A community service doctor's experiences of mental healthcare provision in rural Eastern Cape.

BACKGROUND:  Literature shows that in South Africa there are insufficient resources to meet mental healthcare needs. At general or district hospital level, the non-specialist doctor is often responsible for the holistic assessment and management of mental health service users. Such situations inevitably increase doctors' care load as they are required to treat across disciplines. We highlight the particular challenges faced by a community service (CS) doctor in this context. METHODS:  The presented case study formed part of a larger project that investigated public mental healthcare provision in the Eastern Cape province. Data were collected through a once-off semi-structured interview with the participant. The interview was transcribed and data analysed by utilising thematic analysis to yield results. RESULTS:  The study suggests that the CS doctor experiences being overloaded with duties, and feels overwhelmed in a healthcare context that lacks resources needed for service provision, which may lead to inadequate mental healthcare provision to public health service users. CONCLUSION:  Healthcare facilities in rural parts of the Eastern Cape province are in need of assistance. This in-depth account highlighted the consequences of working on the front line of a disadvantaged and under-resourced health system. The presented account can be interpreted as a cry for help by CS doctors for relevant authorities to improve access and provision of mental healthcare in the area.Contribution: The paper provides an exploration of the circumstances wherein mental healthcare is provided in rural parts of South Africa.

Evaluating workforce needs: an investigation of healthcare professionals' attitudes, beliefs and preparedness towards the management of Para athlete mental health at the Tokyo 2020 and Beijing 2022 Paralympic Games.

OBJECTIVES: To examine healthcare professionals (HCPs) attitudes, beliefs and preparedness towards the management of Para athlete mental health during the Tokyo 2020 and Beijing 2022 Paralympic Games. METHODS: A cross-sectional observational study was conducted. National Paralympic Committee's HCPs (n=857) working at the Tokyo 2020 and Beijing 2022 Paralympic Games were invited to respond to an anonymous online survey regarding the management of Para athlete mental health in their team. Data were analysed using descriptive frequency statistics. RESULTS: The survey was completed by 256 HCPs (30% of respondents). Most HCPs agreed that mental health was a concern in Para athletes (n=210; 82%). However, half (n=122; 48%) agreed that they did not screen Para athletes for mental health symptoms, and half (n=130; 51%) agreed that there was increased stigma around disclosure of mental health symptoms among Para athletes, compared with athletes without disability. Most HCPs (n=221; 86%) agreed they wanted to improve their knowledge and skills surrounding athlete mental healthcare. Culturally sensitivite, non-discriminatory and contextual factors were highlighted as desired areas of education for HCPs and active information dissemination for Para athletes. CONCLUSION: HCPs working at the Paralympic Games considered Para athlete mental healthcare important and reported perceived stigma, yet indicated low rates of mental health screening. Most respondents expressed the need for mental health education. Culturally sensitive training and active education strategies should be implemented to optimally manage Para athlete mental health.

A qualitative study of the perceived benefits of participating in a spinal cord rehabilitation intervention in a low-middle income country.

PURPOSE: Improving quality of life (QoL) is a major goal of rehabilitation following spinal cord injury (SCI). However, people with disabilities in resource constrained contexts have limited access to rehabilitation and poorer health outcomes, including QoL. There is a paucity of qualitative research on the experiences of persons with SCI involved in rehabilitation programmes in low-middle income countries. This study aimed to assess participants' perceptions of the benefits of a 24-week SCI rehabilitation programme delivered as part of a pilot randomized controlled trial (RCT) in South Africa. MATERIALS AND METHODS: Sixteen participants, with chronic motor-incomplete tetraplegia, were enrolled in a two-arm pilot RCT involving robotic locomotor training, a novel technology, and standard activity-based training (Pan African Clinical Trial Registry (PACTR201608001647143)). Data were collected via in-depth interviews and analysed using thematic analysis. RESULTS: Participants described several improvements in QoL, including enhanced functional independence; reduced secondary complications; and improved psychosocial and emotional well-being. CONCLUSIONS: The holistic approach to rehabilitation calls for the involvement of individuals' views about what matters to them to inform clinical practice and to highlight the role that physical activity and the perceived successes play in shaping the lived experiences after SCI. TRIAL REGISTRATION: Pan African Clinical Trial Registry (PACTR201608001647143), registration date (21st May 2016), study start date (30th Nov 2016)https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=1647.

