|Year : 2022 | Volume
| Issue : 1 | Page : 13-19
Mild anxiety and depression disorders: Unusual reactions to COVID-19 lockdown in caregivers of older adults attending a psychogeriatric clinic in Southwest Nigeria
Olufisayo Oluyinka Elugbadebo, Olusegun Baiyewu
Department of Psychiatry, College of Medicine, University of Ibadan, Ibadan, Nigeria
|Date of Submission||15-Oct-2021|
|Date of Decision||08-Dec-2021|
|Date of Acceptance||23-Dec-2021|
|Date of Web Publication||28-Jan-2022|
Dr. Olufisayo Oluyinka Elugbadebo
Department of Psychiatry, College of Medicine, University of Ibadan, P.M.B 5017, (G.P.O), Ibadan
Source of Support: None, Conflict of Interest: None
Background: Many sub-Saharan African countries have fragile healthcare systems and the mental health care of older adults is in a precarious state. The lockdown that accompanied COVID-19 infection was another monumental event. Objective: This study examined the effect of the restriction and lockdown on the mental health of the caregivers of older patients attending a psychogeriatric clinic in Ibadan, Nigeria. Materials and Methods: We selected 178 dyads of patients and their caregivers. These caregivers were administered a semi-structured questionnaire that collected demographic information and asked questions on effect of COVID-19 on caregiving. In addition, Patient Health Questionnaire-9 and generalised anxiety disorder-7 item scale were administered. Participants were interviewed through telephone. Results: One hundred and seventy-eight patients' caregivers' dyads were interviewed. About 62.4% of the caregivers were children of the patients. More importantly, 97.2% and 93.8% had neither depressive nor anxiety symptoms and the caregivers expressed little worry about COVID-19. There was no significant difference in the mean depressive and anxiety scores in caregivers of patients with and without dementia (F = 0.28, P = 0.60). Caregivers who were lesser than 50 years in age had significantly higher mean score compared with those who were 50 years and above (F = 5.54, P = 0.03). Conclusion: The rate of anxiety and depressive symptoms was very low in this cohort as the lockdown during the pandemic produced little distress to caregivers including those caring for patients with dementia and cognitive impairment. This is a deviation from reports of some other countries and cultures which described psychological implications of COVID-19 on caregivers as severe.
Keywords: Anxiety, caregiver, COVID-19, depression, lockdown, psychogeriatrics
|How to cite this article:|
Elugbadebo OO, Baiyewu O. Mild anxiety and depression disorders: Unusual reactions to COVID-19 lockdown in caregivers of older adults attending a psychogeriatric clinic in Southwest Nigeria. Niger Postgrad Med J 2022;29:13-9
|How to cite this URL:|
Elugbadebo OO, Baiyewu O. Mild anxiety and depression disorders: Unusual reactions to COVID-19 lockdown in caregivers of older adults attending a psychogeriatric clinic in Southwest Nigeria. Niger Postgrad Med J [serial online] 2022 [cited 2022 Sep 28];29:13-9. Available from: https://www.npmj.org/text.asp?2022/29/1/13/336743
| Introduction|| |
The effect of COVID-19 virus pandemic on health and economy meant different things across nations ever since it was reported in 2019, but generally, it has affected both life and livelihood. It was presumed that both of these would be horrendous in developing countries because of poor health and social infrastructure.
Provision of mental health services for the elderly in low- and middle-income countries has always been a daunting task, more so for those living with dementia. Considering the chronic nature of psychiatry disorders, continuity of care in terms of regular follow-up and maintenance medication is the key to preventing relapse and exacerbation of symptoms. Restrictions on movement and scaling down of some health services during the lockdown posed a barrier to accessing mental health care for older adults. Social distancing led to less frequent contact of older adults with family members and friends who were unable to visit regularly either because of restriction or advice by health authorities in order to reduce contagion. Life was indeed tough for community-dwelling elders, as reported by a study from Uganda.
