What Is the Preparedness and Capacity of Palliative Care Services in Middle-Eastern and North African Countries to Respond to COVID-19? A Rapid Survey

Sabah Boufkhed; Richard Harding; Tezer Kutluk; Abdullatif Husseini; Nasim Pourghazian; Omar Shamieh

doi:10.1016/j.jpainsymman.2020.10.025

. 2020 Nov 21;61(2):e13–e50. doi: 10.1016/j.jpainsymman.2020.10.025

What Is the Preparedness and Capacity of Palliative Care Services in Middle-Eastern and North African Countries to Respond to COVID-19? A Rapid Survey

Sabah Boufkhed ^a,^∗, Richard Harding ^a, Tezer Kutluk ^b, Abdullatif Husseini ^c, Nasim Pourghazian ^d, Omar Shamieh ^e,^f

PMCID: PMC7679234 PMID: 33227380

Abstract

Context

Evidence from prior public health emergencies demonstrates palliative care's importance to manage symptoms, make advance care plans, and improve end-of-life outcomes.

Objective

To evaluate the preparedness and capacity of palliative care services in the Middle-East and North Africa region to respond to the COVID-19 pandemic.

Methods

A cross-sectional online survey was undertaken, with items addressing the WHO International Health Regulations. Nonprobabilistic sampling was used, and descriptive analyses were conducted.

Results

Responses from 43 services in 12 countries were analyzed. Half of respondents were doctors (53%), and services were predominantly hospital based (84%). All but one services had modified at least one procedure to respond to COVID-19. Do Not Resuscitate policies were modified by a third (30%) and unavailable for a fifth (23%). While handwashing facilities at points of entry were available (98%), a third had concerns over accessing disinfectant products (37%), soap (35%), or running water (33%). The majority had capacity to use technology to provide remote care (86%) and contact lists of patients and staff (93%), though only two-fifths had relatives’ details (37%). Respondents reported high staff anxiety about becoming infected themselves (median score 8 on 1–10 scale), but only half of services had a stress management procedure (53%). Three-fifths had plans to support triaging COVID-19 patients (60%) and protocols to share (58%).

Conclusion

Participating services have prepared to respond to COVID-19, but their capacity to respond may be limited by lack of staff support and resources. We propose recommendations to improve service preparedness and relieve unnecessary suffering.

Key Words: Palliative care, preparedness, COVID-19, pandemic, epidemic, Middle-East and North Africa

Key message

This study addresses an important gap in the preparedness of palliative care services in the Middle-East and North Africa region to respond to COVID-19 pandemic and other outbreaks. Our survey led to seven recommendations aiming at improving their preparedness and supporting the region's health systems in relieving unnecessary suffering.

Introduction

Elderly people and those with underlying health conditions, such as cancer, are most at risk of developing severe COVID-19 or dying.1, 2, 3 Comorbidities such as diabetes and cardiovascular disease are highly prevalent in the Middle-East, raising concerns for the progress of the pandemic in the region.⁴ In weaker health systems, there is limited capacity to care for COVID-19 patients who require intensive care units because of moderate to severe forms of the disease or complex symptoms such as breathlessness.² ^, ⁵

Palliative care is explicitly recognized under the human right to health, relieving the suffering of patients and families and improving their quality of life and outcomes while saving health-care costs.6, 7, 8 The World Health Assembly has called on countries to provide palliative care in the clinical management of COVID-19 patients.⁹ ^, ¹⁰ This would address the emerging evidence for palliative care needs among COVID-19 patients, including physical symptoms (e.g. fever, breathlessness, fatigue, cough),² ^, ¹¹ spiritual distress related to survival, and psychological distress related to prognosis uncertainty.¹² ^, ¹³

Under the 2015 International Health Regulations (IHR), countries are required to prepare response plans for public health emergencies of international concern.¹⁴ ^, ¹⁵ However, preparedness plans routinely fail to include palliative care.16, 17, 18 The role of palliative care in pandemic responses has been demonstrated, including sharing symptom management protocols and training nonpalliative care health-care workers, supporting patients’ triage and providing psychosocial and bereavement care.¹⁰ The “COVID-19 tsunami of suffering” is likely to increase the need for palliative care, especially in low- and middle-income countries.⁸

