology of pain during the last 2 years of life. The abstract of the study is brief and concise. It captures the background, purpose, design, setting, participants, results, and conclusion. The main objective of the study was to describe the prevalence and correlates of pain during the last 24 months of life among older adults. This was an observational study involving 4703 decedents. The measurement criteria focused on pain that could be considered of clinical significance. This is a level of pain that causes disturbance to a patient even at moderate severity. It was found that pain increased with less time to live. However, the study could not establish the location, cause, and the treatment of pain. The conclusions of the study on palliative care and pain are generally agreeable.

Waghorn, Young, and Davies (2011) researched to find out the opinions of patients with cancer on the relative importance of place of death in the context of a good death in a cancer center in England. The primary purpose was to establish the relative importance of place of death to those with advanced cancer and undergoing treatment. The data collection was done by gathering information from electronic patient record system. The patients were also interviewed on end of life issues. The patients also indicated the factors that they associated with good death. 120 patients were involved in the study.

The study found that 80 patients representing 67% indicated that home was an acceptable place of death while 51 (42.5%) of them said that they would prefer to die at home (PPD). The researchers give further findings from their study on the various opinions of individuals. However, the authors conclude that place of death may not be a reliable factor to determine the quality of end of life healthcare provisions. It can thus be concluded that the findings are reliable given the huge number of patients involved in the study. A smaller number would have raised more questions given the subjective nature of study, the study of opinions.

Conclusion

It is quite evident that palliative care is meant to benefit the patients who are dying and patients suffering from killing conditions such as cancer. As some writers have noted today cancer has become one of the leading killer diseases in the world. The most interesting thing about it is that it cuts across all generation therefore palliative care would be useful at all ages (Davies, 2004).

When it comes to carrying out a deeper research on a particular need, researchers should ensure that they at least try and cover a majority of the population in a given region so that they can develop a clear insight pertaining to the disease or a service need like palliative care. Furthermore bearing in mind that the world is comprised of different people with different cultural backgrounds researchers need to try and understand these variations so that when they are writing their conclusions they ensure it covers a greater portion of some of these communities. For example the issue of looking down upon people characterized in some communities should have been known by researchers if they had carried out their research comprehensively. Lughton (2006) argues that no culture is greater than the other and therefore people should never despise what other people believe in as this is important in trying to enlighten them so that they can change the way they look at certain things like people suffering from killing diseases like cancer.

The four studies conducted on palliative care reviewed by the author did not come to a clear cut answer for the need for palliative care, however researchers recommend its use and to conduct further studies. On the other hand, the number of cases participated in those studies is small and hence indicates further studies to be conducted on larger samples in different communities. Although the palliative care has been criticized for all negative aspects of it, it is worth giving credit where it is due and where evidence proved its benefits for the dying patients. Therefore, I recommend for its continued use even in future and maybe implanted in Oman at a wider angle after further studies are conducted.

References

Bass, M., 2006. Palliative care resuscitation. New York: John Wiley and Sons.

Belchamber, C. A. and Gousy, M. H., 2004. Rehabilitative care is a specialist palliative day care centre: A study of patients perspectives. International Journal of Therapy and Rehabilitation, 11 (9), pp. 425-433.

Beresford, B., 2007. Palliative care, social work, and service users: making life possible. London: Jessica Kingsley Publishers.

Boog, K. M. and Tester, C. Y., 2008. Palliative care: a practical guide for the health professional: finding meaning and purpose in life and death. Amsterdam: Elsevier Health Sciences.

Buckley, J., 2008. Palliative care: an integrated approach. New York: John Wiley and Sons.

Charlton, R., 2002. Primary palliative care: dying, death and bereavement in the Community. Abingdon: Radcliffe Publishing.

Clark, D., 1999. Reflections on palliative care. Buckingham. Open University Press.

Clark, D., 2002. Palliative care for older people in care homes. Buckingham. Open University Press.

Connell, T., Fernandez, R. S., Griffiths, R., Tran, D., Agar, M., Harlum, J., Langdon, R., 2010. Perceptions of the impact of health-care services provided to palliative care clients and their carers. International Journal of Palliative Nursing, 16 (6), 274-284.

Craft, P. S., Burns, C. M., Smith, W. T. and Broom, D. H., 2005. Knowledge of treatment intent among patients with advanced cancer: a longitudinal study. European Journal of Cancer Care, 14, pp. 417-425.

Davies, E., 2004. Palliative care. Geneva: WHO.

Dickman, A., 2010. Drugs in palliative care. Oxford. Oxford University Press.

Fallon, M. and Hanks, G. W., 2006. ABC of palliative care. Hoboken: Wiley-Blackwell.

Faull, G., 2005. Handbook of palliative care. Hoboken: Wiley-Blackwell.

Foley, K., 2004. When the focus is on care: palliative care and cancer. Pennsylvania. American Cancer Society.