Furthermore, at the initial stage of the pandemic, relatively little information was available on infectivity of the virus, course and outcome. For example, it was predicted that the countries in sub-Saharan Africa would record more deaths than the rest of the world based on the existing fragile health system, but that did not turn out to be so. It was also predicted that mortality would be higher in older persons worldwide, especially those with comorbid conditions and persons living with dementia. Even though data are sparse on mortality in Africans, anecdotal reports indicate that this may be so. In a recent report from COVID-19 treatment facilities in Lagos – Nigeria, 211 of 2184 persons admitted (9.66%) were aged 60 years and older, while 35 of 77 persons who died (45.5%) were 60 years and older. Those who had at least one comorbid condition had an odds ratio of 2.45 (95% confidence interval [CI] 1.26–4.76, P = 0.008) chance of dying. Eldercare in most African countries is family care, as nursing homes are unpopular and few. Thus, caregivers of older adults in Africa have to learn to cope with the additional stress of COVID-19 pandemic on the already existing burden of caring for their wards, especially those with mental health problems which might result in anxiety and depressive symptoms.
This study sought to document the effect of the COVID-19 pandemic and the lockdown measures on the mental health of the caregivers of elderly patients attending a psychogeriatric clinic during the lockdown period.
| Materials and Methods|| |
A cross-sectional study of caregivers of older adults attending a psychogeriatric clinic, which adopted semi-structured questions to assess difficulties experienced during lockdown and administration of standard questionnaires to measure anxiety and depression symptoms. The data for this survey were collected during the lockdown period, from 30 April 2020 to 29 May 2020, an important period when services were scaled down to the barest minimum because of the lockdown imposed in the southwest region of Nigeria, where all our patients are residents. During this period, only acute emergencies were attended to by health workers wearing protective equipment, and virtually all clinics in government hospitals were closed.
This study was approved by the University of Ibadan/University College Joint Ethical Committee (UI/EC/20/0241), Biode building, University College Hospital, Ibadan, Oyo State, on 27 April 2020. All participants in this study gave verbal consent.
Study site and population
This study was conducted at the psychogeriatric clinic of the Tony Anenih Geriatric Centre, which is located at the University College Hospital, Ibadan. Tony Anenih Geriatric Centre is a standalone facility dedicated to the care of older adults aged 60 years and over. The centre runs clinics in family medicine, geriatric psychiatry, neurology, ophthalmology and dentistry and there is a small admission facility for acute emergencies shared by all the units. This study was carried out amongst caregivers of patients who are registered in the geriatric psychiatry clinic, during the lockdown period when regular clinics did not hold.
From the local database available at the geriatric psychiatry unit of the centre, a list of patients who were still attending the clinic as of December 2019 audit (prior to the pandemic) was obtained. A total of 314 patients were identified. These were patients who have not dropped out of treatment. Dropout of treatment in this clinic is defined as missing a scheduled appointment without re-establishing a follow-up visit for at least 6 weeks from the scheduled appointment date.
Information of patients and caregivers, including their telephone numbers, are also available in the psychogeriatric database. These were accessed and telephone calls were made to caregivers. Patients' caregivers who could be reached through their registered phone numbers, who resided with patients for at least 3 months prior to the lockdown and consented to participate in a telephone interview were included in the study.
Sample size calculation
The Yamane's formula for a known population was used to estimate the minimum sample size. CI of 95% and margin error of 0.05 were assumed. The sample size was calculated as follows:
Minimum sample size;
N = Number of total population
e = margin of error set at 0.05
To compensate for non-response rate of 10% (which is ≈ 16), the sample size was taken to be 178. Caregivers were consecutively recruited until the desired sample size of 178 was obtained. Only those who consented and met the inclusion criteria were recruited for the study.
This is a semi-structured questionnaire, especially designed for collecting data on socio-demographic and clinical characteristics of participants. It also asked specific questions on and how the pandemic affected:
- Patient's care in terms of accessing outpatient services, purchase of medications and provision of basic needs
- Quality of time spent with patient, fear of contracting the virus and how that affected care.