In 2012, national health systems in the Middle East region used their influenza surveillance systems to detect the MERS-CoV, and most countries have tested their preparedness plans.¹⁴ ^, 19, 20, 21, 22, 23, 24, 25 In Middle Eastern countries with fragile or limited health-care systems, the COVID-19 pandemic may cause enormous challenges to fragile health systems.²⁶ ^, ²⁷

Palliative care in the Middle East and North African region is a relatively new development, with no country having fully integrated it within the health system.²⁸ ^, ²⁹ With a Muslim majority in the region, the pandemic may have an additional religious or spiritual impact for populations.30, 31, 32, 33 A systematic review of end-of-life care in Muslim-majority countries highlighted the central role of families in the decision-making process, as well as the need for spaces to perform rituals and to address preferences for pain management.³⁴ The preparedness and capacity of palliative care services to respond to COVID-19 in the MENA region is still unknown. To inform policy and appropriate and timely responses, we aimed to evaluate the preparedness and capacity to respond to COVID-19 within palliative care services of the Middle-East and North Africa region.

Method

Study Design and Settings

We developed, piloted, and conducted an exploratory cross-sectional online survey, using WHO's 2005 International Health Regulations²⁵ and online survey methodological guidelines.³⁵ ^, ³⁶

Population and Sampling

Nonprobabilistic sampling combining convenience and snowball sampling was used to recruit representatives of palliative care services in the Middle-East and North Africa region: Afghanistan, Algeria, Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, Oman, Palestine, Pakistan, Qatar, Saudi Arabia, Syria, Tunisia, Turkey, United Arab Emirates, Yemen. We aimed to recruit at least one service per country and to have only one respondent per service. The services included hospices, hospital services, and home- and community-based care.

There is no comprehensive formal list, registry, or network of palliative care services for the Middle-East region. There are limited palliative care services and publicly available information on the existing official registry of palliative care services for the countries that could give a framework to draw a representative sample of services. Therefore, we identified services using publicly available information and the research team's networks as follows. We yielded 60 contacts from the Atlases of Palliative Care,37, 38, 39 International Association for Hospices and Palliative Care (IAHPC) directory,⁴⁰ and a rapid Google and PubMed search. We yielded a further 160 contacts from our professional networks, partners of Research For Health in Conflict in the Middle-East and North Africa (r4hc-mena.org), and disseminated our survey through the World Health Organization's Eastern Mediterranean Region (WHO-EMRO) network for palliative care. Countries from WHO-EMRO located in sub-Saharan Africa were approached in a separate survey we conducted with the African Palliative Care Association.⁴¹

Data Collection

The original survey questionnaire was initially designed by researchers from Italy and the UK for an early assessment of the Italian palliative care response early during the COVID-19 pandemic who shared with us the questionnaire in English.⁴² We further developed it to include existing international recommendations, especially the IHR, and evidence for generic preparedness to respond to infectious disease outbreaks or pandemics,¹⁹ ^, 23, 24, 25 ^, 43, 44, 45, 46, 47 and recommendations for palliative care response and roles in epidemics and pandemics.¹⁶ ^, ¹⁷ R4HC-MENA research team members adapted the survey to the region using professional experience and key preparedness literature for the region.¹⁹ ^, ²⁰ ^, ²⁶ ^, ⁴⁸ The full questionnaire was available in English and Arabic (see Appendix I and II). It was developed in English then translated into Arabic by a bilinguistic professional translator, and the translations were reviewed by two independent experts. The translation was then tested during the pilot, where two researchers not involved in the translation completed both versions and gave feedback. No corrections were suggested.

Data were collected online using the SmartSurvey™ platform, permitting one answer per computer on the online platform, and enabled the anonymity function so IP addresses were not collected. The survey link was emailed to 190 contacts across the region, inviting them to participate (institutions providing care) and disseminate (via professional networks).

Recruitment to the online survey was opened on 05/26/20 and closed on 06/22/2020, with responses permitted until 06/26/2020. Reminders to complete the survey were sent twice during the period.