Forman, W. B., 2003. Hospice and palliative care: concepts and practice. Sudbury: Jones & Bartlett Lea

Introduction

Throughout history, people have been using their reasoning to determine what is right or wrong in different circumstances and in justifying why it is so. This criterion is the basic foundation of normative ethics. In most cases, health care professionals encounter highly complex issues while dealing with their patients or the health care system at large. Handling such issues requires a strong foundation based on knowledge and skills that can be applied so as to generate solutions that benefit both the patient (in terms of quality treatment) and the organization as regarding to the management of risks and preservation of life (Ashcroft, Dawson & Draper, 2007). Arguably, for one to be recognized as a professional, he/she must understand the foundation of the field of practice. In other words, a health care professional is expected to fully understand the nuts and bolts that hold the health care system together. The same case applies in ethical studies.

Ethics in the healthcare business is not simply doing what we consider to be right. As mentioned earlier, issues encountered in this sector are often exceedingly complex and assuming that there is a one-shoe-fits-all approach to dealing with these issues is an outrageous fallacy. To make matters worse, the society and other health care professions also have their inflexible ethical expectations. To this end, it is not only logical, but also wise for a healthcare practitioner to have a strong foundation and a deeper insight in the theories and principles of ethics if they are to act professionally in regard to decision-making processes (Ashcroft, Dawson & Draper, 2007). This paper shall set out highlight various ethical theories and principles that are used in the health care sector. This shall aim at elaborating how these theories and principles can be applied to solve issues in this sector.

Ethics and Health Care: A Brief Overview

There are various documented theories that can be applied in solving ethical issues in the health care sector. You may be questioning the importance of knowing such theories and principles. Well, the answer is that a lack of a solid ethical foundation leaves an individual with no other choice but to make decisions that lack a solid structure to support those decisions (Morrison & Monagle, 2009). A practitioner would therefore lack the ability to defend his/her actions whenever the need arises. In addition, you would not be adequately equipped to deal with the issues that are inherent in todays health care sector. As such, understanding the ethical theories that apply in health care delivery is not only pivotal, but also a necessity in todays dynamic, and aggressive working environment.

Important of Ethical Theories in Health Care

Morrison and Monagle (2009) contend that we live in an era whereby technological advancements in the medical and scientific arenas are constantly presenting people with challenges that demand similar thought processes. Resource allocation is slowly becoming global, new diseases are cropping up globally, nature is taking its toll on our lives and people all over the world are finding it more difficult to cope as poverty and diseases become a common place to the global population. Understanding ethics presents people with an avenue through which solutions for these vexing situations can be found.

In addition, equipping ourselves with adequate ethical knowledge enables us to work with others (colleagues, patients, policy-makers and stakeholders). This means that ethical understanding enables practitioners to understand alternative views thereby fostering cultural competence on a global scale (Brannigan & Boss, 2000). Ashcroft, Dawson and Draper (2007) define normative ethics as the study of what is considered as right or wrong. As such, normative ethics sets out to examine the formulated theories of ethics and how they apply in various fields such as health care. With this in mind, you may be tempted to think that normative ethics offer conclusive outcomes since they set out to determine the right course of action that can be taken to solve a particular issue, and explain why it is the right move. However, there are many disagreements in various fields such as health care, engineering and even business on how the results are interpreted.

There are various types of ethical theories that are often used in healthcare situations. Some of these theories shall be defined, elaborated and applied in health care.

Authority-Based Theories

In this category, the theories are often based on religious faith such as Christianity, Buddhist or Muslim ethics. Marlin (2002) asserts that in some cases, theories in this category are based on ideologies. For example, Karl Marx writings, and theories that try to explain capitalism. These theories are based on what an authority considers to be right. As such, the ethicist in this case tries to determine the ruling that the authority would pass in regard to the given problem. Marlin (2002) states that in most cases, ethical teachings often avoid religion-based ethical theories despite the constant protest from those who hold deep religious beliefs. In health care, religious-based theories should never be used to solve issues or make decisions. Geirson and Holmgren (2010) attribute this to the fact that there is a worldwide disagreement on which authority reigns over the rest. This is tricky since there is no prescribed way of knowing which authority or ideology is correct. Most of the theories in this category are normative relative to whoever uses them. As such, they often lead to conflicts and there is no method to sort them out that is agreed upon.

Despite these limitations, there are some benefits that can be accrued from understanding this category of theories. For example, all religions have their own beliefs regarding the source and solutions for ailments and suffering. In most cases, patients often have their religious beliefs and attitudes that help them make sense and find comfort in their circumstances. On the plus side, understanding authority-based theories enable practitioners to deliver a more patient-focused treatment or solution. However, an ethical dilemma may arise whenever a patient feels as though his/her religious beliefs have been violated or disrespected by the practitioner.

