WHO Quality Of Life-BREF Questionnaire Research Articles

Correlation between Quality of Life and Burden in Caregivers of Advanced Stage Cancer Patients on Best Supportive Care.

Patients with advanced cancer with incurable diseases are generally cared for by their families in India. There is a lack of data on the perceived caregiver burden, quality of life (QOL) of patients and caregivers in India, especially among cancer patients not on any oncologic management. We conducted a cross-sectional study among 220 patients of advanced cancer on best supportive care and their respective 220 family caregivers. Our primary objective was to identify a correlation between caregiver burden and QOL. After taking informed consent from both patients and caregivers, we assessed the QOL of the patient using the European Organization for the Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 15 Palliative Care (QLQ C15PAL) questionnaire from the patient, assessing the Caregiver Burden using Zarit Burden Interview, assessing the QOL of the caregiver using the WHO QOL BREF Questionnaire, in a single session during their routine follow-up in the Palliative Care Clinic of our institution. We noticed a statistically significant negative (Spearman) correlation between the Caregiver Burden as assessed by Zarit Burden Interview (ZBI) and the psychological (r = -0.302, P < 0.01), social (r= -0.498, P < 0.01) and environmental (r = -0.396, P < 0.01) domains of the WHO QOL BREF Questionnaire. Caregiving Burden as assessed ZBI total score was noted to have a statistically significant negative correlation with physical functioning (r = -0.37, P < 0.01), emotional functioning (r = -0.435, P < 0.01) and global QOL scores (r = -0.499, P < 0.01) assessed from the patient using the EORTC QLQ C15 PAL questionnaire. It also had a statistically significant small positive correlation with EORTC QLQ C15 PAL symptom scores, such as dyspnoea, insomnia, constipation, nausea, fatigue and pain. The median caregiver burden score was 39, showing higher burden as compared to previous studies. Caregivers who were spouses of the patient, illiterate, homemakers, with low-income families reported higher burden. A high perceived caregiving burden is associated with impaired QOL in family caregivers of advanced cancer patients on best supportive care. Multiple patient related factors and demographic factors tend to affect burden of the caregiver.

Factors affecting the uptake of national practice guidelines by physicians treating common CVDS in out-patient settings

Aim To study factors that influence the consistency of real prescriptions with applicable national guidelines for outpatient physicians in the management of patients with common cardiovascular diseases (CVDs).Material and methods This was a cross-sectional study based on 16 randomly selected municipal polyclinics, where internists filled in validated questionnaires, including the Maslach Burnout Inventory - Human Services Survey (MBI-HSS), Hospital Anxiety and Depression Scale (HADS), Visual Analogue Scale (VAS), WHO Quality of Life - BREF (WHOQOL-BREF), and the Personal Decision-Making Factors (PDF-25). Participating physicians provided outpatient case reports of sequentially arriving patients with a high risk of CVD or confirmed CVDs during 2-3 working days, corresponding to the questionnaire period of ±1 week. The consistency of the prescriptions recorded in these case reports with the Russian Society of Cardiology (RSC) Guidelines was assessed.Results This study included 108 physicians (mean age, 44.0±13.1 years, 87.0 % women) who provided case reports of 341 patients (mean age, 64.4±13.2 years, 59.5 % women) with most common diagnoses of arterial hypertension (92.1 %), ischemic heart disease (60.7 %), and chronic heart failure (32.8 %). According to results of multivariate regression analysis, the following factors increased the likelihood of the prescription inconsistency with the guidelines: the fact that the physician had the highest attestation category (OR 2.56; 95% CI 1.39-4.7; p&lt;0.002), attended professional events less than 2 times in 5 years (OR 2.23; 95% CI 1.18-4.22; p=0.013), had an additional, part-time job (OR 15.58; 95% CI 1.51-160.5; p=0.021), was prone to prescribe familiar trade names (OR 2.04, 95% CI 1.08-3.85; p = 0.028), perceived drug supply problems as an important factor influencing the decision making (OR 5.13, 95% CI 2.69-9.75; p&lt;0.001), and a total score on the emotional exhaustion scale (OR 1.03, 95 % CI 1.01-1.06; р=0.031). Also, this likelihood was increased by older age of the patient (OR 3.29; 95 % CI 1.65-6.55; р&lt;0.001) and excessive alcohol consumption by the patient (OR 1.79, 95 % CI 1.31-2.43; р&lt;0.001). The likelihood of non-compliance with the guidelines was reduced by a high assessment of own health status according to the WHOQOL-BREF questionnaire (OR 0.19; 95% CI 0.05-0.72; p = 0.014), a high assessment of own working conditions (OR 0.76; 95% CI 0.64-0.9; p=0.002), and postgraduate education within the last 5 years (OR 0.14; 95% CI 0.06-0.36; p&lt;0.001).Conclusion The study identified the factors that influence the likelihood of the consistency of prescriptions made by outpatient physicians for patients with CVD with applicable national clinical guidelines. Among these factors, the most important ones were access to educational events, additional, external part-time job, indicators of inertia of previous practice, problems with drug provision, satisfaction with own health status and working conditions, and emotional exhaustion (a component of professional burnout), older age of patients and their excessive alcohol consumption.

