Health Promotion International, Vol. 15, No. 4, 313-320,
December 2000
© Oxford University Press 2000
Danish pupils' perceived satisfaction with the health dialogue: Associations with the office and work procedure of the school health nurse
University of Copenhagen, Institute of Public Health, Blegdamsvej 3, 2200 Copenhagen N, Denmark
Address for correspondence: Ina K. Borup Damhusdalen 15 C 2610 Roedovre Denmark E-mail: I.Borup{at}socmed.ku.dk
 |
SUMMARY |
|---|
 TOP SUMMARY INTRODUCTIONMATERIAL AND METHODSRESULTSDISCUSSIONCONCLUSIONS AND IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
|---|
The aim is to identify how environmental factors, perceived by the pupils, are associated with the pupils' perceived satisfaction with a good health dialogue. This article focuses on the pupils' perception of the health office and the work procedure of the school health nurses. The present article is based on data from the 1994 Danish part of the WHO-collaborative study Health Behaviour in School-aged Children. A nation-wide random sample of pupils 11, 13 and 15 years old (n = 4046) answered a standardized questionnaire about perceived health, health behaviour, social situation, the school as a workplace and the health dialogue. The final model of the multivariate logistic regression analysis revealed eight predictor variables of perceived satisfaction with the health dialogue and three confounder variables. The predictors were: comfortable health office OR = 1.20 (95% CI 1.11–1.30), pupils sat by the desk OR = 1.12 (95% CI 1.03–1.23), pupils influenced the content of the dialogue yes/no: OR = 1.43 (95% CI 1.27–1.60), yes/don't know: OR = 0.80 (95% CI 0.72–0.89), sufficient time OR = 1.33 (95% CI 1.23–1.44), the school health nurse listened carefully OR = 1.24 (95% CI 1.13–1.35), the school health nurse talked a lot OR = 0.91 (95% CI 0.85–0.98), gave good advice OR = 1.28 (95% CI 1.18–1.43), let the pupils talk OR = 1.17 (95% CI 1.07–1.28). The confounders were: pupils' sex: female OR = 1.23 (95% CI 1.14–1.33); and age: low age OR = 1.20 (95% CI 1.07–1.35) or high age OR = 0.84 (95% CI 0.76–0.93), but not medium age, high school satisfaction OR = 1.53 (95% CI 1.31–1.77), and low school satisfaction OR = 0.74 (95% CI 0.63–0.87).
Key words: environmental factors; health promotion; health survey; pupils; school health nurse
|
INTRODUCTION |
|---|
|
TOPSUMMARYINTRODUCTIONMATERIAL AND METHODSRESULTSDISCUSSIONCONCLUSIONS AND IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
|---|
In a number of Western, industrialized countries, the school health nurses are part of the school health services and participate in health promotion efforts. In Denmark this is practised by an annual health dialogue and health education (National Board of Health, 1995
).
In several countries, i.e. UK and the Nordic countries (Mattock, 1991; Williamson, 1992; Neylon, 1993; Borup, 1998a; Borup, 1998b; Borup, 1998c), the school health nurses regularly invite pupils to a health dialogue, an open-ended discussion about the pupils' health and health-related issues. In Denmark, this health dialogue has replaced and reduced routine screening procedures of the pupils' height and weight, hearing and vision.
The aim of the health dialogue is to focus on children's strengths and resources to enable them to make healthy choices and to stay healthy into adult life.
School satisfaction is found to be an important factor for the pupils' benefits from learning processes (Rutter, 1983; Samdal et al., 1998). Borup found that learning about health is related to school satisfaction and to low age (Borup, 1998b). Further, Borup found that factors related to pupils, the health dialogue and the school environment, predict pupils' perceived satisfaction with the health dialogue (Borup, 1998c). Therefore, satisfaction becomes important for the pupils' perception of learning about health.
Hart-Zeldin et al. claim that the family is the child's first environment for learning health values and behaviour (Hart-Zeldin et al., 1990). As the child becomes older, school, peers and media begin to influence health behaviour, although the family continues to support the child, and this is consistent with Rutter's findings (Rutter, 1985).
