A Baseline Survey: An Assessment of Cervical Cancer and Cervical Cancer Screenings Knowledge in Women
Danielle Bauman
University of North Carolina Wilmington
DECLARATION
I solemnly declare this paper is my own original work. Submission partially fulfills a Bachelor of Science degree in Public Health at the University of North Carolina Wilmington under the guidance of Dr. Naa Ashiley Vanderpuye-Donton, field internship supervisor, Dr. Vera Opata, field supervisor, and Elisabeth Baynard, academic internship advisor. This paper has not been submitted before for any purpose, either professional or academic.
Electronic Signature: Danielle Bauman
Printed Name: Danielle Bauman
Date: November 29, 2020
Abstract
Cervical cancer is the fourth most common cancer in the world and will result in the death of two out of three Ghanaian women diagnosed with it (World Health Organization [WHO], 2020a; (Bruni et al., 2019). The purpose of this survey was to determine a baseline for how much Ghanaian women seeking medical care know about cervical cancer and cervical cancer screening options. A cross-sectional baseline survey was given to 152 women aged 18 to 74 who utilized the services at the IHCC to assess their cervical cancer knowledge. Data was analyzed using the SPSS software focusing on descriptive statistics and comparing means. The results showed that 54% of the women knew what cervical cancer was, 58% had heard of cervical cancer screening, 12% had heard of genital warts, 10% had been examined for cervical cancer, 13% knew what a pap smear was, and 6% had heard of a VIA. The results also indicated those with a tertiary level of education had higher knowledge of all questions asked. A more thorough educational program on cervical cancer, its causes, preventions, and treatments are necessary to take control of the disease.
Keywords: cervical cancer, cervical cancer screening, pap smears, HPV, genital warts,
Ghanaian women, cancer education, VIA
Background
Statement of the Problem
Cervical cancer is the fourth most common cancer in the world. Most cases are a result of the human papillomavirus, a common virus transmitted through sexual contact. Lesions begin growing on the cervix, and they dissipate with little to no noticeable symptoms. Without early detection, those who are prone to infection, such as women who are living with HIV, are more likely to develop aggressive cervical cancer (World Health Organization [WHO], 2020a). Although all women are at risk, those over 30 years old are the most commonly afflicted (Centers for Disease Control and Prevention [CDC], 2020). In 2018, 570,000 women were diagnosed with cervical cancer resulting in the death of more than half of them (WHO, 2020a). Sub-Saharan Africa carries the highest burden of cervical cancer with 19 out of the top 20 countries, worldwide, with the most cases (WHO, 2020b).
Although there are multiple studies encompassing a myriad of aspects of cervical cancer knowledge and education around Ghana and other West African and East African countries, there is a gap in the literature focusing particularly on the IHCC, a pro-poor private health facility, and the women who use its services. With the completion of this knowledge survey, the researcher, the IHCC staff, and community health workers have a better overview where more educational focus as well as more services for women need to be placed. The long-term result of improving the cervical cancer education as well as early screening services will be a reduction in deaths due to treatable cervical cancer.
Barriers to the Problem
Education about cervical cancer, screening, and treatment is one of the largest barriers to finding a solution to his problem. A National Screening Program was developed in 2005 but progress has dwindled. As a result, there are not enough places that screen using VIA. Pap smears are only conducted upon request at a few private clinics (Ministry of Health, 2011).
Purpose
The purpose of this survey was to determine to what extent women who visit the International Health Care Center (IHCC) for services know about cervical cancer. This includes cervical cancer knowledge as well as knowledge of screening services.
Objectives
The survey worked toward two objectives. The first objective was to assess the knowledge of cervical cancer among the female clientele who report to IHCC for any service. The second objective was to determine if there is a need for increased cervical cancer education and screening at IHCC. Both objectives encourage preventative care and early detection before tertiary care is even needed. The overall goal of proving the need for increased cervical cancer education and screening was reached through the survey by questioning a sample of Ghanaian women seeking medical care at the International Health Care Center for their general well-being to answer the research question, “What is the range of knowledge most Ghanaian women, who use the IHCC services, have regarding cervical cancer?”