Assessment of depressive and anxiety symptoms
- Patient Health Questionnaire-9 (PHQ-9) was used to assess depressive symptoms in caregivers. The PHQ-9 is a 9-item questionnaire used for screening the presence and severity of depression. Scores of 1–4 represent no depression, 5–9 mild depression, 10–14 moderate depression, 15–19 moderately severe depression and 20–27 severe depression. The PHQ-9 is based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) depression diagnostic criteria and takes into cognizance the frequency of the symptoms which is subsequently factored into the scoring severity index. The questionnaire has been used to screen for depression in different populations in Ghana and Cote d'Ivoire and internal consistency (Cronbach's α) ranged from 0.65 to 0.71., A Cronbach's α of 0.53 was obtained in the present study
- Generalised anxiety disorder-7 (GAD-7) item scale is a screening tool for anxiety disorders and was used to assess for anxiety symptoms in caregivers. It has seven questions to which the responses are categorised as 'not at all,' 'several days,' 'more than half the days' and 'nearly every day,' respectively to which scores of 0, 1, 2 and 3 are allocated. The GAD-7 score is obtained by adding up the scores with a total of 5, 10 and 15 regarded as cut-off points for mild, moderate and severe anxiety, respectively. Psychometric properties of the questionnaire have also been determined in pregnant women in Ghana and Cote d'Ivoire with Cronbach's α of 0.67 and 0.69, respectively. A Cronbach's α of 0.67 was also obtained in the present study.
All questionnaires were iteratively translated to Yoruba language, the common language in the study location; and subjects were either administered with the English or Yoruba version of the questionnaires. One of the authors along with a research assistant who had previously been trained in administration of research questionnaires administered the questionnaires over the phone.
Questionnaires were administered via the telephone as the study was done during the COVID-19 lockdown period. The aim and objectives of the study were explained to the participants in full and thereafter verbal consent was obtained. Diagnosis for each patient which is based on DSM-IV criteria, was extracted from case records.
The data collected were summarised using descriptive and inferential statistics. The linear relationship between the age of caregivers and scores on GAD-7 and PHQ-9 was determined using a correlation analysis. We did a subgroup analysis comparing the anxiety and depressive scores based on whether a working caregiver was employed by government agencies or by private organisations. This was because several personal and private businesses could not generate funds to pay salaries, while government employees were paid regularly and in full despite the lockdown.
Furthermore, we grouped patients' diagnoses into dementia and mild cognitive impairment versus other psychiatric diagnoses postulating that having a cognitive disorder could make adherence to the needed precautions against contracting the infection, such as handwashing, wearing face mask and social distancing, difficult. This could contribute more to the already existing high burden of care associated with caring for dementia and subsequently higher anxiety and depressive scores for their caregivers. For example, it was reported from Taiwan that special permission had to be obtained so that people with dementia were not punished if they failed to wear masks in public.
Groups were compared using mean standard deviation, t-test and analysis of variance as appropriate. A post hoc analysis was done to determine the true differences in the mean scores on GAD-7 and PHQ-9 for subcategories of caregivers' age and relationship with the patients, at 95% CI and significance set at <0.05. Analysis was done using the Statistical Package for the Social Science version 20.0 (SPSS Statistics for windows, Released 2011, IBM Corp, Armonk, NY).
| Results|| |
A total of 178 patient-carer dyads were recruited for the study. [Table 1] depicts the demographic characteristics of the patients and their caregivers. The mean age of patients was 72.1 (±7.6) years and the median age was 72 years, with their ages ranging from 60 to 96 years, while the mean age of caregivers was 48.9 (±14.2) years; median age was 45 years with their ages ranging from 16 to 86 years.
Gender was about equal for both caregivers and patients. Education was dichotomized into none or at least 1 year of schooling, and more caregivers attended school. Most caregivers were family members, only 3.9% and 0.6% were paid caregivers and friends, respectively. More children than spouses were caregivers.
[Table 2] shows the responses to the questions on the semi structured questionnaire; most respondents did not feel their wards risked higher chances of being infected by the virus if they came for consultation nor did they feel they were powerless in preventing their wards from contracting COVID-19. However, they had difficulties in accessing medical care, no difficulties in purchasing prescribed drugs or with provision of daily needs. About equal number said yes or no to the statement that the lockdown availed opportunity for quality care for their wards.