This paper addresses processes which take place within the health dialogue and not traditional epidemiological outcome measures. The processes are seen as pre-requisites for the outcome of the health dialogue, e.g. acquired knowledge, changed health behaviour and improved health. Thus, the outcome will usually appear later as a result of the health dialogue. Whitener et al. point out that learning is both a process and an outcome (Whitener et al., 1998).
Several studies (Rudd and Walsh, 1993; Rutter, 1983; Rutter, 1985) reveal that the school environment clearly influences the academic skills and health outcomes of adolescent pupils. Therefore, the health office becomes an important factor in learning about health, as the health dialogues take place at the office.
The most healthy environments are small, safe and intimate communities. Within these communities, the needs of the pupils are met and pupil participation in decision-making is fostered (Rudd and Walsh, 1993).
Rutter finds that pupils' school outcome was better in schools where teachers were available to talk to children about problems at any time (Rutter, 1983; Rutter, 1985), and further, where pupils reported that if they needed this they would talk to a member of the staff about a personal problem. Rutter raises the question whether the school affects the children or the children affect the school (Rutter, 1985), but finds that there is a true influence on children stemming from characteristics of the school environment, but there might still be variables that affect both, which we are not aware of.
The purpose of this paper is to identify how environmental factors, as perceived by the pupils, are associated with the pupils' satisfaction with the health dialogue. This article will focus on two environmental aspects of the health office as a learning environment, i.e. the pupils' perception of the physical environment of the health office and the pupils' perception of the work procedure of the school health nurse. The analysis includes sex, age and school satisfaction as confounder variables.
|
MATERIAL AND METHODS |
|---|
|
TOPSUMMARYINTRODUCTIONMATERIAL AND METHODSRESULTSDISCUSSIONCONCLUSIONS AND IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
|---|
In 1982, a European Cross-National Survey about schoolchildren's health, lifestyle and health behaviour was initiated as a WHO-co-ordinated project (HBSC). The aims were:
- to increase understanding of—and to monitor over time—young people's health and health-related behaviour;
- to gain insights into the influences that the school, the family and other social contexts have on young people's lifestyles;
- to influence the development of programmes and policies to promote the health of young people;
- to promote cross-disciplinary research into young people's health and lifestyles through international networking of health researchers.
The survey has been repeated five times and each survey includes data from a large representative sample of school children in three age groups: 11, 13 and 15 year olds. The 1993/1994 survey includes mainly 22 European countries (King et al., 1996). All participating countries used the same questionnaire and the same procedure to collect data, in order to ensure comparability of data. The pupils followed a standardized instruction from their teacher. The questionnaire includes three parts: (i) a core of basic questions, which are repeated every time in all the countries; (ii) questions as ‘the theme of the year’ which are asked in all countries, but not every time; and (iii) questions added by each individual country. The theme of the year in 1994 involved the school as a work environment for the pupils, psychosocial health, injury-related behaviour and social inequality. As a result of this, the questions about the health dialogue and contacts to the school health nurse were included in the Danish survey. Denmark has completed the survey five times, in 1985, 1988, 1991, 1994 and 1998 (Due and Holstein, 1997a; Due and Holstein, 1997b). The questions related to the school health nurse were added only in the Danish survey. In Denmark the age groups 11, 13 and 15 year olds correspond to grades 5, 7 and 9.
Method
The study sample was selected by a stratified random cluster sampling method, and the cluster was the school class. When cluster sampling is employed, pupils' responses cannot be assumed to be independent because pupils within the same class or school are most likely to be similar to each other than to pupils in general. Cluster sampling produces standard errors which tend to be higher than would be the case if the same size of sample was obtained when using simple random sampling. If standard errors increase, the sample size should be increased. The recommended minimum sample size for each age group is 1536 pupils to assume a confidence interval of ± 3%. When the number of classes eligible for sampling is unknown, the number can be estimated based on the population in each school. If a school has four classes eligible for sampling, each of those classes should have the same likelihood of being drawn in the sample as a school with only one eligible class. Assuming an average of 25 pupils per class, 62 classes would be required to achieve the recommended sample size of 1536 pupils per age group.
The country was stratified into five areas: (i) Central Copenhagen; (ii) Copenhagen suburbs; (iii) three towns with a population of more than 100 000; (iv) towns with a population of more than 5000; and (v) rural areas including villages.