Functional Status, Quality of Life, and Physical Activity of Senior Club Members-A Cross-Sectional Study.

This study aims to assess the functional status, quality of life, and physical activity (PA) of the elderly who are members of senior social clubs. The study included 63 participants (65–95 years old) who were members of a seniors club. The study utilized the following instruments: Barthel scale, Lawton’s scale of Instrumental Activities of Daily Living (IADL), WHO Quality of Life-BREF questionnaire, author’s survey questionnaire containing questions about the type of PA. Duration of membership in the senior club has a statistically significant effect on Barthel index score (F = 19.68, p < 0.001) and Lawton’s IADL scale results (F = 17.59, p < 0.001). All four domains of life quality were strongly related to the duration of attendance to senior clubs. Participants who attended the senior club for more than five years were more likely to report a longer PA duration than participants who attended the senior club for less than 5 years (Chi2 = 25.84, p < 0.001). Attendance to senior social clubs has a strong positive impact on functional status, quality of life, and PA of the elderly. Moreover, our study identified numerous social-demographic factors associated with PA, quality of life, and functional status of senior club members.

Effectiveness of a hybrid arts-based Cognitive Behavioral Therapy intervention for patients with non-malignant chronic pain.

Chronic Pain (CP) is defined as pain that persists or recurs for more than 3 to 6 months and may be conceived as a health condition in its own right. CP is a frequent condition, affecting an estimated 20% of people worldwide and requires special treatment and care. CP can contribute to depression, anxiety, sleep disturbances, poor quality of life and increased health care costs. Psychosocial approaches based on a cognitive conceptualization of pain can provide a solid foundation for research and clinical work. The development of a 10 week-session group treatment was based on key principles from the literature on Cognitive Behavioral Therapy for Chronic Pain (CBT-CP) and Creative Arts Therapy, integrated with advances in research on CP management framework. The aim of this study is to evaluate a CBT-CP arts-based group intervention for patients with non-malignant CP addressing the biopsychosocial factors that influence pain perception. A total of 100 University Pain Management Unit outpatients participated, 50 in the intervention group and 50 in the control group (treatment as usual). In analyses of the pretest-posttest research design intervention including all participants, treatment gains were observed in almost all domains examined: severity of pain measured by the Brief Pain Inventory, conceptualization of mental pain measured by the Orbach and Mikulincer Mental Pain Scale, tolerance for psychological pain measured by the Tolerance for Mental Pain Scale, anxiety and depression levels measured by the Hospital Anxiety and Depression Scale, and quality of life measured by the WHO Quality of Life-BREF Questionnaire. The participants' mean age was 52.3 years and most were female (84%). Findings suggest that postprogram, there was significant reduction in pain intensity (p<0.001), depressive symptoms (p<0.001), confusion about pain (p=0.037), and improvement of emotional distress tolerance (p=0.012) and global health-related quality of life (p<0.001) in the intervention group. Beneficial effects can be expected from the implementation of an integrated CP intervention (including: creative and CBT techniques) reappraising some of the coping responses defined as adaptive within current psychosocial non-malignant CP regimens.