In regard to the influence of authority-based theories in the formulation of health care policies, Hester (2001) argues that acknowledging and understanding the religious philosophies behind these theories may enable a practitioner to steer away from contentious issues (such as abortion, euthanasia and resource allocation among others) that may offend or undermine the religious beliefs held by the people responsible for making the policies. For example, when dealing on an international perspective, a healthcare practitioner who understands the alternative views held by different parties can find a common morality that is readily acceptable by all members, thereby ensuring that the policies made are readily acceptable to all.

Similarly, it should be noted that religion plays a pivotal role in helping people determine what is right or wrong. This can be attributed to the fact that all religion provides answers regarding the nature of the world and how we should exist in it. In addition, religions help people understand themselves, their purpose and how they should co-exist with each other in this earthly realm. In short, religion explains the world and how each individual fits in it. Conclusively, it is not advisable for a health care practitioner to apply this category of theories in the field. However, they can be used as a tool to provide quality treatment to patients, or to negotiate agreeable terms where health care policies are concerned. On a personal note, having an understanding of authority-based theories enable an individual to better understand his/her religious stand thereby acting as a guideline that prevents the practitioner from imposing his/her religious views on the patient and vise versa.

Virtue Ethics Theory

This theory as defined by Melia (2004) argues that we should find a solution for humanity and then work towards achieving that solution. It focuses on finding perfection and excellence in all we do. It therefore proposes that as human beings, we should work towards developing ourselves to excellence by using the best of our ability. The questions in this theory include: What kind of an individual should I become? Or how can we live together in harmony? Devettere (2009) contends that this theory is very influential in formulating professional code of ethics in the health care sector. Virtues are described as desirable moral qualities. According to Melia (2004), this theory was founded on the tenets that everyone is innately virtuous but there is need for development and nurturing before a person can exhibit a virtuous character. This sentiment is further supported by Loewy and Springer (2004), who defines elitism as a state in which a person who has been nurturing virtues becomes virtuous after long practice.

As mentioned earlier, the virtue ethics is all about exhibiting the highest good we possibly can. This theory is very important since it helps practitioners maintain professional conduct. Understanding this theory enables practitioners to better their character and that of their patients. In addition, Greenhalgh (2007), states that virtue ethics enable practitioners to balance their obligations more efficiently. For example, there are some treatments such as chemotherapy, which are harmful to the patients but beneficial in the long-run. A professional practitioner equipped with the knowledge of virtue ethics can effectively communicate the harms as well as the benefits of such treatments to the patient and get consent to administer the treatment.

In addition, if the patient views the practitioner as a virtuous person, their confidence in the services provided increases. Also, caregivers who have practical wisdom (a virtue) are able to find viable solutions and work towards attaining them. As such, people who have practical wisdom can consult each other and come up with appropriate remedies to different issues. Over the years, healthcare organizations have used such people to form ethics committees which help in determining ethical courses of actions and resolving conflicts. Such progress has been made possible through the understanding of what the virtue ethics theory entails.

On the same note, Loewy and Springer (2004) contend that a virtuous person (one having practical wisdom) can effectively decide on which theory to apply so as to solve an issue. Take a physician for example; their primary duty is to cater for the needs of their patients. However, this is not their only obligation they have other duties such as recruiting, training and firing employees, as well as conducting scientific studies and managerial duties. All these roles are handled differently and different theories can be used to diffuse them. In such cases, an individual who has undergone the professional socialization process recommended in this theory is more likely to select and apply the theories that ethically examines and solves the problem.

Biomedical Principles Emanating From Virtue Ethics Theory

The four core ethical principles used in healthcare delivery have their roots in the virtue ethics theory (Greenhalgh, 2007). They include beneficence, non maleficence, justice and autonomy. Beneficence refers to the caregivers responsibility to extend kindness/goodness to their patients. This principle dictates that healthcare practitioners have the responsibility to keep the patients interest before their own by ensuring that they get the most benefit from all health care related practices (Greenhalgh, 2007). The second principle of non maleficence states that health care practitioners should avoid doing harm to others. This principle sets out to protect patients from practices that may put them at risk or at harms ways in a health care setting (Devettere, 2009).

The third principle of justice suggests that health care practitioners should treat their patients fairly, equitably and lawfully without malice or discrimination. The final principle is that of autonomy, which refers to the ability to make decisions for oneself without external or emotional influences. This principle holds that people should always respect the decisions made by others and that making decisions for other people without their permission is wrong or in ethical terms; paternalism. These four principles show virtuous characteristics that should be inherent in all health care practitioners. Not only do they protect the patients from harm and unfair health care practices, but they help the practitioners act in an ethically and legally acceptable manner (Loewy & Springer, 2004).

Natural Law Ethics

In this research, the theory of natural law is interpreted using the foundation laid by St. Thomas Aquinas (Engelhardt, 2006). The key idea behind this theory is that nature has a rational and providential order of occurrences (Engelhardt, 2006). As such, no human being should interfere with this order. This theory is very important in health care and it is mostly applied in debates regarding abortion, euthanasia, social justice and birth control (Cherry, 2004). As a health care practitioner, it is important to understand this theory because it helps us understand the difference between good and evil practices in accordance to the natural order of life.