Rehabilitation plays an integral role in prompting and integrating positive experiences and changes in QoL for people with spinal cord injury (SCI), especially in a resource constrained context where there is limited opportunity to participate in rehabilitation interventions.Locomotor training and activity-based training can enhance perceived functional independence and psychosocial well-being following SCI.Rather than focus on traditional physiological outcomes, rehabilitation interventions can address quality of life outcomes in order to improve well-being in a way that is meaningful to people with SCI.

Robotic locomotor training in a low-resource setting: a randomized pilot and feasibility trial.

PURPOSE: Activity-based Training (ABT) represents the current standard of neurological rehabilitation. Robotic Locomotor Training (RLT), an innovative technique, aims to enhance rehabilitation outcomes. This study aimed to conduct a randomized pilot and feasibility trial of a locomotor training program within South Africa. MATERIALS AND METHODS: Individuals with chronic traumatic motor incomplete tetraplegia (n = 16). Each intervention involved 60-minute sessions, 3x per week, for 24-weeks. Outcomes included feasibility measures and functional capacity. RESULTS: 17 out of 110 individuals initiated the program (recruitment rate = 15.4%) and 16 completed the program (drop-out rate = 5.8%) and attended sessions (attendance rate = 93.9%). Both groups showed a significant increase in upper extremity motor score (MS) and abdominal strength post intervention. Only the RLT group showed a significant change in lower extremity MS, with a mean increase of 3.00 [0.00; 16.5] points over time. Distance walked in the Functional Ambulatory Inventory (SCI-FAI) increased significantly (p = 0.02) over time only for the RLT group. CONCLUSIONS: Feasibility rates of the intervention and functional outcomes justify a subsequent powered RCT comparing RLT to ABT as an effective rehabilitation tool for potentially improving functional strength and walking capacity in people with incomplete SCI.

Spinal cord injury causes severe limitations to functional capacity, independence, and quality of life.Robotic Locomotor Training is growing rehabilitation modality for people with spinal cord injury, but currently its effects on functional capacity are limited.In a relatively small sample, this study shows that large, randomized control trials are feasible within a low-income setting.The preliminary findings of this study show that 12 weeks of locomotor training can improve ambulatory function and functional strength in individuals with spinal cord injury.

Role of security guards in healthcare settings: a protocol for a systematic review.

INTRODUCTION: There is a paucity of literature on the comprehensive roles of security guards in healthcare, regardless of day-to-day observations of security guards playing an extensive role in this field. Thus, this review will systematically explore the roles of security guards in healthcare contexts to create a centred body of evidence. METHODS AND ANALYSIS: The study will systematically review existing quantitative and qualitative peer-reviewed literature on security guards in institutional healthcare so as to understand their roles. We will conduct the systematic review on 10 electronic databases: BioMed Central, SocIndex, ScienceDirect, Google Scholar, JSTOR, PsycARTICLES, PsycINFO, Scopus, Web of Science and PubMed. Data extraction will be in the form of a word document. Mendeley software will be used to keep track of references, while the systematic review software, Rayyan, will be used for the screening, inclusion and exclusion of articles. If necessary, reviewer number 3 will conduct a third review should any disputes arise between the two initial reviewers. Quality assessment of the articles will be measured with the Critical Appraisal Skills Programme tool for articles in terms of the research aims, methodology used, sample, data analysis, presentation of findings, values of the research, as well as trustworthiness if it is a qualitative study or reflexiveness if it is a quantitative study. Studies dating back 32 years will be incorporated for a comprehensive review. ETHICS AND DISSEMINATION: This systematic review will use publicly available peer-reviewed data from electronic databases and will, therefore, not require an ethical review, but rather, an ethics waiver. The systematic review protocol will be submitted for ethics waiver clearance from the Stellenbosch University Health Research Ethics Committee. The findings from this review will be disseminated through peer-reviewed publications and conferences. PROSPERO REGISTRATION NUMBER: CRD42022353653.

"It is in the Nature of Men": The Normalization of Non-Consensual Sex and Intimate Partner Violence Against Women with Acquired Physical Disabilities in South Africa.