Literature Review
Researchers and scientists agree that cervical cancer is preventable with proper screenings and treatable with early detection (WHO, 2020a; Calys-Tagoe, Aheto, Mensah, Biritwum, & Yawson, 2020). A Papanicolaou smear (PAP) is a simple and common method for detecting precancerous cells in the cervix and has cut the overall mortality rates due to cervical cancer by up to 74 percent globally since it became common practice (Ebu, Mupepi, Siakwa, & Sampselle, 2014). The doctor inserts a tool, called a speculum, into the vagina and then scrapes cells from the cervix. However, this scraping is sent to a laboratory for testing which can increase the cost to both the client and the facility. Visual inspection with acetic acid (VIA) is a procedure easily understood and can be performed by nonphysician medical providers. Because there are no lab tests to run as it is a “see and treat” procedure, it is a more cost-effective alternative to the pap smear in low–to–middle income countries (Sahasrabuddhe, Parham, Mwanahamuntu, & Vermund, 2011). This begs the question, why do approximately two out of three women in the West Africa region who are diagnosed with cervical cancer die from the disease every year? (Bruni et al., 2019). There are common themes that emerged from most studies. They include barriers such as lack of knowledge including that of the disease, of the symptoms, of the risk factors and of prevention, unaffordable treatments, and some misinformation and popular beliefs (Binka, Doku, & Awusabo-Asare, 2017; Ebu & Ogah, 2018; Tapera et al., 2019; Tchounga et al., 2019). Without proper intervention, cervical cancer is projected to rise in Africa from approximately 60,661 deaths to 100,737 deaths (WHO, 2018).
Barriers
The Deficiencies
Knowledge. All research on this topic leads to a general lack of knowledge regarding cervical cancer. While Tapera et al. found that those in their study in Zimbabwe barely knew the disease existed, Binka et al. found their subjects from rural Ghana to be more lacking in the understanding of the cause of the disease, the symptoms, and the prevention and treatment options (2019; 2017). In fact, evidence shows that women in rural areas of low to middle income countries (LMICs) do not have reasonable access to clinics or community health workers to learn about the disease. Some women in an Ethiopian study from 2013 had to travel over 100 km to get medical assistance so they tend to not seek it until there are advanced symptoms (Hailu & Mariam, 2013). At that point, they are most likely terminal.
National screening program. Many researchers point to the lack of a national screening program or a national policy regarding cervical cancer screening throughout much of West Africa as part of the problem (Calys-Tagoe et al., 2020; Donkoh et al., 2019; Nartey, Hill, Amo-Antwi, Nyarko, Yarney, & Cox, 2018). Australia began a new National Cervical Screening Program in December of 2017. It has contributed to a minimum of a 15 percent reduction in cervical cancer case (National Cervical Screening Program, 2020). Screening programs have been shown to be effective in LMICs. World Health Survey data from 2004 shows that Mexico, who had a screening program in place for some time, had a higher percentage of women, approximately 65 percent, who experienced more effective cervical cancer screening coverage than the United Kingdom (UK) and was not far behind Australia. The same data shows Ghana’s coverage to be roughly 4 percent (Olsen et al., 2016).
The Cost
Cost of treatment. Like many other countries, Ghana has a national health insurance scheme (NHIS). According to the NHIS website, cervical cancer treatment is covered (NHIS, 2020). Yet, according to Nartey et al., the hospitals still rely on out-of-pockets payments. There is the possibility that some women will refuse treatment due to their inability to pay for radiotherapy and chemotherapy (Nartey et al., 2018). As previously mentioned, some health facilities, such as oncology centers, are too far from rural areas. The transportation cost, alone, is unaffordable, without even considering the cost of the treatment, the lodging for the duration of the stay, and the amount of times the treatment would need to be repeated creating the same affordability issues over again (Nartey et al., 2018; Tapera et al., 2019).
Cost to personal life. Even in the case that treatment is financially an option, in many instances, the women are the primary source of income for their family (Binka et al., 2017). If the disease, including the treatment for it, causes severe illness, the women cannot work and will end up in debt. For those that do seek treatment, it is not uncommon for them to take out a loan, sometimes from a family member. This can cause tremendous stress within the family. It can even create marital strain as, at times, during the treatment, the woman cannot engage in intimate acts with her husband. In one study, the inability to have sexual intercourse caused a woman’s partner to leave her (Binka et al., 2017).