This theory therefore proposes that under no circumstance should the life of an individual be cut short by another person because this would disrupt the rational and providential purpose of life. However, there are various issues that have been forwarded by critics of this theory. Opponents of this theory argue that in as much as the decisions formed through this theory are specific; the details surrounding the issue may change (Gensler, 2011). So the question is: how does a practitioner know that his/her decision is right under this theory? The principle of double effect was therefore developed to act as a guide to ethical decision making under this theory.

This theory is founded under four basic assumptions. The first assumption is that we try our best to avoid evil effects because we do not desire for them to happen. Secondly, the immediate effect of any decision made should be good. Thirdly, the good effect should not be as a result of an evil act. This assumption suggests that the end should not justify the means. Finally, the principle assumes that the good effect should always outweigh or at least be greater than the evil effect. These assumptions can therefore help a practitioner make ethical decisions in situations where there is a conflict between what is good or evil (Gensler, 2011).

For example, abortion is considered as an evil by most people, however, saving the life of a pregnant woman is considered as a good deed. Similarly, euthanasia is in some areas considered as an evil, but using morphine to alleviate pain is good. As such, by applying the principle of double effect, a practitioner is better placed to make ethical decisions because the assumptions behind this principle act as guidelines to effective and ethical decision-making.

Discussion: Value of Ethical Theories in Health Care

No matter the circumstances, decisions have to be made and accounted for. As such, understanding the aforementioned theories (among others) is pivotal to health care professionals since it helps them choose the appropriate theory t apply in different situations. Arguably, without these theories, decisions made regarding treatment, prescriptions, patient care and health care policies would be left at the mercies of personal feelings, rational and perspectives of the parties involved. As a result, patients would suffer since there would be no mechanism to determine or justify the decisions made by practitioners.

For health care managers and practitioners, these theories help them act in the best interest of the patients by applying the practical wisdom discussed in the virtue ethics theory. For clinicians, they can apply the deontological approach and perform their duties as subscribed. Managers are also better placed to decide on the best course of action, all the while adhering to the policy and rules that are set in place to govern the activities of their staff.

In regard to policy making, these theories can come in handy when a particular policy maker wishes to understand, evaluate and determine the most probable attitude held by various stake holders. Knowledge of these theories in such cases help policy makers decide on policies that are most likely going to be approved by stakeholders because they appeal to their sense of justice and ethical conduct.

Conclusion

Evidently, the twenty-first century comes with various health care ethical challenges to individuals, society and organizations that participate in this sector. As such, a deeper understanding of the ethical theories that govern this sector is not only logical, but also necessary if ethical conduct is to prevail. From this research, it is clear that individual ethical theories cannot suffice in creating appropriate responses for the challenges that are inherent of this sector. As a result, a detailed review of different theories has been provided and scenarios in which each theory can be applied provided.

While not all theories have been discussed, it is clear that having a foundation of ethical theory is critical in ensuring that quality services are offered to various stakeholders. In addition, knowledge of these theories helps health care practitioners make correct decisions, and provide adequate support for their decisions. By applying these theories and their principles, professionals in the health care sector will be able to do their work more efficiently, all the while minimizing the chances of gross misconduct and harmful practices that may eventually cost them their careers.

Cultural and Ethical Implications of DNA testing: Application of Theory

Introduction

The past few decades have witnessed great scientific breakthroughs, inventions and discoveries due to technological and intellectual advancements. The biological field of studies has as a result improved in terms of sophisticated equipment as well as advanced procedures used in diagnostic processes that were once considered as theories and reserved only for the well-to-do specialized hospitals. One of the most notable technological advances in this field is arguably the development and implementation of genetic testing. Jonsen, Veatch and Leroy (1998) define genetic testing as the process through which the presence of genetic markers within the patients body of specific ailments can be determined or detected. The importance of this testing cannot be elaborated fully considering that over 3% of all children in the united states are born with severe genetic disorders (Jonsen, Veatch & Leroy, 1998).

According to the Uhlmann, Schuette and Yashar (2010), the main purpose of genetic testing is to treat, cure or prevent disorders that are genetic in nature. One of the main benefits of this procedure is that it enables patients to know whether or not they have any genetic disorder. As such, this information can be used to formulate preventive measures or start treatment before the disorder takes its toll on the person. This paper shall set out to evaluate the cultural, social and ethical issues that surround genetic testing. This shall be done by employing various theories and analyzing the impact genetic testing has on people in regard to decision making.

Importance of genetic testing

According to the principles of biomedicine, the principle responsibilities of health care practitioners are to preserve life, alleviate pain and restore health of their patients using the available resources. Genetic testing presents practitioners with an avenue through which these responsibilities can be fulfilled. New technologies and research advancements have enabled practitioners to identify various genetic disorders and risk factors that affect mankind. Genetic testing falls under this category and it has played a pivotal role in identifying such disorders rapidly and efficiently than other methods. Lerman, Croyle and Tercyak (2002) contend that genetic testing may in the future become a common practice in medical routines.