This study employed a cross-sectional, qualitative individual interview methodology to explore South African women with physical disabilities' experiences of intimate partner and sexual violence, inclusive of non-consensual and coerced sexual intercourse. For the participants, disability was a factor that intersected with gender norms to create vulnerability to abuse, and that patriarchal ideologies constructing how women should perform their gendered roles in marriage or sexual partnerships, as well as disability stigma, exacerbated this vulnerability. It is important to develop understandings of the different risk factors for violence - at the individual level and in the context of dyadic relationships - to develop programming to better support women.

Evaluating workforce well-being: an investigation of healthcare professionals' mental health and burnout symptoms at the Tokyo 2020 and Beijing 2022 Paralympic Games.

OBJECTIVE: To explore the prevalence of symptoms of mental health conditions and burnout of healthcare professionals (HCPs) working during the Tokyo 2020 Paralympic Games and the Beijing 2022 Paralympic Winter Games. METHODS: In this cross-sectional, observational study, HCPs working during the Tokyo 2020 and Beijing 2022 Paralympic Games were asked to complete an online, anonymous survey, which included demographic questions and questions regarding mental health symptoms including depression (Patient Health Questionnaire 9-item depression scale) and anxiety (Generalized Anxiety Disorder 7-item scale) as well as burnout (Maslach Burnout Inventory-Human Services Survey: depersonalisation, emotional exhaustion, personal accomplishment). Correlation coefficients (r) were calculated between demographic characteristics and mental health symptoms. RESULTS: In total, 256 HCPs (of 857 HCPs; 30%) completed the surveys. Twelve and eight per cent of HCP scores fell within the moderate to severe depression and moderate to severe anxiety categories, respectively. More than 30% reported moderate to high burnout (depersonalisation: 36%; emotional exhaustion: 36%; personal accomplishment: 58%). In addition, thoughts of self-harm and/or suicidality were reported by some HCPs (8%). Weak correlations were observed between age and depression (r=-0.13, p=0.046), anxiety (r=-0.16, p=0.010) and burnout (emotional exhaustion: r=-0.14, p=0.032; personal accomplishment: r=0.27, p<0.001). CONCLUSION: Although most HCPs reported good mental health, this study suggests that a subset of HCPs experienced symptoms of depression, anxiety, burnout or thoughts of self-harm during the Tokyo 2020 and Beijing 2022 Paralympic Games. While the generalisability of these findings outside of COVID-19 restrictions should be tested, appropriate guidance and mental health support of HCPs leading up to the Paralympic Games should be prioritised.

To queue or not to queue: Facility managers and mental health care users' experiences of integrated health care in a rural South African district.

BACKGROUND: A key feature of South Africa's state health care strategy since 1994 has been the development and expansion of services towards integrated health care at primary health care level. Within the new system, emphasis has been on the integration of patients with mental health care needs with other patients where multiple health conditions and needs would be addressed simultaneously. As part of a larger study into mental health care in a predominantly rural district, we investigated the experiences of facility managers and mental health service users in rural clinics within the system of care. We were interested both in their views as to the advisability of the integrated model and the ways in which they managed any challenges they may have experienced within the system at local level. METHODS: Data were collected through once-off semi-structured interviews with facility managers and mental health care service users to gather qualitative information. Narratives were transcribed and translated into English. Transcriptions were imported to Atlas.ti 22 and analysed through Thematic Analysis. RESULTS: The integration of mental health care into routine primary health services poses challenges to treatment delivery and to patients who come for treatment. Our study also suggests resegregating mental health care as a possible solution to facilitate service delivery and treatment to service users. CONCLUSION: This research provided first insights into facility managers' and service users' views of integrated mental health care at primary health care level in this district. While mental health care services have been expanded and integrated into primary health care over recent years, the system may not have been as streamlined as in other parts of the country. The integration of mental health into primary health care can pose various challenges to facilities, health care providers, and mental health service users. Managers in these constrained circumstances have observed that resegregating mental health care from physical treatment, as in the past, may be deemed more effective for health care provision and reception. Generalised integration of mental health treatment with physical care should be approached with caution unless there is wider scale provisioning and greater organisational change.

The Care Dependency Grant for children with disabilities in South Africa: perspectives from implementation officials.