Data Analysis

Descriptive analyses were conducted following de-duplication. Quantitative data were analyzed using Stata (version 16): categorical variables described as frequencies and percentage; continuous variables as median and interquartile range (IQR). Open-ended questions were coded thematically, and the dominant themes reported.⁴⁹

Ethics

Ethical approval was obtained from King's College London Research Ethics Office (reference LRS-19/20–19,091). Data were collected and stored following the UK 2016 General Data Protection Regulation. Informed consent was obtained online from participants within the survey.

Findings

Respondents and COVID-19 Situation in Their Services

There were 113 engagements with the online survey (65 for the English version and 48 for the Arabic one), 69 individuals completed the survey (37 in English and 32 in Arabic) of which 67 gave consent (completion rate: 59%). The final sample was 43 (33 English and 10 Arabic) after de-duplication. Of 21 countries in the region, 12 had a least one participant (57%). We received no participation from nine countries (Afghanistan, Algeria, Iraq, Qatar, Tunisia, United Arab Emirates, Yemen) (33%). For two countries (Libya and Syria), we could not identify a contact (9%).

Table 1 describes the participants’ characteristics. Half were medical doctors (53%) and one-fifth were nurses (19%). Two in five services were public or governmental (40%) and the majority were hospital based (84%). Responding services had a median of 500 patients per year (IQR: 200–2500; 4 missing data), and 33 services reported having beds (median: 13; IQR: 8–25).

Table 1.

Respondents' Characteristics (N = 43)

	n	%
Country
Turkey	14	33
Jordan	12	28
Other (Bahrain, Egypt, Iran, Kuwait, Lebanon, Morocco, Oman, Pakistan, Palestine, Saudi Arabia: 1 to 3 respondents per country)	17	40
Respondent's current role(s)
Doctor or medical officer	23	53
Nurse	8	19
Manager or responsible for the service and doctor, nurse or psychosocial professional^a	5	12
Manager or responsible for the service	3	7
Psychosocial professional	3	7
Other (Operations Manager)	1	2
Type of organisation
Public	17	40
Nonprofit charity	5	12
Mixed^b	4	9
Private	3	7
Missing	14	33
Type of service^c
Within hospital	36	84
Within community	13	30
Outpatient	10	23
Inpatient	7	16
Hospice/service having beds	33	77
Services which reported a case (possible, suspect or confirmed)	27	63

	Yes	No	Unsure or Do not Know	Missing or N/A
	n (%)	n (%)	n (%)	n (%)
Case definition for confirmed, probable, and suspected COVID-19 cases	30 (70)	9 (21)	4 (9)	0 (0)
Written procedure for “what to do” in the service in case of COVID-19 case among
Patients	38 (88)	4 (9)	0 (0)	1 (2)
Health-care professional staff member	38 (88)	3 (7)	1 (2)	1 (2)
Volunteers and medical staff	35 (81)	5 (12)	2 (5)	1 (2)
Relatives and visitors	33 (77)	6 (14)	3 (7)	1 (2)
Staff and volunteers going in the community	28 (65)	7 (16)	7 (16)	1 (2)
Written procedure for “what to do” in the service in case of infectious diseases among
Patients	28 (65)	6 (14)	5 (12)	4 (9)
Relatives and visitors	24 (56)	7 (16)	7 (16)	5 (12)
Health-care professional staff member	30 (70)	4 (9)	6 (14)	3 (7)
Volunteers and medical staff	26 (60)	5 (12)	7 (16)	5 (12)
Staff and volunteers going in the community	19 (44)	8 (19)	12 (28)	4 (9)
Policies or procedures modified as a measure to avoid contagion
Operators' protection (personal protective equipment)	39 (91)	1 (2)	0 (0)	3 (7)
Visitors/relatives (number of visitors, hours, etc.)	38 (88)	0 (0)	2 (5)	3 (7)
Dead body handling	35 (81)	4 (9)	3 (7)	1 (2)
Patients' admission to the service	34 (79)	1 (2)	3 (7)	5 (12)
Volunteer support	24 (56)	6 (14)	6 (14)	7 (16)
Care of the relatives after the patient's death	19 (44)	13 (30)	7 (16)	4 (9)
Do Not Resuscitate	13 (30)	16 (37)	4 (9)	10 (23)
Procedure to support health-care providers to manage stress	23 (53)	16 (37)	4 (9)	0 (0)
Recommendations if you or someone in your household becomes ill with COVID-19 symptoms	39 (91)	3 (7)	1 (2)	0 (0)