Another advantage that can be accrued from genetic testing is that medical practitioners are able to detect dormant mutated genes that may be present in patients who physically seem healthy. This is important because people with such a condition may continue living normally oblivious of the health dangers that lurk within their bodies. The implication of such a test in this case is that once the carrier has been notified of his/her condition, viable preventive or curative measures can be recommended so that the patient is enlightened on the available choices.

This gives the patients an opportunity to make informed decision on the best course of action that should be taken to counter their condition. This advantage coincides with the virtue ethics theory which states that practitioners should always set out to do good to their patients. As such, informing the patient of the underlying condition and laying out the choices of treatment is in line with this theory and ensures that genetic testing are used for good (to better the patients well being).

Evidently, the health care systems adopted by most nations are shifting from the traditional curative approaches to preventive approaches of health care delivery. This move is supported by the deontological theory which places more emphasis on duty. The core duty of health care professionals is to improve the physical and mental well being of their patients. Genetic testing gives practitioners a chance to carryout this duty in the sense that the tests are preventive in nature. For example, if a patient tests positive for a disease such as cancer or diabetes, the results can be used to devise means of mitigating the disease from ever developing. For example, Bettina and Dunn (2001) assert that through genetic testing, genetic markers for Huntingtons disease were used to come up with the linkage analysis, which is effective in identifying unaffected carriers. This discovery has in the past decade proven to be effective when it comes to helping carriers cope with the disease.

Genetic testing has also gained popularity due to the fact that most employers today request all their employees to take the tests as part of the company policy. This move previously met a lot or criticism as people feared that it was a strategy of screening employees for genetic disorders that affected their ability to perform efficiently. However for DNA profiling to be used successfully, there has to be a DNA database where tissue samples, genetic information and personal data is stored indefinitely. This brings about the real fear that this information may be misused therefore leading to an infringement on the rights afforded to the individual. Brent (2000), states that this discriminatory tendency was forbidden by law. The author further contends that while it is legalized in some states, employers are legally advised not to make any employment decision based on the results of these tests (Brent, 2000). This is in line with the principle of justice which dictates that people should be treated equitably and fairly regardless of their differences.

The benefit of these tests to employers is that they are better placed to make informed decisions on the insurance policy to take for an employee as well as other medical allowances. In addition, these tests enable employers to identify an employees susceptibility to various working conditions thereby enabling the employer to properly assign tasks to the employee. In addition, the test results are of great importance to employers since insurance firms always require the medical history of a client so that they can effectively assess the risks and other factors. Such information help insurance companies decide on which cover an employee should be placed.

Each individual has some level of doubt regarding his/her health at some point in time. As such, it may be argued that there are many factors that may influence an individuals decision to get a genetic test. For example, most people always dream of having a family in future. Despite this parental desire, there are always some doubts on whether the child will have any complication or disability. To this end, genetic testing (prenatal testing) provides such potential parents with an ease of mind in the sense that they can be tested for genetic markers that are inheritable (Boskey, 2007). While the emotional impact of such results may affect people differently, the virtue ethics theory recommends that counseling should be offered to test subjects before and after the test to help them cope with the results.

Impact of genetic testing on decision making

Arguably, genetic testing has gained prominence in the medical arena mainly due to the fact that it is among the latest procedures in medical advancement. As a result, companies have emerged that offer these tests at a fee. While these companies propose that their aim is to provide easy access to such services to clients, some states have been forced to shut down some of these companies and in some instances discourage people from soliciting genetic testing services from the same. These moves have been necessitated by the fact that the results of these tests have varied effects on how people make life decisions (Euan, 2009).

Jonse, Veatch and Leroy (1998) indicate that in most genetic testing procedures, the decisions made by the individuals are to a large extent influenced by cultural and emotional factors as opposed to the perceived risks that the results indicate. As such, a pregnant mother may be culturally inclined to terminate a pregnancy because the results of a genetic test indicate that the unborn child may have a genetic disorder. Such a decision is not based on the risks of having the baby, but on the mothers or societal view on having a disabled child. Such a decision has no relation to the facts presented by the results.

In such a case, it may be argued that genetic testing goes against the theory of natural law, which states that, there is a rational and providential order of things in nature. This means that man should not interfere with nature since everything has a purpose and it should exist until nature decides otherwise. As such, the decision to terminate a pregnancy simply because it proves to be challenging is unethical. This point disregards genetic testing in relation to its influence in decision making.

Similarly, the choices that are made through genetic testing include but are not limited to decisions to have a child, to abort and to pursue preventive care among others. Lerman, Croyle and Tercyak (2002), state that other factors that should be considered when making decisions include the severity of the disease, available treatments and the disease in question. Hartley et al (1997) state that results from studies conducted on couples who stood the risk of getting Tay-Sachs disease indicated that 85% of the women test subjects agreed to get tested. The authors further state that out of the 85%, 81% of the women agreed to take the test because they feared that their children would contract the disease. The decisions made after the test were mostly determined by the subjects emotions rather than the findings.