Association of alcohol use with quality of life (QoL): A community based study from Puducherry, India

BackgroundThere is a paucity of information available on the severity of alcohol use with quality of life (QoL). Hence this study aimed to assess the association of alcohol use with QoL. MethodsA community-based cross-sectional study was conducted among 316 adult men aged ≥18 years in Puducherry, South India. Individuals were selected using a multistage sampling technique. WHO AUDIT and WHO QoL BREF questionnaire were used. Multiple linear regression analysis was used to assess the independent association of alcohol use with QoL. ResultsMean (SD) age at initiation was 25.1 (8.8) years. The prevalence of probable dependence was 8.2% (95% CI 5.4–11.8%), and hazardous or harmful use was 27.8% (95% CI 24.8–35.1%). Overall mean (SD) score of QoL was lower among alcohol users compared to non-alcohol users [50.7 (10.9) vs 63.5 (10.1), p-value <0.001]. QoL score was significantly lower among alcohol users in QoL rating and health satisfaction; also in physical, psychological, social relationship, and environmental domains. High-risk alcohol users and urban residence had 11.2 and 4.1 less QoL scores respectively and educated had 7 more QoL scores compared to the reference category. ConclusionsAlcohol use is associated with low quality of life. There is a need of alcohol-deaddiction strategies to reduce alcohol use and improve their QoL.

An assessment of the work ability, disability and quality of life of working people of pre-retirement and retirement age in Poland - a cross-sectional pilot study.

The aim of this work was to assess the work ability, health status, disability and quality of life of working people of pre-retirement and retirement age, as well as to analyze factors affecting the ability to perform work in older age. A cross-sectional pilot study was conducted in the Podkarpackie and Świętokrzyskie voivodeships, Poland, in randomly selected workplaces of intellectual nature. It was carried out by means of direct interviews in the workplace of the surveyed people, using the Work Ability Index, a questionnaire based on the WHO Disability Assessment Schedule 2.0, the WHO Quality of Life-BREF questionnaire, the Geriatric Depression Scale, and the Visual Analogue Scale (VAS). The criteria for inclusion were: age 55-75 years and informed consent to participate in the study. Overall, 201 complete questionnaires were included in the analysis. Demographic data is presented using descriptive statistics measurements. The logistic regression model was used to identify factors related to work ability. The vast majority (69.66%) of employees performing intellectual work had moderate or poor work ability. The average level of general disability in the studied group was mild (20.65), and the quality of life was quite good (64.73). A significant problem among the surveyed people was a quite high average level of pain (VAS = 3.99), the occurrence of depression (73.63%), as well as musculoskeletal (64.18%) and cardiovascular diseases (52.24%). The most important factor contributing to a better work ability was the adaptation of the workplace to functional and healthrelated needs (OR = 7.79). Psychological well-being (OR = 1.12), cognitive performance (OR = 0.97) and a smaller number of chronic diseases (OR = 0.58) were also important factors. Preparation of elderly people for professional activity should be conducted in 2 different ways, i.e., by means of education and implementation of an active, healthy lifestyle, and increasing control over one's own health and factors determining it, as well as by the proper organization of working space, and quick access to treatment and rehabilitation, especially in the case of musculoskeletal and cardiovascular diseases. Int J Occup Med Environ Health. 2021;34(1):69-85.

The quality of life in adult patients treated for Cushing's disease in childhood.

Numerous studies assessed the quality of life (QoL) of adult patients after Cushing's disease (CD) treatment. Available professional literature reveals that hypercortisolemia caused by CD may negatively impact the mood and social life. However, data on QoL of adult patients after CD treatment in childhood are scarce. Aim of the study: To study the QoL of adult patients treated for CD in childhood. Eighteen out of 29 adult patients diagnosed in childhood with CD and/or treated at one center participated in asurvey and completed WHO Quality of Life-BREF questionnaire. The influence of selected prognostic factors for the QoL has been analyzed. Patients data were compared with acontrol group with the same age and sex. Participants (10 women and 8 men) were at the mean age of 28.93 years (19.75-40.33). No significant difference in the QoL was noted between analyzed patients and controls. Patients with hypopituitarism had lower results in domain 4 in comparison with patients without hypopituitarism (p=0.31) and lower results in domain 2 in comparison with the control group (p=0.045). Patients with ahigher age at disease onset had lower results of the QoL in domain 1 (p=0.031). During long-term follow-up the QoL of patients after CD treatment in childhood is not significantly different wit QoL of healthy controls. Further studies are needed to expand the knowledge of factors that may contribute to the QoL in CD patients who were treated in childhood.