	Median (IQR)
Perceived effects on staff
Anxious about getting infected themselves^a	8 (7–9)
Anxious about the need to care for their own relatives^a	8 (6–9)
Anxious about the need to care for their children who may not be at school^a	8 (6–9)
Worried regarding potential issues for their interaction with the community if the service is known to manage a potential COVID-19 case^a	7 (5–8)
Perception of the risks in the coming week^b
Hospice/palliative care staff are at risk of being infected by COVID-19	5.5 (4–7)
Hospice/palliative care service is at risk of closing because of an infection in the hospice or service	5 (2–7)

	Procedure Specific to COVID-19	Procedure for Infectious Diseases in General or to Another Specific Highly Infectious Disease (e.g. Influenza, Ebola, Tuberculosis, etc.) Please specify for which disease(s):
- patients	□ yes □ no □ don’t know	□ yes □ no □ don’t know
- relatives and visitors	□ yes □ no □ don’t know	□ yes □ no □ don’t know
- healthcare professional staff member	□ yes □ no □ don’t know	□ yes □ no □ don’t know
- volunteers and medical staff	□ yes □ no □ don’t know	□ yes □ no □ don’t know
- staff and volunteers going in the community	□ yes □ no □ don’t know	□ yes □ no □ don’t know
- Other, please specify:	□ yes □ no □ don’t know	□ yes □ no □ don’t know

- Policy for visitors/relatives (number of visitors, hours etc.)	□ yes □ no □ not sure □ N/A
- Policy for operator protection (personal protective equipment)	□ yes □ no □ not sure □ N/A
- Policy for patients' admission to the hospice	□ yes □ no □ not sure □ N/A
- Volunteer support policy	□ yes □ no □ not sure □ N/A
- Policy on how to handle dead patients	□ yes □ no □ not sure □ N/A
- ‘Do Not Resuscitate’ (DNR) policy	□ yes □ no □ not sure □ N/A
- Policy regarding care of the relatives after the patient's death	□ yes □ no □ not sure □ N/A
- Other policy modified, please specify:

-all staff working in or for the hospice or service (medical, administrative, cleaning staff, etc.)?	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other:
-all patients that attended or have attended the hospice or service?	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other:
-all relatives that visited or have visited the hospice or service?	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other:
-patients visited in the community?	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other:

-Patients' symptoms?	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other:
-Patients' outcomes?	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other:
-Treatment given?	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other:
-Dates of patients' visits or stay?	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other:
-Dates of relatives' visits?	□ Yes, a paper-based registry □ Yes, an electronic record □ No □ Other:

	In Your Hospice or Service?	In the Surrounding Community?
-running water?	□ yes □ no	□ yes □ no
-soap?	□ yes □ no	□ yes □ no
-hand sanitizers (with at least 60% alcohol)?	□ yes □ no	□ yes □ no
-electricity?	□ yes □ no	□ yes □ no
-thermometers (contactless, Thermoflash-type)?	□ yes □ no	□ yes □ no
-accessing disinfectant products to continue providing care safely?	□ yes □ no	□ yes □ no
-other, please specify:	□ yes □ no	□ yes □ no