In addition to this, statistics indicate that results from genetic testing carried out during prenatal care increases the chances of abortion. This is attributed to the fact that more knowledge regarding the risks that a particular disease poses to the mother and the child makes abortion an easy choice as compared to when the information is limited. As such, when a pregnant woman discovers that her unborn child is likely to be deformed or disabled in some way, she decides to terminate the pregnancy rather than risking bringing a child that will be socially unaccepted by family members and society. However, it should be noted that such choices are not made under duress and much deliberations and counseling should be done before making the final decision.

Cultural and Ethical Impacts of Genetic testing

Ethically genetic testing should be carried out in a manner that is acceptable to society and individuals. This means that the information gathered during such tests should not be used to discriminate people who are culturally different. This applies mainly to employers and insurance companies, who may be tempted to use such information for screening clients or employees.

Similarly, there are individuals with strong cultural affiliations that should be considered before subjecting them to such tests. Genetic testing in some instances result in the alteration of genetic markers. Some cultures believe that alteration of ones body is a sin. As such, practitioners are ethically bound to present all participants with an informed consent agreement which highlights the nature of the experiment, the risks and the physiological effects that the tests may have on them (European Commission, 2000).

In some cases, people have suffered greatly under the hands of unethical practitioners who put their interests and greed for knowledge before those of the patients. This is unethical and punishable by law. Patients on the other hand should be careful when providing personal information or volunteering for such tests. They should ensure that the people conducting the tests are certified and have only good intentions.

While genetic testing presents humankind with an avenue through which serious diseases can be prevented or cured, people should exercise caution when dealing with such practices. In as much as there are benefits, they should not be realized through harming others or deception (Betta, 2006).

Conclusion

This paper set out to explore an issue in healthcare that has serious implications on ethical and cultural conduct. To this end, this paper has reviewed various concepts and views of genetic testing. To this end, the description of genetic testing has been offered and the issues and concerns surrounding this procedure underscored. As a result, it has been deliberated that genetic testing is highly valued as being an important step in health care delivery, in that its application will become a fundamental component in medicine. In addition, the discussion presented herein has shown that the decisions made in regard to genetic testing results are not as simple as they seem. As such recommendations such as counseling and consultation have been offered so as to ensure that the decisions made are rational as opposed to them being emotional.

Considering that there is no standardized method that can be applied to determine how a person is going to react to the results, these recommendations may help individuals cope and deal with the results more effectively without causing harm to themselves or to others. Counselors should ensure that patients are mentally fit before recommending that they take such tests. In addition, practitioners using this method of testing should ensure that they do them in an ethical manner. This means that they should ensure that the patients understand the parameters of the tests, the benefits, weaknesses and potential impacts.

It has been observed that genetic testing comes with an array of advantages and disadvantages. However, it is evident that the advantages are greater than the disadvantages. As such, genetic testing should be promoted but policies should be put in place to ensure that the tests are conducted in an ethical and legal manner.

Research Methods and Critique

Introduction

Health care is a term that is mostly used to refer to the prevention, cure and treatment of various diseases and injuries

Introduction

We posit two research questions:

1. Being overweight or obese is a high-risk factor for diabetes mellitus.
2. Self-care among middle-aged diabetics is a function of education and income, irrespective of insurance coverage.

Intergenerational obesity rates are worrisome and continue to rise in both North America and Europe. As of 2006, the Centers for Disease Control and Prevention found (2007), more than a third (34%) of U.S. adults 20 years and over were obese. These levels are alarmingly high (CDC, 2007), even though obesity prevalence had not risen by a statistically significant degree from 2003 to 2005.

Beyond the lifestyle changes and medication required for control of blood glucose levels, cardiology professor McMurray pointed out at the recent Heart Failure 2009 Conference (European Society of Cardiology, 2009) that the intertwined syndromes of obesity and diabetes will not only reinforce the standing of heart failure as the leading chronic cardiovascular disease but also cause an explosion in incidence rates of the syndromes. For the one-third of heart failure patients evincing symptoms of diabetes, physicians admit that treatment is very difficult. Unhappily, a longitudinal study of adults who had already had at least one episode of myocardial infarction revealed that the prevalence of obesity rose from 25% to 38% in the decade ending in 2007 (Kotsevaa, Wooda, De Backerb, De Bacquerb, Pyöräläc, and Keild, 2009).

In short, obesity heightens the risk for diabetes which in turn doubles the risk of heart failure.

The management of diabetes is a lifelong matter. It is self-evident then that health care practice in this area relies greatly on the theories of role modeling and self-care. The theoretical framework of self-care proposes that the patient can provide for his care from day to day and that he or she should be able to balance such self-care aspects as physical health status, hope, support, control, and satisfaction with daily living (Erickson, Tomlin, & Swain, 1983; Baldwin, Hibbeln, Herr, Lohner and Core, 2002).