Beliefs
Spirituality often plays an important role in the Ghanaian people when choosing treatment. Sometimes this is due to a lack of understanding of the condition or disease. Because the source of cervical cancer is unfamiliar, some attach the cause of the disease to the idea of witchcraft or angry spirits looking for revenge (Asare & Danquah, 2017; Tapera et al., 2019). The use of alternative medicine, such as herbal treatments, are still a common way to treat pains rather than seeking more western medicine. This can cause a delay in diagnosis and life-saving treatment. This can also cause a toxic mix for those who use both traditional medicine with orthodox treatments such as surgery and chemotherapy (Yarney et al., 2013).
Methodology
Study Design and Study Location
A simple six question baseline, cross-sectional survey, as seen in appendix A, to measure knowledge of cervical cancer and experience including cervical cancer screenings was conducted between the beginning of October and the middle of November 2020 at the IHCC located in the Haatso areas of Greater Accra, Ghana. The survey was dichotomous as the restricted format of questions was easy and increased the chance of high response rates.
IHCC is a reduced-fee clinic that provides care to residents of Ghana and, although it is a private facility that occasionally receives compensation upon service rendered, it is considered a pro-poor facility. IHCC will provide care regardless of a client’s ability to pay. This facility provides affordable, equitable care to all people. Although IHCC provides general medical services, it does not admit patients for overnight stays. However, clients can be observed for a maximum of eight hours and then, if necessary, the IHCC staff will refer the patient to other facilities that will meet their needs. Although its focus is on infectious diseases, the clinic can handle any general medical needs or concerns. Its services include women’s health with cervical cancer screening, examinations, and laboratory testing.
Study Population
The inclusion criteria for the study population was all women who come to the IHCC for care. The type of care was not a factor for inclusion or exclusion of the study. All women who participated in the survey were a minimum of 15 years old and a maximum age of 90 years old as WHO data estimates women seventy and above will see the greatest increase in cervical cancer by 2030. There was no previous knowledge necessary or educational requirement to participate in the survey. All participants took the survey willingly.
The sample size goal was approximately 285 women who were expected to pass through IHCC between October 1st, 2020 and November 13th, 2020. The sample size was calculated based on the population of the 1143 women who visited IHCC from September 2019 through September 17th, 2020. The calculation included a 95% confidence level and a 5% margin of error. Due to the single location of the survey and the short time frame, every woman between the ages of 15 and 90 years of age who entered the clinic had the possibility to take the survey. Because several proctors were used, a simple random sampling naturally occurred.
Data Collection
Each survey was conducted manually by an IHCC nurse trained to obtain the answers to the survey. The questions and answers were then entered into Microsoft Excel by an IHCC staff member. The survey was given on a daily basis to each woman who had not previously taken it. The survey questions were dichotomous except for one that required a location in the event the answer was ‘yes.’ All surveys were given in English, but a translator was available in the event the participant spoke only a traditional Ghanaian language. Demographic data was collected that included age, marital status, education level, and profession. Other data collected measured the knowledge of cervical cancer and the knowledge of gynecological screenings.
Data Analysis
At the end of the survey distribution time frame, November 13th, 2020, the electronic survey results in Microsoft Excel were cleaned and coded. The dichotomous answers to specific variables were given a nominal measurement score where 0 represented “NO,” 1 represented “YES,” and 2 represented “N/A” for the cells that were left unanswered. Education was grouped into four categories. Those who answered NIL and primary were put grouped together as “NIL/Primary” and coded as 3. Those who answered MSLC (Middle School Leaving Certificate), junior high, and high school were grouped into the category named “secondary” and coded as 4. The third category was tertiary which equals university level and was coded as 5. The final category was for the answers left blank which were filled with “N/A” and coded with 2. The coded Excel sheet was then entered into the SPSS program to be analyzed. The primary data analyses used were descriptive statistics and compare means. From here, the mean score and the standard deviation were calculated to determine what range of knowledge most Ghanaian women, who use the IHCC services, have regarding cervical cancer. Age was an independent variable used for comparison to determine if there is more knowledge among younger or older women. Education was also an independent variable, with four levels, used to explore whether higher education, especially those with a tertiary education, had a better base of knowledge regarding cervical cancer and screening than those with a secondary education or lower.
Ethical Considerations
Permission to conduct this survey was granted by the International Health Care Center. Participants took part in the survey voluntarily.