For people with disabilities, appropriate social protection interventions can contribute to breaking the cyclical relationship between poverty and disability and may improve social inclusion. In South Africa, a national social assistance programme provides 'social grants' to individuals on the basis of poverty, age, or disability. These grants have been extensively studied but there has been little investigation into the Care Dependency Grant, designed to support the care of children with disabilities. These children consistently have far poorer outcomes on key metrics for wellbeing, health, and education than their non-disabled peers. More attention ought to be focused on uplifting this profoundly marginalised population. We present initial findings from interviews with officials at the South African Social Security Agency, the country's grants implementation agency. These narratives add weight to the growing local and international consensus that complementary interventions and effective intersectoral collaboration may greatly enhance the impact of cash transfers.

HIV and gender identity expression among transfeminine women in the Western Cape, South Africa - a thematic analysis of data from the HPTN 071 (PopART) trial.

Introduction: Transfeminine women in South Africa have a high HIV risk due to structural, behavioural, and psychosocial factors. Transfeminine women and feminine identifying men who have sex with men (MSM) are often conflated or grouped with transgender or MSM categories in HIV service programming, although they don't necessarily identify as either. We aimed to investigate gender expression among feminine identifying people who were assigned male at birth. We examined how local conceptualizations of sexuality and gender intersect with the key population label of 'transgender' imported into local HIV programming. Methods: A qualitative cohort nested within the HPTN 071 (PopART) trial included longitudinal, in-depth interviews with eight transfeminine women (four who disclosed as living with HIV). Data were collected approximately every six weeks between January 2016 and October 2017. We discuss gender identification presented in participants' daily lives and in relation to HIV service access. Results: Of the eight participants, only one accepted 'transgender' as a label, and even she used varying terms at different times to describe her identity. For participants, a feminine identity included dressing in normatively feminine clothes; using feminine terms, pronouns and names; and adopting stereotypically feminine mannerisms. Participants would switch between typically feminine and masculine norms in response to contextual cues and audience. For example, some participants accepted identification as masculine gay men amongst their family members, but amongst peers, they expressed a more effeminate identity and with partners they took on a feminine identity. Conclusions: Our findings are amongst the first exploratory and descriptive data of transfeminine women in South Africa. We show how transfeminine women navigate fluid gender identities that could pose a challenge for accessing and utilizing HIV services that are currently set up for transgender individuals or MSM. More work needs to be done to understand and respond to the diverse and shifting ways people experience their gender identities in this high HIV burden context.

The hermeneutics of recovery: Facilitating dialogue between African and Western mental health frameworks.

The widespread use of faith-based and traditional healing for mental disorders within African contexts is well known. However, normative responses tend to fall within two camps: on one hand, those oriented towards the biomedical model of psychiatry stress the abuses and superstition of such healing, whilst critics adopting a more 'local' perspective have fundamentally challenged the universalist claims of biomedical diagnostic categories and psychiatric treatments. What seemingly emerges is a dichotomy between those who endorse more 'universalist' or 'relativist' approaches as an analytical lens to the challenges of the diverse healing strands within African contexts. In this article, we draw upon the resources of philosophy and existing empirical work to challenge the notion that constructive dialogue cannot be had between seemingly incommensurable healing practices in global mental health. First, we suggest the need for much-needed conceptual clarity to explore the hermeneutics of meaning, practice, and understanding, in order to forge constructive normative pathways of dialogue between seemingly incommensurable values and conceptual schemas around mental disorder and healing. Second, we contextualise the complex motives to emphasise difference amongst health practitioners within a competitive healing economy. Finally, we appeal to the notion of recovery as discovery as a fruitful conceptual framework which incorporates dialogue, comparative evaluation, and cross-cultural enrichment across divergent conceptualisations of mental health.

Crip the elders and get out of white privilege free.

The question of identity positioning in relation to engagement with issues of social exclusion is complex. I am a white non-disabled South African man working on disability and care issues. I reflect on my representation of my parents, through memoirs and of Elsa Joubert, a doyenne of African writing. My depiction of these people as profoundly affected by disability and illness provides me as a privileged white scholar a way of marking my difference from stereotypical oppressive positioning. Though my rhetorical manoeuvres do not undercut the intention of my work, they point to broader, difficult questions about positioning and identity politics. I use my links to and concern with disability and illness to signal my appreciation of difference and exclusion, but questions of power and positioning remain.

Differences in white matter microstructure in first-episode schizophrenia spectrum disorders vs healthy volunteers and their association with cognition.