Surveing the Quality of life in Employees health centers of Yazd Province in 2011

Introduction: Quality of life is a subjective and multidimensional concept that in recent years has been noticeable by researcher due to multilateral widespread of technology and industrialization process. Quality of life, was is individuals understanding of their status in the context of physical, mental and social impacts and to indicate the status of a resident in a country or region. The purpose of this study was determination the quality of life in employees health centers of Yazd province about healthy life styles in 2011.&#x0D; Methods : This research was a cross - sectional study in which 501 staff employed in 12 central areas of health centers of Yazd as census method were enrolled . Data collection tool was WHO Quality of Life-BREF questionnaire (WHOQOL-BREF) including 26 questions,). After data collection , it was analyzed by using SPSS software as well as statistical t-test and ANOVA.&#x0D; Results: The results shown that the employees health centers of Yazd province were acquired 67.9% of the quality of life score. The way in which the dimensions of physical, psychological, social relationships and environment were obtained 72.9, 65.5, 70.2 and 63.15 ​​percent from the maximum score; Respectively. The quality of life score based on age, gender, type of employment, work experience and climate conditions were significant (p≤ 0.05).&#x0D; Conclusions: Therefore it was suggested to improve the quality of life of employees health centers, officials with proper planning includes considering educational , cultural, recreational and sport programs ,, providing healthy nutrition, installing motivation and responsibility in them as well as paying proper salary and benefits, take effective steps in this way.

The association between body composition and quality of life among elderly Italians.

This study aimed to assess the body composition and quality of life in elderly Italian people and to value the association between these variables. Height, weight, humerus breadth, circumferences, skinfolds, and hand grip strength were measured in 256 older adults (age: M: 81.1 ± 7.3, F: 84.9 ± 8.1 years). Body mass index, waist-hip ratio, waist-height ratio, upper-arm areas, and body composition parameters were calculated. Quality of life (QoL) was measured by WHO Quality of Life-BREF questionnaire (WHOQOL-BREF). Differences between sexes were valued. A multiple regression analysis was carried out to assess the influence of nutritional status and of socio-demographic characteristics on QoL. The participants were in average overweight. Even if the percentage of overweight/obese subjects was high in both sexes, males presented a more centripetal fat distribution. These characteristics, joined to data regarding lower values of arm-muscle area and hand grip strength, put males at greater risk of cardiometabolic diseases. Regarding quality of life assessments, psychological domain showed the worst scores, and, marital status resulted the main explanatory variable for this domain. Social care facilities for the elderly people require planning strategies based on health promotion criteria in order to accentuate active ageing interventions to ameliorate the quality of life of residents.

The influence of sleep disorders on the quality of life in patients with chronic low back pain.

Low back pain (LBP) is one of the most common pain syndromes, and its prevalence has increased significantly in the past three decades. The aim of this study was to evaluate the effects of insomnia and daytime sleepiness on the quality of life (QOL) of patients suffering from chronic back pain. It is a cross-sectional study conducted among 100 people (aged 25-75 years - mean age 49.53 ± 10.92) treated in a neurological clinic for chronic back pain lasting longer than 3 months. The diagnostic survey method was applied for the purposes of this study with the use of: the author's questionnaire and standardised questionnaires that is Visual Analogue Scale (VAS), Epworth Sleepiness Scale (ESS), Athens Insomnia Scale (AIS) and Polish version of WHO Quality of Life-BREF questionnaire (WHOQOL-BREF). The results were statistically analysed. Analysis of the study material showed that 83% of patients suffered from insomnia (scored 6 or more points on the AIS) and 29% experienced mild daytime sleepiness. People who were more sleepy during the day were characterised by lower perception of the QOL (r = -0.034, p = 0.029) and lower perception of general health (r = -0.035, p = 0.04). Analysis of multiple variables (using linear regression) showed that independent predictor of the QOL in all domains is the result of the AIS questionnaire (p < 0.05). Sleep disorders - both insomnia and daytime sleepiness - are a common health problem experienced by people with LBP. Insomnia is an important predictor affecting the QOL in people with LBP.

Determinants of Quality of Life and the Need for Support for the Elderly with Good Physical and Mental Functioning.