From a list of all Danish public and private schools we sampled at random 10 schools from each area. The aim was to include 50 schools, of which 45 including 234 classes accepted to participate. The remaining schools did not participate because of practical reasons or resistance from class teacher, parents or pupils. The five schools were distributed over areas 1, 2, 3 and 4.
The number of pupils who responded to the survey was 4046 corresponding to 99% of all pupils present at school on the day, and 91% of pupils formally enrolled in the sampled classes. According to the protocol, the survey was completed anonymously and thus, it was not possible to make a detailed analysis of non-respondents.
The pupils answered a standardized questionnaire. The school board, headmaster and pupils' council approved the study in advance, and the school health nurse was informed. If the schools did not reply within the scheduled time, repeated mailing and telephone calls were made to assure their response.
Data are the pupils' self-reported assessment of the contact with the school health nurse through a health dialogue. These questions included 18 variables about the pupils' perception of the health dialogue, the school health nurses' work procedure and office, and an open-ended question about the assessment of the health dialogue. This paper reports data from the Danish survey in 1994 (Due and Holstein, 1997a; Due and Holstein, 1997b).
The predictor variables were: ‘What did the health office look like: comfortable, dreary, nice?’; ‘Did you sit by the desk?’; ‘Did you have time enough to talk about your own concerns?’; ‘Were you interrupted?’; ‘Did the school health nurse support your own ideas?’; ‘Did the school health nurse let you talk?’; ‘Did the school health nurse listen a lot?’; ‘Did the school health nurse talk a lot?’; ‘Did the school health nurse give good advice?’; ‘Did you decide what you were going to talk about?’; ‘Did the school health nurse decide what you were going to talk about?’ (Yes, no, don't know).
Confounder variables were chosen by two criteria: (i) associations with the predictor variables; and (ii) association with the outcome variable, so three key variables fulfilled these criteria: age, sex and school satisfaction, which were measured by the following question: ‘How do you feel about school at present?’ (like it a lot, like it a bit, don't like it very much, don't like it at all).
The outcome variable, perceived satisfaction, was measured by the following question:
Think about the latest health dialogue with the school health nurse. Was it: very good, good, fairly good, not good.
In addition, the pupils could describe in their own words what actually made the health dialogue good or not good.
Regarding parents' permission, this study was undertaken through the school board, which is the parents' democratically elected board. Every school in Denmark has a school board of parents elected by the parents, and the school board has the right to decide issues in all school matters. The school board is the parents' voice. We asked every school board for permission and collaboration in this study, as well as the pupils' council's acceptance and collaboration.
The statistical analysis includes bivariate contingency tables (stratified by age and sex) combining the predictor variables, confounder variables and outcome variable. The contingency tables are tested for independence with chi-square test (p < 5%). A multivariate logistic regression analysis by the SAS CATMOD procedure was performed in order to identify the most important predictors. All analyses were carried out separately for girls and boys.
The multivariate analysis
The predictor variables were categorized into two groups: (i) physical environment; and (ii) work procedure and furthermore the confounder variables. The analyses were carried out for each group of variables separately and all significant predictors were entered into the final model. The analysis was first carried out separately for girls and boys. These analyses revealed no differences in the pattern of associations among girls and boys. Consequently, in order to gain more statistical power the analysis was repeated for the total study population with sex and age as well as school satisfaction as confounder variables. In order to reduce the number of missings in the multivariate models, we re-coded missing in two ways: items with a yes/no response key: missing re-coded into no. Items with a yes; no; don't know response key: missing re-coded into don't know. This way the number of missings in the final model was reduced to 158.
|
RESULTS |
|---|
|
TOPSUMMARYINTRODUCTIONMATERIAL AND METHODSRESULTSDISCUSSIONCONCLUSIONS AND IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
|---|
Table 1
presents the bivariate analysis and shows which environmental factors were associated with the pupils' perceived satisfaction with the health dialogue, separately for girls and boys.
|
The table illustrates only the proportion of the satisfied health dialogues; the residual is not indicated, therefore, the ciphers do not sum up to 100%.