OBJECTIVE: Both cognitive impairment and alterations in white matter tissue microstructure are well recognised in schizophrenia. We investigated whether differences in white matter microstructure underpin cognitive impairments in patients with first-episode schizophrenia spectrum disorders when controlling for multiple confounding factors. METHODS: We employed a cross-sectional study design and compared fractional anisotropy (FA) between individuals diagnosed with first- episode schizophrenia spectrum disorders (FES) (n = 68) and matched healthy controls (n = 120). We conducted multiple analyses of covariance (ANCOVAs) to compare the mean FA values for patients and controls across 27 white matter tracts. We conducted exploratory correlation analyses to determine if white matter tract differences were associated with global cognitive impairment as well as deficits across seven cognitive domains. RESULTS: We found widespread reductions in FA in patients compared to controls, after controlling for confounding variables, such as age, biological sex, education, substances, and childhood adversities. We found a significant positive correlation between the attention/vigilance domain and the splenium of the corpus collosum and external capsule after correction for multiple comparisons. In the control group we found no significant correlations between FA and cognition. CONCLUSION: Our findings provide a neurobiological basis for attentional cognitive deficits in schizophrenia, highlighting a potential role for the splenium of the corpus collosum and external capsule.

Challenges and opportunities of centring the African voice in disability research.

In 2020, the African Network of Evidence to Action on Disability (also known as AFRINEAD) hosted its 10th conference in Cape Town. This paper synthesises inputs by the three authors as plenary addresses, particularly focusing on the challenges and opportunities of centring African voices in disability research. Our concern in this article is to engage with the question of exclusion as an issue not just in the everyday lives of people with disabilities but also in the world of ideas - the ideational space. We suggest that a reimagined disability study depends on the centring of African experiences, voices and knowledges. This is especially so as there are African concepts that are not rigorously pursued in research. African Renaissance thinking makes allowance not only for critically reflecting on the historical and contemporary constructs of disability but also for fashioning a higher civilisation in which people with disabilities can exist within society as worthy and valued human beings.

Experiences of Organisations of (or That Serve) Persons with Disabilities during the COVID-19 Pandemic and National Lockdown Period in South Africa.

Organisations have long played an effective role in advocating for and actioning crucial developmental and humanitarian functions around the world, often under challenging conditions, as well as servicing the health needs of persons with disabilities. This article reports on the experiences of organisations of (or that serve) persons with disabilities, hereafter called service providers, during the COVID-19 lockdown period in South Africa beginning 26 March 2020. Organisations participated in an online survey as well as virtual narrative interviews to voice out their experiences. Five major themes emerged: (1) difficulties in keeping the doors open; (2) continued care under lockdown; (3) restructuring of care (4) government systems and policies; and (5) reaching out to offer and receive support. The findings demonstrate that the South African government failed to ensure targeted support to organisations of persons with disabilities. A remarkable feature of the organisations we interviewed for this small study was their agility in responding creatively to the challenges they faced, despite the difficulties. There is a need for government support to include targeted efforts to support organisation of persons with disabilities during pandemics to avoid worsening service gaps.

Community Support for Persons with Disabilities in Low- and Middle-Income Countries: A Scoping Review.

Over the life course, persons with disabilities require a range of supports to be integrated into their communities, to participate in activities that are meaningful and necessary, and to have access, on an equal basis to persons without disabilities, to community living. We conducted a scoping review of the peer-reviewed and grey literature on community support for persons with disabilities in low- and middle-income countries (LMICs). The main findings of this review concern the following: there are gaps in access to community support for persons with disabilities in LMICs; there are barriers to the provision of such support; formal and informal strategies and interventions for the provision of community support exist across the life cycle and different life domains, but evidence concerning their effectiveness and coverage is limited; and the role of community-based rehabilitation and Organisations of Persons with Disabilities in the assessment of needs for, and the development and provision of, community support, needs to be more clearly articulated. Research needs a more robust theory of change models with a focus on evaluating different aspects of complex interventions to allow for effective community support practices to be identified.

Examining the understandings of young adult South African men who stutter: The question of disability.