Results
The demographics of the female participants consisted of 152 women with a mean age of 41.95 ranging from 18 to 74 years of age with four women who did not provide an age. Most of the women (38.5%) were married, but single status was not far behind (34.5%). Four women did not provide their marital status. Although the education level varied, 18.4% (n=28) had no education through primary education. Secondary education was the highest at 61.2% (n=93) and tertiary level of education was the lowest at 16.4% (n=25). Six women did not provide their level of education. In terms of occupation, 40.3% (n=60) were categorized as traders while seamstress was the second most abundant work demographic with 12.1% (n=18). Other categories of note were unemployed (n=12), hairdresser (n=8) and teacher (n=4). Ten of the women did not provide an occupation.
When running the reliability analysis for internal consistency using Cronbach’s alpha as seen in Table 2, the alpha coefficient for the 6 items is .751 which suggests an acceptable internal consistency (a reliability coefficient of .70 or higher s considered acceptable). Based on missing variables within the six items, 11.2% (n=17) cases were excluded when processing the reliability statistics.
Question Results
The mean scores for all positive answers are shown in Table 1. On the first question, “Do you know what cervical cancer is?,” there was a mean score of .54 (n=151; SD, .500). Approximately 70 (46.1%) women did not know what cervical cancer was and 81 (53.3%) women stated they did know what cervical cancer was. One (.7%) participant did not answer. The age for those who answered they did not know what cervical cancer was averaged around 40.49. Those who were familiar with the diseases averaged around 43.18 years of age. When looking at the means of the independent variable of education (Table 2), .88 of those with a tertiary level stated they knew what cervical cancer was. Those with a secondary education had a positive mean score of .41, and those with no education or just primary school averaged at .56.
When asked item two, “Have you heard about cervical cancer screening?,” the mean score for a positive answer was .58 (n=151; SD, .495). There were 63 (41.4%) women who were unfamiliar with the screening and 88 (57.9%) who had heard about it. One (.7%) women did not respond. The average age of those who were unaware of cervical cancer screening was approximately 41.48 years old. The average age of women who answered in the affirmative was 42.38. Those with no education through primary education resulted in a mean of .50 with knowledge of cervical cancer screening. Those with a secondary education had a mean of .53, and those women educated at a tertiary level had a mean of .84.
The third item asked, “Have you heard of genital warts?” The mean positive score was .12 (n=141; SD, .327). This resulted in 124 (81.6%) women who were unfamiliar with genital warts and 17 (11.2%) women who had heard of it. There were 11 (7.2%) missing answers. The average age of women who were unaware of genital warts averaged at 41.50 years. The average age of the women who answered positively was 40.38 years. Out of the 25 with a tertiary education, three did not answer regarding if they had heard of genital warts and 11 answered with a no. This means approximately 50% of those that did answer had heard of genital warts. The mean for those with a secondary education was .06, and none of those with no education through primary school knew what genital warts were.
When asked the fourth item, “Have you ever been examined for cervical cancer,” the mean score from the sample was .10 (n=147; SD, .304). Out of the 147 women who answered this question, 132 (86.8%) women had never been examined for cervical cancer. There were 20 (13.2%) women who had been examined. Five (3.3%) did not answer. The average age for those who were examined was 47.57. The average age of the those who had never been examined was 41.57. When comparing education levels, 7% of the 28 women who answered with no education through a primary school education had been examined. Out of the 89 women with a secondary education, 4% had been examined, and 32% of the 25 women educated at a tertiary level had been examined for cervical cancer.
The mean score for item five, “Do you know what a pap smear is,” averaged at .13 (n=151; SD, .340). There were 131 (86.2%) women who did not know what a pap smear was and 20 (13.2%) who did know. One woman (.7%) did not answer this question. The average age of those who were familiar with a pap smear was 48.11 years old. The average age was 41.07 years old of those who did not know what a pap smear was. The mean for those with no education through primary school education was .07. Those with secondary education averaged around .06, and those with a tertiary level had a .46 mean regarding knowledge of a pap smear.