BackgroundThe ageing of population is the reason that there are various strategies developed to help seniors acquire greater independence and a better quality of life. The aim of this study was to explore the relationship between the elderly peope’s need for assistance and assessed quality of life.Material/MethodsThe study included 100 participants who were members of a Seniors Club in Poznań, Poland. The cross-sectional study utilized the following instruments: Abbreviated Mental Test Score (AMTS), Instrumental Activities of Daily Living (IADL), EASY-Care Standard 2010 questionnaire, (WHO Quality of Life-BREF (WHOQOL-BREF) questionnaire.ResultsMembers of the Seniors’ Club showed good functional condition. In the AMTS test, they scored near maximum values (average 9.39±0.77 points), somewhat poorer results were found in the IADL scale (average 20.92±3.96 points). In the EASY-Care questionnaire, the study participants usually required partial support in the following areas: Mental health and well-being (59%), Staying healthy (29%), Getting around (22%), and Seeing, hearing and communicating (22%). The average score on Independence was 13.13±18.51, The risk of breakdown in care scale was 4.39±3.21. The risk of falls affected 21 participants (21%). Quality of life study using WHOQOL-BREF questionnaire found that the highest scores were achieved in Psychological and Environment domains, and the lowest score in the Physical health domain.ConclusionsQuality of life as well as level of independence, risk of falls, and need for 24-hour care were significantly affected by the following factors: urinary incontinence, difficulties in mobility outside the home, despondency, and forgetfulness.

A study on demographic factors affecting quality of life among HIV positive individuals attending a district anti retroviral treatment centre in Mangalore

Background: Prevention and treatment in HIV greatly influences the quality of life (QOL). The objective of the study was to assess QOL of individuals with HIV and its association with demographic factors. Methods: 400 patients with HIV attending the district anteretroviral treatment (ART) centre were interviewed with WHO QOL BREF questionnaire using systematic random sampling. Descriptive statistics, Chi square and independent t test and logistic regression was done to analyse the results. Results: Mean quality of life score was highest in the physical domain (Mean=14.93, ±3.59). Least score was seen for Social domain (Mean=12.30, ±2.37). The physical domain score was highest among those belonging to class 1 SES (Mean=17.50, ±0.707). Domain scores varied significantly (p&gt;0.05) with respect to gender. There was significant variation in domain scores across the different socioeconomic groups except in social domain. Conclusions: Gender, Socioeconomic and marital status significantly affected the QOL of People Living with HIV.

Assessment of quality of life of ASHA workers using WHOQoL-BREF questionnaire

Background: ASHA represents a vital role in the strategy of NRHM. There is scarcity of information on quality of life and factors influencing it on ASHA workers. The assessment of quality of life in this group may help to better understand and develop an insight for measures that can be improved in their lives. The objective of the study was to assess the quality of life among ASHA workers of Mangalore and Udupi taluk, Karnataka. Methods: This is a questionnaire based, cross sectional study conducted for a period of 3 months (June 2015 - Aug 2015) on ASHA workers of Mangalore and Udupi Taluk, Karnataka. Local language Kannada version of WHO QoL BREF questionnaire consisting of 26 questions was used. Results: The mean age of ASHA workers across the study group was 42.40 years. With respect to perception of QoL and health, around 60% felt their quality of life (QoL) was good and health was satisfactory. Maximum and minimum mean scores was observed for self-esteem and financial resources respectively. Among the various domains of QoL, the ASHA workers had higher mean score in social domain, followed by physical, psychological and environmental. Conclusions: The ASHA workers had higher mean score in social domain, followed by physical, psychological and environmental.

Effectiveness of Community Reinforcement and Family Training (CRAFT) on Quality of Life and Depression in Families with Drug Abuse

&lt;p&gt;Drug abuse as a biological, psychological, and social problem affect all life aspects including quality of life and cause socio-psychological problems. This study aimed to evaluate the effectiveness of community reinforcement and family training (CRAFT) Method on quality of life and depression in family members of substance abusers. This was a quasi-experimental study with control group in which the pre-test and post-test were used. In the present study, two experimental groups (CRAFT and Nar-Anon) and a control group were used using the purposive sampling selected from the family members of substance abusers who referred to the methadone treatment clinic in Tehran. Each of groups consisted of 25 people. CRAFT groups were trained in 12 sessions of intervention techniques. Nar-Anon groups participated in self-help sessions and control did not receive any training. All three groups completed the BDI-II Test and WHO Quality of Life-BREF questionnaire and the results were analyzed using SPSS-16. The results of two intervention methods compared with the control group showed no significant effect in reducing depression. CRAFT and Nar-Anon interventions were not effective in reducing the depression of family members of drug abuse patients but both were effective in promoted the quality of their life compared with control group.&lt;/p&gt;