BACKGROUND: A disability studies approach seeks to understand and address political and social issues that affect disabled individuals. Disability studies scholars employ various models of disability to address and oppose the oppression and discrimination of disabled individuals. A disability studies approach, however, has largely been absent in studies that have investigated the lived experiences of people who stutter. AIM: To examine the understandings young adult South African men who stutter hold of whether, and in what way, stuttering may be considered to be a disability. METHODS & PROCEDURES: A total of 15 men who stutter, aged 20-39 years, participated in the study. Semi-structured interviews and two focus groups discussions were conducted to collect data for the study. The data were analysed according to a phenomenological approach and the affective turn in social research. OUTCOMES & RESULTS: The results indicated that some men in this study understood stuttering as a speech disorder that can be controlled, while other men constructed stuttering as a disability, subjectively positioning themselves either as disabled or non-disabled men. CONCLUSIONS & IMPLICATIONS: This article emphasizes the importance of adopting a disability studies approach when examining the lived experiences of people who stutter and enhancing intervention strategies to adequately address the disabled needs of such individuals. WHAT THIS PAPER ADDS: What is already known on the subject? The past few decades have seen researchers investigating the personal and social experiences of people who stutter. However, empirical studies exploring the disabling experiences of people who stutter have been absent from the existing body of knowledge. What this paper adds to existing knowledge? This research aimed to provide comprehensive insight into the disabling experiences of people who stutter. The results gave an insight into the oppression and disablism experienced by people who stutter. More specifically, the findings demonstrated how individuals who stutter are disabled by oppressive communication practices that dominate spaces of education and employment. What are the potential or actual clinical implications of this work? Several men in this study attended speech therapy to gain control over their stuttering. For a number of participants, speech therapy proved a valuable experience, while others saw speech therapy as being out of touch with their lived reality of stuttering. Speech and language therapists are encouraged to employ a disability studies approach in order to enhance intervention strategies to adequately address the disabling needs of people who stutter.

Traditional healers' explanatory models of intellectual disability in Cape Town.

While intellectual disability is experienced worldwide, with much greater rates in contexts of poverty, relatively few studies on intellectual disability have been conducted in low- and middle-income countries. High levels of intellectual disability in South Africa exist alongside high levels of poverty, malnutrition and poor or inaccessible healthcare services. The lack of access to services partly explains why many turn to traditional healers. Within this context there is very limited research on the role that traditional healers play in relation to intellectual disability in South Africa. The current study investigated traditional healers' understanding and beliefs about intellectual disabilities and the treatment modalities that they use. An exploratory qualitative research design was used to examine the views and perspectives of traditional healers on intellectual disability. Fifteen traditional healers participated in the study. Key findings show that the naming of and the terminology used to describe and identify intellectual disability are very much similar to what has been observed in African cultures in general where intellectual disability is identified as an abnormality. Some traditional healers located the presentation of intellectual disability within the biomedical sphere while others gave supernatural explanations for how intellectual disability presents in children and for its causes. All traditional healers expressed a willingness to work with the Western formal healthcare system. Findings on traditional healers' views on future collaborations with the formal health system provide opportunities for these two forms of healthcare services to be synergised for the strengthening and improvement of services provided to children with intellectual disability and their families.

Therapeutic pluralism and the politics of disclosure: breast cancer patients' experiences in public healthcare.

Background: Despite the widespread utilisation of complementary and or alternative medicine (CAM) by breast cancer patients in low-and-middle-income countries, few disclose CAM use to their physicians. Objective: This study examines disclosure CAM use among a small sample of women attending a breast cancer clinic in a public health hospital in the Western Cape, South Africa. Methods: An Interpretative Phenomenological Analysis (IPA) approach was utilised in this study. Semi-structured in-depth interviews were conducted with a convenience sample of 17 women attending a breast clinic in a public hospital. Results: Non-disclosure of CAM use was attributed to minimal time for patient-doctor interactions due to resource constraints in public health facilities and the superior status accorded to biomedical doctors' superior knowledge, associated with paternalism, leading to patients' fear of reproach for using CAM. Consequently, disclosure of CAM only occurred in instances where it was deemed an absolute necessity. Conclusion: Considering the reality of an overstretched public healthcare system, what may be possible is an active attempt to communicate to patients that doctors are aware that patients may use a range of resources (such as CAM), which is their right, and further, recommend patient disclosure of CAM use to their doctors, because of the possibility of drug interactions and other potentially negative effects.