-Healthcare providers	□ yes □ no □ don’t know □ N/A
-Volunteers	□ yes □ no □ don’t know □ N/A
-Resources (material and supplies)	□ yes □ no □ don’t know □ N/A

	n	%
Type of cases reported
Confirmed	14	52
Confirmed + suspected	3	11
Confirmed + suspected + probable	2	7
Confirmed + probable	1	4
Suspected	6	22
Probable	1	4
Cases reported among
Patient	8	30
Patient + relative + physician + nurse^a	4	15
Patient + nurse	3	11
Patient + relative	2	7
Patient + relative + nurse^b	2	7
Patient + physician + nurse	2	7
Patient + physician	1	4
Physician	2	7
Nurse	2	7
Missing	1	4
Location of the cases identified
In the service	9	33
Another service of the hospital where the palliative care is located	15	56
Both in the service and another service	2	7

	n
Case identification
Phone call	10
Hospital dashboard/hospital HIS/infectious diseases teams	8
COVID-19 screening of patients at admission and with symptoms; and of health-care providers	3
Symptoms identified	2
Diagnosed done by service doctor	1
Department officer	1
Call for support	1
Routine examination	1
Laboratory report	1
Missing	2
Actions taken
Referral	14
Isolation/containment measures	10
Reporting	9
Communication with staff	6
Treatment	2
Protection of staff	1
Communication with users	1
Infection control involvement	1
Communication with department head	1
COVID team managed case	1
Home quarantine (for infected staff and contacts)	1
Training with staff	1
Contact tracing	1
Testing of all staff	1
Asymptomatic cases were followed up as outpatient	1
Use of smartphone app to follow-up COVID patients	1
All cancer hospital entrances were closed except for 1 inpatient and 1 outpatient entrance with triage with symptoms screening	1
All patients and caregivers to wear a mask (offered if do not have one)	1
Informed staff of SOP for COVID protection and case detection	1
Daily update and assessment meeting in the unit	1
Missing	3

	n	%
Receiving information
Institutions or person who would inform the hospice/service^a^,^b
Infection control team	13	30
Ministry of Health (MoH)/provincial health directorate	7	16
Head of hospital and/or department/hospital management/administration	6	14
Medical staff (doctors and/or nurses)	3	7
Laboratory/laboratory review online	2	5
Medical/professional society	1	2
Preventive medicine team	1	2
Emergency service	1	2
Do not’ know or N/A or missing	10	23
Person who would be informed in the hospice or service^a^,^b
Designated doctor/doctor in chief/medical director/nursing manager	8	19
Head of hospital and/or department/hospital management	7	16
Infection control team	5	12
Medical/clinical chief	4	9
Medical staff (doctors and/or nurses)	4	9
COVID-19 team	3	7
All staff	2	5
Specialist palliative care physician and consultant/consultant in charge of patient	2	5
MoH	1	2
Professor	1	2
Do not know or missing	10	23
Communication system(s) that will be used to receive information:^b
Mobile phone available 24/7	33	77
WhatsApp/Viber group	21	49
Telephone (in the service)	21	49
Email	16	37
Focal point person identified in the service responsible for collecting and sharing up-to-date information
Yes^c	31	72
No	7	16
Unsure	4	9
Missing	1	2
Sharing information
Any communication means in place to share COVID-19 or other urgent information	41	95
with staff^b
Phone call	28	65
WhatsApp/Viber	27	63
Email	20	47
Text message	14	33

	n
Factors External to the Service	10
Social distancing	2
Fast community spread/community commitment to PPE	2
Second wave	2
Increased number of cases	2
Containment of the diseases	1
Psychosocial consequences of lockdown	1
Service organization	7
Reorganization of work	1
Extension of PC to COVID 19 patients/increase in patients with COVID 19 postintensive care	2
Less patient	1
Admission control	1
Inability of patients to attend the outpatient clinic	1
Limitations in home visits	0
Repeating tests	1
Staff workload and well-being	6
Manage the increased stress and anxiety	3
Inadequate staffing	1
Increased workload	1
Staff infected or quarantined	1
Quality of care (not optimum during a pandemic, delay in treatment)	3
Resources	3
Financial concern and burden (upcoming financial crises-donations)	1
Not enough sterilization equipment	1
Inadequate medicines	1
Other	2
Infection among staff/patient	1
Health system overload	1