Focusing more closely on the management of diabetes, Sousa and Zauszniewski (2006) suggest that useful cues may be had from Orems Self-Care and Banduras Self-Efficacy theories. The former takes into account both self-agency and conditioning factors in explaining what it takes to promote, maintain and structure ones life, function in many milieus, restore health and in general, preserve well-being (Orem, 1995; Wang, 1997; Anderson, 1996).

Conforming with most social learning theories, Banduras Self-efficacy Theory advances the aspects of self-confidence and belief in performing prescribed actions to obtain desired outcomes (1997). Self-efficacy is a multi-faceted capability brought on by directly engaging in required behavior (what Bandura terms enactive mastery experience), vicarious experience, encouragement, and motivation. In turn, there must be support and positive reinforcement in the form of verbal persuasion by a physician or other primary health care professional, physiological outcomes, and a kind of self-satisfaction at being able to cope with the required therapeutic regimen. Others have subsequently validated Self-efficacy Theory in finding that interventions and skill development for self-care management upgrade self-efficacy (Parent & Fortin, 2000) and that the latter is also associated with patient engagement in disease self-care management and adopting a health-promoting lifestyle (Moon and Baker, 2000; Carroll, 1995).

Sample and Methods

Profile

The sample of 2,729 adults from Alameda County is reckoned as an important benchmark because the ethnic composition of the county is said to be representative of the nation as a whole. For what it is worth, the profile of the sample that had undergone baseline interviews in 1965 is as follows:

Women outnumber men by a significant 57:43 ratio (Table 1 in Appendix). The proportion who claim to be homemakers matches almost precisely the population share of women (Table 4). More than two-thirds were married at the time of the survey (69%, see Table 7) while one-fourth of adults were either widowed/widowers or between marriages, so to speak.

Just two in five were employed at the time of the study (Table 2). The large gap is accounted for mainly by the fact that nearly half of the panel first interviewed in 1965 could claim to have retired, at least from a first job (Table 3). Parenthetically, Figure 2 shows that the original panel interviewed three decades earlier were now in their 50s, 60s, 70s, and 80s. The median age was 64 years (Table 10).

Far from being idle, however, around 40% of these retirees were in business for themselves (Table 6). Otherwise, less than one in fifty of the population are students (Table 5).

In point of income class (Table 8), better than one-third of respondents could be counted upper-middle-class or well-off, belonging as they did to households earning at least $50,000 annually in 2003. The seriousness of the low-income skew is shown, however, by the fact that the median income range was $35,000 to $39,999 (Table 10).

Alameda residents are highly educated, given since they were more likely to have had postgraduate education or at least some college rather than secondary education (Figure 1).

Based on claimed weight relative to reported height, over one-third could be classed overweight while another 16.7% were certifiably obese (Table 9).

Results

Research Question 1: Obesity and Diabetes

The survey items of concern here are BMI2 (body mass classes after calculating from the original height and weight variables) and incidence of diabetes (diabx9 in the database). The former is an ordinal variable while the latter, being a simple yes/no question, is a nominal variable.

Examining both variables for central tendency and distribution, one finds that:

• Just 8.4% of the sample admitted to having become a diabetic at any time in the past (Table 11). Only the modal value applies for this nominal variable and that is, of course, the answer no (92%).
• Measures of variance are not applicable at this level of measurement.
• For body mass index, effectively an ordinal variable, the modal value is healthy weight (45%, see Table 12 and Figure 3).
• Variance applies to this item but it appears low at 0.6 on a four-point scale (Table 13).
• There is a rightward skew to the BMI variable (see Table 13) and this is confirmed by visual inspection of Figure 3. In short, healthy BMI may be the case more often than not but the population tends to be overweight or outright obese.

The hypotheses can be articulated as follows:

H₀, the null hypothesis = Formally, body mass index status is equal for both categories of the variable diabetic status. In short, the BMI distribution is equal regardless of diabetes status.

H_a, the alternative hypothesis = Formally, body mass index status is not equal for both categories of the variable diabetic status. In short, BMI distribution is equal regardless of diabetes status.

Given the categorical nature of the diabetes incidence variable, the ANOVA assumption of the normal distribution cannot be relied on. The nonparametric Kruskal-Wallis H Test  comparing the medians of two or more samples to determine if the samples have come from different populations  is then used in place of a One-Way ANOVA.

The results (Table 14) show, first of all, that the mean rank for BMI is at 1,590.22 (see Table 14) for those who professed to be diabetic. This is higher than the 1,286.78 mean ranks calculated for non-diabetics. Table 15 shows the significance of the Kruskal-Wallis statistic is p < 0.001, which is substantially greater than the criterion level of significance of ± = 0.05 for 1 degree of freedom. Since this means that there is an infinitesimally small chance that the differences in BMI across patient conditions occurred at random, we reject the null hypothesis and conclude that the analysis supports the research hypothesis that the average rank for BMI is truly greater for diabetics than non-diabetics. Diabetics are more likely to be overweight or obese.