|Table 2: Responses of caregivers to the impact of COVID-19 and lockdown on the care of patient|
Click here to view
[Table 3] shows overall scores on PHQ-9 and GAD-7. On PHQ-9, 2.2% of the caregivers had mild depressive symptoms, 0.6% had moderate depressive symptoms and none of the participants had severe depressive symptoms, while on GAD-7, 5.6% had mild anxiety symptoms and 0.6% had moderate anxiety symptoms. Majority (97.2% and 93.8% respectively) had neither depressive nor anxiety symptoms. In the caregiver subgroup analysis for anxiety and depressive symptoms, we found significant differences in the mean score for GAD-7 based on the caregivers' age category (F = 3.54, P = 0.03) and relationship of caregiver with the patient (F = 3.89, P = 0.02); with higher scores amongst caregivers lesser than 50 years and those who were neither spouses nor children of the patients. We did not observe any significant differences in the mean score of both GAD-7 and PHQ-9 for caregivers of patient with dementia and cognitive disorders compared to others (F = 0.28, P = 0.60) as well as for caregivers who are government employees compared to private employees (F = 1.19, P = 0.28).
Age of the caregiver and relationship of the caregiver to the patient were the variables significantly associated with scores on GAD-7. In the post hoc analysis, the true difference in mean score on GAD-7 was observed between caregivers <50 years of age and those who are 50 years and above, while for the relationship of the caregivers to patients, a true difference was observed amongst the spouses and children [Table 4].
|Table 4: Anxiety and depressive symptoms outcome and caregiver subgroup analysis|
Click here to view
| Discussion|| |
A number of peculiarities are related to this study. In the first instance, the demographic pattern of caregivers shows that they are generally younger and most are family members; only 3.9% are employed caregivers and 0.6% friends. More important also is the fact that overall, 62.4% of caregivers are biological children compared with 21.3% of spousal caregivers. This reflects the general trend in developing countries where the offspring has a moral obligation to look after their parents in old age, as reported amongst Moroccan and Turkish communities resident Netherlands. In those groups, the eldest daughter or wife of the eldest son served as primary caregivers for their older adults. In their setting, family care is perceived as a better form of care compared to professional care including residential care.
An implication for younger age group of caregivers (especially children) is that while caregiving might affect employment; they have the energy to get things done for their wards, better and faster than their parents and the spouses; but they also have the responsibility of caring for their own young children. In the multi-generational living arrangements that obtain in our setting, it could happen that older grandchildren of teenage group could take care of some aspect of caregiving. These factors might have affected the result in this study in which caregivers felt they are able to prevent their wards from being infected by the virus (even if that is questionable), while they acknowledged that the lockdown made access to health care difficult. They also felt comfortable with getting refills of medicine for their wards. We observed a significant difference in mean score on GAD-7 with the age dichotomized into <50 years and 50 years and above. Those lesser than 50 years had higher mean score compared to those who were 50 years and above. As stated above, this younger group is saddled with caregiving while still in the active employment. They are prone to the burden overload as caregivers, worker as well as providing care for their own immediate family. All these combined with the effect of the lockdown could have more psychological sequelae on this active age group. Although caregivers who were neither spouses nor children had a higher score on GAD-7, the true difference after post hoc analysis was between spouses and children. In most situations, spouses and children take up the role of caregiving as part of filial obligation.,
Faller et al. surveyed filial care in Brazilians, Lebanese, Chinese, French and Peruvians older adults living in a region of Brazil. While filial care was obligatory from cultural and religious perspective for Lebanese, older French adults indicated they would not like to be burden to their adult children and were ready to live in institutions. Other groups are in between the two extremes.
This study was done at the height of the lockdown when clinical services were available only for acute medical emergencies; patients were only seen with medical personnel fully donned in protective gowns and majority of older adults had no access to health care. Although there was increased suspicion of Covid-19 at clinical assessment during the period, that was not confirmed by laboratory tests.
Makaroun et al. in a commentary observed that there is increased chance of elder abuse during this period. There is also the chance of increased substance use in caregiver due to increased anxiety and depression resulting from increased stress in caregiving during this period. Giebel et al. reported on the socio-economic and health implications of the lockdown on older adults in rural Uganda. When we examined the results of the GAD-7 and PHQ-9, in our study, it becomes clear that very few caregivers could be classified as anxious or depressed during the period of the lockdown and none met the clinical (DSM-IV) diagnosis of either anxiety or depression. Furthermore, we postulated that caregivers of older adults attending a psychogeriatric facility (especially those with dementia) will experience increased symptoms of anxiety and depression during a lockdown period due to COVID-19. However, our findings did not support our postulation. This finding is contrary to the report from a similar study by Li et al. that determined the prevalence of depression and anxiety amongst caregivers of people living with neurocognitive disorders in China during the COVID-19 pandemic. In that study, almost half of the caregivers had anxiety symptoms, while about a third had depressive symptoms. Similar report was obtained from another study conducted in West Bengal, India, on the psychological impact of the COVID-19, where it was reported that about a fifth of the respondents experienced depressive symptoms, while a larger part felt worried about financial restraint during the lockdown and a third had difficulty adjusting to this 'new normal.'