The pupils perceived the health dialogue as good when they influenced the content, and had sufficient time to talk about their concerns without interruption. According to the work procedure of the school health nurses, the pupils perceived the health dialogue to be good when the school health nurse supported their ideas; when she let them talk; when she listened carefully, talked less, and asked the pupils about their health and gave them good advice. As for the environment, a comfortable and nice health office where the pupils sat at the desk supported the pupils' perception of the health dialogue positively. A stratified analysis on age (not represented in the table) showed that the associations were found in all three age groups. All the associations appear to be similar among boys and girls in the same age group. Therefore, the result of the stratified analysis is not displayed in the table.
A few pupils made explicit comments on the environment: informative examples were: ‘The school health nurse only talked about herself and the health office was dreary’. ‘The good thing was that the school health nurse listened, the bad thing was that she did not pull the curtains when she examined me’. ‘The health dialogue was very neutral, we were weighed, then we talked about something, which I do not remember’. ‘She was kind and nicely dressed’. ‘I find that the office is boring, but my health was fairly good’. ‘The office was so silent and cold and the school health nurse just stared at me and looked at the clock’. ‘The school health nurse talks baby language, like..., therefore it was not such a good talk’. Several pupils included their opinions about the atmosphere, e.g. ‘She was kind and there was a good atmosphere’.
The multivariate logistic regression analysis (Table 2) showed that the confounder variables: sex, age and school satisfaction had a strong association with pupils' perceived satisfaction with the health dialogue, but even when the analysis was controlled for these confounder variables, the predictor variables had a strong effect. Eight significant predictor variables of the pupils' perceived satisfaction with the health dialogue persisted: a comfortable health office OR = 1.20 (95% CI 1.11–1.30); the pupils sat by the desk OR = 1.12 (95% CI 1.03–1.23); the pupils decided the contents of the health dialogue, yes/no: OR = 1.43 (95% CI 1.27–1.60), yes/don't know: OR = 0.80 (95% CI 0.72–0.89); and they had enough time to talk about their own concerns OR = 1.33 (95% CI 1.23–1.44). Further, if the school health nurse did not talk a lot OR = 0.91 (95% CI 0.85–0.98), she listened carefully OR = 1.24 (95% CI 1.13–1.35 ), gave good advice OR = 1.28 (95% CI 1.18–1.43) and let the pupils talk OR = 1.17 (95% CI 1.07–1.28). The significant confounder variables were: female sex OR = 1.23 (95% CI 1.14–1.33), low age OR = 1.20 (95% CI 1.07–1.35) or high age OR = 0.84 (95% CI 0.76–0.93), as well as high satisfaction with school OR = 1.53 (95% CI 1.31–1.77) and low satisfaction with school OR = 0.74 (95% CI 0.63–0.87). Background factors: social class, type of urbanization and structure of family were examined, but were not significantly associated with perceived satisfaction with the health dialogue.
|
|
DISCUSSION |
|---|
|
TOPSUMMARYINTRODUCTIONMATERIAL AND METHODSRESULTSDISCUSSIONCONCLUSIONS AND IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
|---|
This study has a robustness because of the large representative study sample. Another strength is that the study presents the pupils' perceptions.
The study also has some weaknesses. As a cross-sectional survey it does not provide explanations, but associations. The validity of the variables based on the questions, unfortunately, is unknown. However, the pupils' additional notes support the idea of the pupils' self-reported evaluations as a valid measure of their answers to the questionnaire. The paper has focused on perceived satisfaction as an outcome measure of processes within the health dialogue. The outcome of the health dialogue does not necessarily imply a change in health behaviour. It could as well be emotional feelings, satisfaction with the visit because the child was met and understood, and therefore inclined to return with health needs later. Satisfaction with the visit may be very important for outcome with the health dialogue and future change in health behaviour.
This paper revealed that environmental factors, as perceived by the pupils, were associated with their perceived satisfaction with the health dialogue.
According to Kolb's experiential learning theory (Kolb, 1984), learning and development are transactions between a person and the environment. The process of experiential learning involves four steps within a cycle: concrete experience (CE); reflective observation (RO); abstract conceptualization (AC); and active experimentation (AE). This paper addresses the pupils' concrete experiences (CE) of the health dialogue. Kolb states that learning and development are transactions between a person and the environment (Kolb, 1984). The office and work procedure of the school health nurse became in this way important for the pupils' perceived satisfaction with the health dialogue. The school health nurse could stimulate the learning processes positively when the pupils decided the topics to discuss and had enough time to talk about their concrete experiences (CE). This she could do when she did not talk a lot herself, but was a good listener and gave good advice. These predictors were not only important factors according to learning environment, but also in the learning processes.