Qualidade de vida e aspectos auditivos de trabalhadores do transporte coletivo urbano

RESUMO Objetivo: avaliar a qualidade de vida de trabalhadores do transporte coletivo urbano, associadamente ao seu conhecimento e queixas sobre audição, zumbido e tontura. Métodos: descritivo, qualitativo e transversal. A coleta foi realizada no Hospital Universitário de Santa Maria, com amostra de 26 profissionais, submetidos à versão abreviada do questionário de avaliação de qualidade de vida - WHO Quality of Life-Bref Questionnaire (WHOQOL - Bref) - e a um questionário sobre conhecimento e queixas relacionadas a audição, tontura e zumbido. Os dados foram analisados por meio do Software Statística versão 9.0, considerando um nível de significância de 5%. Resultados: a amostra caracterizou-se por 100% de indivíduos do sexo masculino, com média de idade de 38,03 anos e tempo médio de serviço de 11,29 anos; 88,46% dos sujeitos trabalhavam em contato direto com o trânsito urbano e expostos a ruídos no ambiente externo à empresa. Quanto ao perfil auditivo, 88,46% referiram ouvir bem. Quanto às queixas: 23,07% relataram zumbido e 26,92% tontura. Com relação aos hábitos de prevenção de perda auditiva, 73,07% referiram não adotar nenhuma conduta. As respostas do WHOQOL-Bref evidenciaram uma boa percepção de qualidade de vida destes sujeitos. Conclusão: os trabalhadores do transporte coletivo avaliados no presente estudo apresentaram um bom nível de qualidade de vida, consideráveis conhecimentos e limitadas queixas no que diz respeito aos temas audição, zumbido e tontura.

Quality of Life after Stapled Hemorrhoidopexy: A Prospective Observational Study

Objective. The objective of the study was to assess the change in quality of life (QOL) of patients undergoing stapled hemorrhoidopexy (SH) using WHO Quality of Life-BREF (WHOQOL-BREF) questionnaire. Methods. The study sample comprised patients with symptomatic II, III, and IV degree hemorrhoids, undergoing SH. The patients were asked to complete WHOQOL-BREF questionnaire before and one month following the surgery. Result. There were 20 patients in the study group. The postoperative pain score measured by visual analogue scale at six hours postoperatively was 7.60 ± 1.23, which reduced to 0.70 ± 0.92 at 24 hours. The items in the WHOQOL-BREF had high-internal consistency or reliability as shown by high Cronbach's alpha coefficient which was 0.82 and 0.90 for pre- and postoperative questionnaires. There was significant improvement in the overall perception of QOL and health, and in physical and psychological domains. There was modest improvement in environmental domain, while no change was noted in social domain. Conclusion. SH improved the quality of life of patients treated for hemorrhoids.

Exploring the quality of life (QOL) in the Indian software industry: a public health viewpoint

Our objectives were to describe the QOL and its determinants among software professionals of Kolkata, and to compare the same according to information technology (IT) and IT-enabled services (ITeS) sub-sectors. An institution-based cross-sectional study was conducted among software professionals of Kolkata applying a two-stage stratified random sampling technique. The WHO QOL BREF questionnaire was administered along with a list of pertinent variables. Overall, the analysis for 338 software professionals (177 IT and 161 ITeS) clearly demonstrated significant differences between mean scores of these two sectors for each of the six outcome domains of WHO QOL BREF. Multilevel multivariate analysis outlined 13 significant predictors of QOL-four positive (age, regular fitness regimes, foreign placements and changing companies frequently) and the rest of the nine, negative (multiple sex partners, multiple addictions, extended working hours, night-shift duties, income, expenditure, carrying office work home, current illness and ITeS company type). Our study helps in obtaining a clear understanding of the multifaceted risk factors prevailing in this sector, the majority of which can be effectively addressed by specific health promotional interventions. A dedicated health policy is mandated at both government and company levels.