Why are there few persons with anxiety and depression in this study? The reasons are unclear, but it could be because the lockdown in Nigeria was probably less restrictive compared to China and India as people could still access the market on specified days; hence, some food items could be bought, even though hospital services were seriously impacted. Second, COVID-related experiences in terms of infectivity and mortality rate were lesser compared to countries in Europe, Asia and America. It could be assumed that people react to what they see. Although the government introduced lockdown and people complied, low infectivity and mortality resulted in moderate response to agitation and anxiety about Covid-19. This is borne out in their response that they did not feel their wards could be infected by going for regular consultation in hospital and that they did not feel powerless preventing their loved ones from contacting COVID-19. While some of these ideas might be unrealistic, they no doubt have moderated anxiety reactions and that is reflected in our result.
As of 9th June 2020, a total of 79,948 persons in Nigeria were tested for COVID infection, of which 12,801 persons were confirmed positive and 361 persons reported dead. Mortality rate was 0.45% from the sample and 2.8% from confirmed cases, which is lower compared to the 5% death rate in confirmed cases globally. A higher mortality rate was reported in those who were 60 years and above as well as in people with existing comorbidities. The median age in Nigeria is 18 years which is quite lower than the median age of 46 and 47 years reported in Germany and Italy, respectively. The lesser death rate in Nigeria can be accounted for by the relatively younger population. For example, the mean age of caregivers in the present study is 48.9 (±14.2) and the median age is 45 years.
Finally, even though the media space is flooded with news bordering on the effect of the COVID-19 pandemic, it would appear that people in our cohort have the impression that the effect being painted is far-fetched and even if brought nearer, only older adults will become vulnerable that might even have the coloration of ageism. Another explanation may be that some people propagate the theory that COVID-19 is a hoax, it is a ploy created by government for self-gratification and to get money from donors abroad. In addition, a few religious leaders query the existence of the virus when speaking with their congregations. Finally, it is important to consider influence of the Peltzman effect which describes 'risk compensation', a theory that suggests that people typically adjust their behavior to perceived levels of risk. The perception of participants in this study (though wrong) is that there is little risk associated with COVID-19 infection and that reflects on the prevalence rates of anxiety and depression in them.
A caveat should be borne in mind in the interpretation of the findings of this study. Due to the cross-sectional nature of the study; only an association can be implied but not causality. Finally, because of the filial relationship, some respondents might have understated their subjective feelings so that it does not appear that they are unhappy with caregiving.
The study was performed at the peak of the lockdown giving us an insight to how the lockdown affected the participants. It was also one of the very few studies conducted amongst the vulnerable elderly group within a local context.
| Conclusion|| |
The rates of both depression and anxiety in the cohort are low. More importantly, we did not find a difference between subjects diagnosed with dementia and those diagnosed with other psychiatric illnesses. The reasons for these are unclear, but future studies should look into this; in our cohort for different reasons, caregivers are less worried about the possibility of being infected.
Although anxiety scores were non-diagnostic of a disorder, having higher anxiety scores amongst younger caregivers might be a pointer to provide supportive services for this particular group of caregivers who might be overwhelmed with an extra burden of caring for their wards in addition to other responsibilities.
In addition, it will be expedient to further explore the caregivers' perspective about the pandemic. This might have played a major role in their reaction to the pandemic, influenced their attitudes and affected their health practices.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Baiyewu O, Elugbadebo O, Oshodi Y. Burden of COVID-19 on mental health of older adults in a fragile healthcare system: The case of Nigeria: Dealing with inequalities and inadequacies. Int Psychogeriatr 2020;32:1181-5.