The sixth item of the survey asked if the respondent, “Do you know what a VIA is.” The mean score was .06 (n=151; SD, .238). Out of the sample, 142 (93.4%) women had never heard of a VIA. Nine (5.9%) women were familiar with a VIA. One woman (.7%) left this question blank. The median age for those who answered in the affirmative to VIA knowledge was 53.13 years. The average age for those who answered in the negative was 41.35 years. Out of the 25 women educated at the tertiary level, 16% knew what a VIA was. The 92 who answered this question with a secondary education averaged 2% in the affirmative. Approximately 7% of the 28 women who answered this question and were in the “NIL/Primary” education category knew what a VIA was.
An additional item was added at the end of the survey requesting the willingness to be examined for cervical cancer. The mean number was .85 (n=149; SD, .356). There were 127 (83.6%) women willing to be examined. There were 22 (14.25%) women who were not willing to be examined. Three (2%) did not respond about their willingness to be examined for cervical cancer. Women with the mean age of 41.55 were willing to be examined. The mean age of the 22 women who were unwilling was 45.59. Of the tertiary educated women who answered, 88% were willing to be examined. 87% of those who answered with a secondary education were willing to be examined. Within the NIL/Primary level educated women, 75% of those who
answered were willing to be examined.
Table 1 – Mean
Table 2 – Corresponding education |
||||||||||||||||||||||||||||||||||||||||||||||||||||
| Education Level | Do you know what cervical cancer is? | Have you heard about cervical cancer screen? | Have you heard of genital warts? | Have you ever been examined for cervical cancer? | Do you know what a pap smear is | Do you know what a VIA is? | Would you be willing to be examined for cervical cancer | |||||||||||||||||||||||||||||||||||||||||||||
| N/A | Mean | 1.00 | .67 | .17 | .20 | .17 | .17 | 1.00 | ||||||||||||||||||||||||||||||||||||||||||||
| N | 6 | 6 | 6 | 5 | 6 | 6 | 6 | |||||||||||||||||||||||||||||||||||||||||||||
| Std. Deviation | .000 | .516 | .408 | .447 | .408 | .408 | .000 | |||||||||||||||||||||||||||||||||||||||||||||
| NIL/Primary | Mean | .56 | .50 | .00 | .07 | .07 | .07 | .75 | ||||||||||||||||||||||||||||||||||||||||||||
| N | 27 | 28 | 26 | 28 | 28 | 28 | 28 | |||||||||||||||||||||||||||||||||||||||||||||
| Std. Deviation | .506 | .509 | .000 | .262 | .262 | .262 | .441 | |||||||||||||||||||||||||||||||||||||||||||||
| Secondary | Mean | .41 | .53 | .06 | .04 | .06 | .02 | .87 | ||||||||||||||||||||||||||||||||||||||||||||
| N | 93 | 92 | 87 | 89 | 93 | 92 | 91 | |||||||||||||||||||||||||||||||||||||||||||||
| Std. Deviation | .494 | .502 | .234 | .208 | .247 | .147 | .340 | |||||||||||||||||||||||||||||||||||||||||||||
| Tertiary | Mean | .88 | .84 | .50 | .32 | .46 | .16 | .88 | ||||||||||||||||||||||||||||||||||||||||||||
| N | 25 | 25 | 22 | 25 | 24 | 25 | 24 | |||||||||||||||||||||||||||||||||||||||||||||
| Std. Deviation | .332 | .374 | .512 | .476 | .509 | .374 | .338 | |||||||||||||||||||||||||||||||||||||||||||||
| Total | Mean | .54 | .58 | .12 | .10 | .13 | .06 | .85 | ||||||||||||||||||||||||||||||||||||||||||||
| N | 151 | 151 | 141 | 147 | 151 | 151 | 149 | |||||||||||||||||||||||||||||||||||||||||||||
| Std. Deviation | .500 | .495 | .327 | .304 | .340 | .238 | .356 | |||||||||||||||||||||||||||||||||||||||||||||
Discussion
Despite the medical advances of early detection for cervical cancer, the disease continues to kill two out of three women diagnosed with it in Sub-Sahara Africa. The results of the survey showed that knowledge of the disease and how to prevent it through screening is minimal. The study showed that, although slightly more than half of the sample population had heard of cervical cancer and cervical cancer screening, that was where most of the knowledge surrounding the disease ended.