In this study the focus has been on learning processes within the health dialogue. A recent study by Borup reveals five predictors for a supportive health dialogue (Borup, 1998c), and are as follows: the pupils' influence on the health dialogue; satisfaction with school; well being at school; very good self-rated health; and high academic achievement. These findings include further weight to this study and the importance of a good school climate.
Eight significant predictor variables and three confounder variables in the multivariate analyses were highlighted. Two predictors were related to the health office climate. These findings were supported by the results of Jones et al. from their study of the clinic (Jones et al., 1997). Jones et al. asked adolescents about their ‘ideal’ surgery (Jones et al., 1997), and they stated that the clinic should be bright and colourful and more ‘user-friendly’ for adolescents. Hagquist and Starrin claim that school and local environments are regarded as important elements of health education (Hagquist and Starrin, 1997), and the physical and social environment can be either supportive or non-supportive for the learning processes. In the stage of reflective observation (RO) in Kolb's learning cycle it is essential to watch and listen to the learning processes. In this way, the environment may influence the pupils' expectation of the health dialogue. Traditionally, the health offices can be rather dull and placed in a remote part of the school, and thereby symbolize a ‘non-supportive environment’, and may indicate that health is not valuable. The setting of the office also mirrors those who use the office and their interests and needs, which means that the school health nurse may be associated with the office. McKibben and DiPaolo argue in their study about the optimal health office that the facilities of the school health nurses must be a priority in order to meet the health needs of the pupils (McKibben and DiPaolo, 1997). They claim that in USA the school health office is a primary care facility for many pupils. Rutter et al. (Rutter et al., 1979) find that children's observed behaviour in school is strongly associated with school process variables and that children develop behaviour as a response to the school environment. Rutter et al. (Rutter et al., 1979) also claim that the influence can go both ways: from individual to environment and vice versa. This means that less satisfied pupils may associate the health office with ill-health and depowering instead of empowering (Anderson, 1986). Anderson also claims that: (i) depowering means giving other people advantage over us; and (ii) that others are better and more expert (Anderson, 1986). Anderson's statements imply that it was important that the school health nurse listened to the pupils and that the pupils influence the health dialogue in order to learn from it.
A successful health dialogue included: a supportive environment, a school health nurse who participated both with concrete knowledge, i.e. good advice, and a positive atmosphere such as a sensitivity to incline the pupils to participate on their own terms.
The pupils who were satisfied with the health dialogue had a basis of school satisfaction. Several studies (Rutter, 1985; Samdal et al., 1998; Borup, 1998c) have revealed the importance of school satisfaction. The school is the daily learning arena for adolescents, and to fully understand how the pupils learn about health we have to search out principles according to how they interpret their world (Kalnins et al., 1992; Kalnins et al., 1994).
|
CONCLUSIONS AND IMPLICATIONS |
|---|
|
TOPSUMMARYINTRODUCTIONMATERIAL AND METHODSRESULTSDISCUSSIONCONCLUSIONS AND IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
|---|
The office and the work procedure of the school health nurse are associated with the pupils' satisfaction with the health dialogue.
If a health dialogue is to be successful, the school health nurse must be aware of the supportive or non-supportive influence the environmental factors have on learning processes.
A deeper understanding of how the environment influences the pupils' satisfaction with health promotion may be accomplished by observational studies and qualitative interviews.
|
ACKNOWLEDGEMENTS |
|---|
|
TOPSUMMARYINTRODUCTIONMATERIAL AND METHODSRESULTSDISCUSSIONCONCLUSIONS AND IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
|---|
I thank the National Board of Health, the Danish Nurses Council's Foundation, the Nurses Research Foundation and the Nordic School of Public Health for grants. I also thank Professor MD Lennart Köhler and Associate Professor mag. scient. soc. Bjørn Holstein for useful comments on this manuscript. Dr Candace Currie, University of Edinburgh is the international scientific project co-ordinator.
|
REFERENCES |
|---|
|
TOPSUMMARYINTRODUCTIONMATERIAL AND METHODSRESULTSDISCUSSIONCONCLUSIONS AND IMPLICATIONSACKNOWLEDGEMENTSREFERENCES |
|---|
Anderson, J. (1986) Health skills: the power to choose. Health Education Journal, 45, 19–24.