Yang Y, Li W, Zhang Q, Zhang L, Cheung T, Xiang YT. Mental health services for older adults in China during the COVID-19 outbreak. Lancet Psychiatry 2020;7:e19.
Giebel C, Ivan B, Burger P, Ddumba I. Impact of COVID-19 public health restrictions on older people in Uganda: 'Hunger is really one of those problems brought by this COVID.' Int Psychogeriatr December 2020; 32:1–15.
Bianchetti A, Rozzini R, Guerini F, Boffelli S, Ranieri P, Minelli G, et al.
Clinical Presentation of COVID19 in dementia patients. J Nutr Health Aging 2020;24:560-2.
Abayomi A, Odukoya O, Osibogun A, Wright O, Adebayo B, Balogun M, et al.
Presenting symptoms and predictors of poor outcomes among 2,184 patients with COVID-19 in Lagos State, Nigeria. Int J Infect Dis 2021;102:226-32.
Elugbadebo O, Ojagbemi A, Adefolarin A, Gureje O. Access and discontinuity of care at an outpatient mental health service for older people in South Western Nigeria. Community Ment Health J 2021;57:1518-24.
Kasiulevičius V, Šapoka V, Filipavičiūtė R. Sample size calculation in epidemiological studies. Gerontologija 2006;7:225-31.
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: Validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13.
Anum A, Adjorlolo S, Kugbey N. Depressive symptomatology in adolescents in Ghana: Examination of psychometric properties of the patient health questionnaire-9. J Affect Disord 2019;256:213-8.
Barthel D, Barkmann C, Ehrhardt S, Schoppen S, Bindt C. Screening for depression in pregnant women from Côte d'Ivoire and Ghana: Psychometric properties of the patient health questionnaire-9. J Affect Disord 2015;187:232-40.
Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: The PHQ primary care study. Primary care evaluation of mental disorders. Patient health questionnaire. JAMA 1999;282:1737-44.
Barthel D, Barkmann C, Ehrhardt S, Bindt C. Psychometric properties of the 7-item generalized anxiety disorder scale in antepartum women from Ghana and Côte d'Ivoire. J Affect Disord 2014;169:203-11.
Hwang TJ, Lin YT, Shen LJ, Tang L, Lapid MI. How Taiwan prevented the outbreak of COVID-19: A focus on psychological strategies and measures. Int Psychogeriatr 2020;32:1121-4.
van Wezel N, Francke AL, Kayan-Acun E, Devillé WL, van Grondelle NJ, Blom MM. Family care for immigrants with dementia: The perspectives of female family carers living in the Netherlands. Dementia 2016;15:69-84.
Alzheimer's Association. Alzheimer's Disease Facts and Figures. Chicago, IL: Alzheimer's Association; 2007.
Wolff JL, Kasper JD. Caregivers of frail elders: Updating a national profile. Gerontologist 2006;46:344-56.
Faller JW, Zilly A, Alvarez AM, Marcon SS. Filial care and the relationship with the elderly in families of different nationalities. Rev Bras Enferm 2017;70:22-30.
Adebusoye LA, Cadmus EO, Labaeka EO, Ajayi SA, Olowookere OO, Otegbayo JA. Caring for older adults during the COVID pandemic and beyond: Experience from a specialized tertiary facility for the care of older persons in a low resource setting. Pan Afr Med J 2020;35 Suppl 2:99.
Makaroun LK, Bachrach RL, Rosland AM. Elder abuse in the time of COVID-19 increased risks for older adults and their caregivers. Am J Geriatr Psychiatry 2020;28:876-80.
Li Q, Zhang H, Zhang M, Li T, Ma W, An C, et al.
Prevalence and risk factors of anxiety, depression, and sleep problems among caregivers of people living with neurocognitive disorders during the COVID-19 pandemic. Front Psychiatry 2021;11:590343.
Chakraborty K, Chatterjee M. Psychological impact of COVID-19 pandemic on general population in West Bengal: A cross-sectional study. Indian J Psychiatry 2020;62:266. [Full text]
Aiyewumi O, Okeke MI. The myth that Nigerians are immune to SARS-CoV-2 and that COVID-19 is a hoax are putting lives at risk. J Glob Health 2020;10:020375.
[Table 1], [Table 2], [Table 3], [Table 4]