The third item regarding genital warts could have the greatest implications in the future. If the knowledge of the general population aligns with the results of this survey, <15% of the entire female population between the ages of 15 and 90 in the Greater Accra region would know what genital warts were. This would put women who are unaware they are carrying HPV at greater risk of developing cervical cancer. Those who are HIV-seropositive may present with a more invasive cervical cancer a decade before a woman with no HIV antibodies (Lomalisa, Smith, & Guidozzi, 2000). The need for education on the topic of genital warts remains urgent due to the high incidence of HIV in the Sub-Sahara Africa region ( Nketiah-Amponsah, Codjoe, & Ampaw, 2019).
The results of the fourth, fifth, and sixth items are most likely the consequence of the previously mentioned literature regarding the lack of a cervical cancer screening program and the lack of coverage for preventative care through the NHIS (Nartey et al., 2018; NHIS, 2020). It is likely the more educated the women, the greater their chance of gathering information about the disease. At the point of entering a university, it is assumed the women had transitioned into urban living if their families were in the rural areas. This would make more clinics accessible for examination.
Age and education do seem to play a role in the women’s knowledge of many of the variables asked. The results point to those ranging from an average of 42 years old through an average of 53 years old answered “yes” more frequently than those younger. The largest age gap average involved both pap smear knowledge and VIA knowledge which are both procedures used to detect changes in the cervix. Another large gap with the older mean answering in the affirmative was based on item four, “Have you ever been examined for cervical cancer?” It is possible that the women who average 47 years old and older took part in the short-lived National Screening Program, but without a qualitative survey, the data does not exist (Ministry of Health, 2011).
Education undoubtedly plays a role in whether or not a woman answered “yes” or “no” on this baseline survey. The women with the tertiary education had the highest average of affirmative answers with each question. As noted above in Table 4, these women (n=22-25) consistently had a higher mean, 10% to over 30%, out of the total sample size(n=141-151). As also noted in Table 4, it does come with some surprise that the NIL/Primary education category and the secondary education category vary little between the two. In all but one item, they both fall under the mean of the total sample size.
As a whole, there is great indication that there is much lacking in the knowledge of Ghanaian woman regarding cervical cancer. This is evident by the percentage of women in the study who never heard of genital warts, never had a cervical cancer examination, never heard of a pap smear, or heard of VIA. As the higher educated women only counted for approximately 16.5% of the sample size, the need to educate Ghanaian women of all ages and backgrounds presents as necessary.
Limitations
The participants were recruited based on their use of the services at the IHCC only, a pro-poor private clinic. Most of the women have either a primary or secondary level education and work in a skilled trade; thus, the results cannot be generalized to all women of Ghana. Due to Covid-19, there was a sizeable decrease in walk-in patients into the clinic throughout most of 2020. Although the sample size should have been 285 women, was a quarantine in place due to Covid-19 which most likely deterred some women from seeking medical attention for several months in the first half of 2020. This caused a major limitation in reaching the recommended sample size. Out of the six main items of the survey as well as the demographics, there were a few blanks. Although the missing cells were accounted for in the SPSS analysis of the mean score for age, the results could be slightly skewed as the frequency tables looked at the valid percent and the cumulative percent.
Conclusion and Recommendations
This survey is not the first of its kind but based on the results, it is necessary. The findings of this study provide an evidence-based need for basic education for women about cervical cancer and the importance of screening. Until Ghana offers young men and women an affordable vaccine for the Human Papillomavirus(HPV), more emphasis needs to be placed on increasing the awareness of HPV and genital warts, and how it develops into cervical cancer. Health providers, such as those at the IHCC, should take an active role in educating the women who use their services and advocating for more availability of affordable gynecological services at the IHCC as well as other clinics around the country. Although a small percentage of the sample population were unwilling to have an exam, the fact that 85% of the sample was willing shows there is an audience and a need for the education and the vital service screening provides in saving lives of women.
Acknowledgments
The author graciously acknowledges the tremendous effort by Guro Sorensen (IHCC head nurse), Owusu Barnabas (medical lab scientist and IT officer), Joana Amponsah (IHCC nurse), Janet Agbeve (IHCC nurse), Priscilla Affum (IHCC nurse), and Francisca Nyarko (national service personnel) for their effort to ensure survey participation and data collection. The author also thanks Dr. Vera Opata for her recommendations, instruction, and support on the survey questions and manuscript drafts in creating a publishable final copy and to Dr. Naa Ashiley Vanderpuye-Donton with her assistance in editing, support, advise, and mentorship throughout the survey process.
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Appendix A