Borup, I. K. (1998a) Pupils' experience with the annual health dialogue with the school health nurse. Scandinavian Journal of Caring Sciences, 12, 160–169.[ISI][Medline]
Borup, I. K. (1998b) Adolescents learning health promotion: pupils' evaluation of contacts with the school health nurse. Vård i Norden, 18, 26–31.
Borup, I. K. (1998c) Psycho social and health factors' influence on the students' perceived benefit of the health dialogue. Health Education Journal, 57, 339–350.
Due, P. and Holstein, B. (1997a) Health and Well-being Among Children and Adolescents (Danish). FADL, Copenhagen.
Due, P. and Holstein, B. (1997b) Smoking habits among 11–15 year-olds, 1984–1994 (Danish). Ugeskrift for laeger, 159, 1090–1093.[Medline]
Hagquist, C. and Starrin, B. (1997) Health education in schools—from information to empowerment models. Health Promotion International, 12, 225–232.
Hart-Zeldin, C., Kalnins, I. V., Pollack, P. and Love, R. (1990) Children in the context of ‘achieving health for all: a framework for health promotion'. Canadian Journal of Public Health, 81, 196–198.[ISI][Medline]
Jones, R., Finlay, F., Simpson, N. and Kreitman, T. (1997) How can adolescents' health needs and concerns best be met? British Journal of General Practice, 47, 631–634.
Kalnins, I. V., Hart, C., Ballantyne, P., Quartaro, G., Love, R., Sturis, G. and Pollack, P. (1994) School-based community development as a health promotion strategy for children. Health Promotion International, 9, 269–279.
Kalnins, I. V., McQueen, D. V., Backett, K. C., Curtice, L. and Currie, C. E. (1992) Children, empowerment and health promotion: some new directions in research and practice. Health Promotion International, 7, 53–59.
King, A., Wold, B., Tudor-Smith, C. and Harel, Y. (1996) The Health of Youth. A WHO Cross-National Survey. WHO Regional Publications, European Series no. 69.
Kolb, D. (1984) Experiential Learning. Experience as the Source of Learning and Development. Prentice Hall, Toronto.
Mattock, C. (1991) Stepping off the medical treadmill. Health Visitor, 64, 154–156.[Medline]
McKibben, C. and DiPaolo, S. (1997) Promoting the construction of an optimal nurse's office facility: one school district's experience. Journal of School Nursing, 13, 22–29.
National Board of Health (1995) Forebyggende sundhedsordninger for børn og unge (Health Services for Children and Adolescents) (Danish). Danish Committee for Health Education.
Neylon, J. (1993) Health promotion for school children. Nursing Standard, 7, 37–40.
Rudd, R. E. and Walsh, D. C. (1993) Schools as healthful environments: prerequisite to comprehensive school health? Preventive Medicine, 22, 499–506.[ISI][Medline]
Rutter, M. (1983) School effects on pupil progress: research findings and policy implications. Child Development, 54, 1–29.
Rutter, M. (1985) Family and school influences on behavioural development. Journal of Child Psychology Psychiatry, 26, 349–368.[ISI][Medline]
Rutter, M., Maughan, B., Mortimore, P. O. and Smith, J. A. (1979) Fifteen Thousand Hours. Open Books, London.
Samdal, O., Nutbeam, D., Wold, B. and Kannas, L. (1998) Achieving health and educational goals through schools —a study of the importance of the school climate and the students' satisfaction with school. Health Education Research, 13, 383–397.
Whitener, L., Cox, K. and Maglich, S. (1998) Use of theory to guide nurses in the design of health messages for children. Advances in Nursing Science, 20, 21–35.[Medline]
Williamson, T. (1992) Health care interviews by school nurses. Health Visitor, 65, 402–404.[Medline]
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||