Research Question 2: Three Antecedents of Self-Care for Diabetics

Given the proposition that self-care among elderly diabetics is a function of education and income, irrespective of insurance coverage, the survey items of concern here are incidence of diabetes (diabx9 in the database) as the filter variable, sweat9 (exercise enough to work up a sweat) as the dependent variable at an ordinal class of measurement, and possible independent variables in HINS9 (no health insurance), the ratio variable EDUC9 (Years of education), and INCOME9 (total income in 1993).

Screening crosstabulation (Table 16) reveals that health insurance is unlikely to discriminate among diabetics who work out or not since less than 4% of diabetics had no health insurance of any kind. Irrespective of insurance status, therefore, one tests for the hypotheses:

H₀¹, There is no difference in self-care exercise frequency by the level of education.

H_a¹, Self-care exercise frequency increases with the level of education.

H₀², There is no difference in self-care exercise frequency by household income.

H_a², Self-care exercise frequency increases with household income.

Since the levels of measurement are either interval or ratio, it is possible to employ parametric tests, specifically the ANOVA, to compare means of exercise frequency across levels of the independent variables education and income.

At 12.10, the F result for between-groups differences by level of income (see Table 17) is higher than the table values for thirteen degrees of freedom at ± = 0.05. The significance statistic is p <0.001, suggesting that such differences by income could not have occurred by random variation alone. Hence, one rejects the null hypothesis and concludes that diabetic patients from higher-income households are more conscientious about adhering to a self-care and lifestyle regimen that includes exercising enough to work up a sweat.

Since there is a degree of auto-correlation between income and educational attainment, it stands to reason that the F value associated with between-group differences by level of education is also high enough for df=16 to return p<0.001. Again, we reject the second null hypothesis and conclude that complying with vigorous physical workouts is more likely when the patient is better-educated.

References

Anderson, J. A. M. (1996). Basic conditioning factors, self-care agency, self-care, and well-being in homeless adults. Unpublished doctoral dissertation, Wayne State University, Detroit, Michigan.

Baldwin, C. M., Hibbeln, J., Herr, S., Lohner, L. & Core, D. (2002). Self-care: As defined by members of the Amish community utilizing the theory of modeling and role-modeling. Journal of Multicultural Nursing & Health, 8(3) 60-64.

Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: W. H. Freeman.

Carroll, D. L. (1995). The importance of self-efficacy expectations in elderly patients recovering from coronary artery bypass surgery. Heart and Lung: Journal of Acute and Critical Care, 24(1), 50-59.

Centers for Disease Control and Prevention (2007) New CDC study finds no increase in obesity among adults; but levels still high. National Center for Health Statistics, Office of Communication (301) 458-4800.

Erickson, H., Tomlin, E. & Swain, M. A. (1983). Modeling and role-modeling: A theory and paradigm for nursing. Englewood Cliffs, N.J.: Prentice-Hall.

European Society of Cardiology (2009) Obesity and diabetes double risk of HF  Patients with both conditions very difficult to treat. Atlanta: NewsRx Health, proceedings of the Heart Failure 2009 Conference, 138.

Kotsevaa, K., Wooda, D. De Backerb, G., De Bacquerb, D., Pyöräläc, K. & Keild, U. (2009, April 1) EUROASPIRE III: a survey on the lifestyle, risk factors and use of cardioprotective drug therapies in coronary patients from 22 European countries. European Journal of Cardiovascular Prevention and Rehabilitation, 16(2) 121-137.

Moon, L. B. & Baker, J. (2000). Relationships among self-efficacy, outcome expectancy, and postoperative behaviors in total joint replacement patients. Orthopaedic Nursing, 19(2), 77-85.

Orem, D. E. (1995). Nursing: concepts of practice. (5th ed.). St Louis, MO: Mosby.

Parent, N. & Fortin, F. (2000). A randomized controlled trial of vicarious experience through peer support for male first-time cardiac surgery patients: impact on anxiety, self-efficacy expectation, and self-reported activity. Heart and Lungs: Journal of Acute and Critical Care, 29(6), 389-400.

Sousa, V. D. & Zauszniewski, J. A. (2005/2006). Toward a theory of diabetes self-care management. Journal of Theory Construction & Testing, 9(2) 61-67.

Wang, C. Y. (1997). The cross-cultural applicability of Orems conceptual framework. Journal of Cultural Diversity, 4(2), 44-48.

Appendices

Table 1

Table 2

Table 3

Table 4

Table 5

Table 6

Table 7

Table 8

Table 9

Table 10

Table 11

Table 12

Table 13

Table 14

Table 15

Table 16

Table 17: Self-care/Exercise by Level of Income

Table 18: Self-Care/Exercise by Educational Attainment