	n
Infection control	8
Quick control of COVID-19/vaccine	2
Barrier measure and screening	2
Preventive measures/social distancing and hygiene	3
Isolation	1
Resources for service	6
Training/rapid training and orientation	2
Sufficient staff number	1
Getting tests	1
Financial help and support	2
Regulations	3
Obey instructions	1
Lockdown	1
Fines for violators	1
Team support	3
Team work/meeting	1
Psychosocial support	1
More support from service/administration	1
Individual behavior	2
Awareness raising	1
Individuals being careful	1

	n
Service overload	3
Staff shortage	1
Time restraints	1
Work pressure	1
Training/awareness	2
Lack of education of HCP/lack of knowledge of PC role	1
Lack of training	1
Lack of integration of PC into oncology	1
Attitudes of HCP	1
Communication problems	1
Most of the resources and efforts directed to COVID response	1
Limit of consultation because of the use of video conferencing	1
Single center experience	1

	n
Getting infected and transmitting COVID 19	11
Getting ill/nosocomial COVID	7
infecting family and patients	4
Impact of COVID on healthcare	6
Closing service due to COVID	1
Patient outcome	1
Resources drained for COVID and negative impact on other services including PC	1
Infection control	4
Asymptomatic transmission	1
Spike in cases that would overwhelm capacity/second wave/not being able to control the virus	3
Impact of COVID on society	2
The changes after pandemic	1
Related socioeconomic problems and medical problems	1
Other	1
To forget	1

	n
Nonmedical palliative care	34
Psychological	17
Social	2
Spiritual	7
Bereavement and grief support	7
Nutrition	1
Medical care/consultations	14
Consultations/Medical support and care	5
Follow-up of patients and family	1
Pain and symptom management	6
Treatment/medication refill	2
End-of-life management	9
Managing end of life	8
Communication with family at the end of life	1
Education	3
Caregiver education	2
Teaching	1
Other	2
Communication with HCW	1
COVID-19 positive consultation/referrals	1

	n
Disadvantages of using technology
Resources	9
Internet connection/accessibility	4
Lack of technology devices for some patients/society	4
Time pressure	1
Trust and cooperation	4
Cooperation from the patients' family/relatives hiding information from patients	2
Difficult to build rapport/trust	2
Appropriateness issues	3
Difficult for elderly patients	1
Difficult for end-of-life care	1
Difficulty or lack of knowledge to use technology	1
Lack of body language when not face-to-face communication	3
Difficulty in documenting, medical evaluation or examining patient, and assessing symptoms	2
Acceptance issues	2
Adaptation	1
Acceptance from society	1
None	2
Other	3
Psychosocial issues	1
Difficulty in reaching individuals	1
Inaccuracy in some appointments and related issues in session program	1
Advantages of using technology
Remote care delivery and management	8
Medical care, pain management	2
Appointment and follow-up	2
Communication between medical care personnel and patients	2
To postpone follow-up	1
Relief and psychological support for patients to face the crisis	1
Mean to control transmission (less risky/enabled to protect ourselves/stay confined at home)	6
Communication - generic	2
Communication	1
Communication with HCP	1
Other	7
Support	2
Working well	2
Convenient, easy, practical	1
Direct contact	1
Saves time and effort	1
Missing	6

PERMALINK

What Is the Preparedness and Capacity of Palliative Care Services in Middle-Eastern and North African Countries to Respond to COVID-19? A Rapid Survey

Sabah Boufkhed

Richard Harding

Tezer Kutluk

Abdullatif Husseini

Nasim Pourghazian

Omar Shamieh

Abstract

Context

Objective

Methods

Results

Conclusion

Key message

Introduction

Method

Study Design and Settings

Population and Sampling

Data Collection

Data Analysis

Ethics

Findings

Respondents and COVID-19 Situation in Their Services

Table 1.

Policies and Procedures

Table 2.

Infection Control Measures and Resources

Table 3.

Table 4.

Information Systems, Communication, and Technology

Palliative Care Staff and Expertise to Support Pandemic Response

Table 5.

Table 6.

Discussion

Strengths and Limitations

Recommendations

Disclosures and Acknowledgments

Footnotes

Appendix I. Questionnaire in English

ABOUT YOU AND YOUR SERVICE

CURRENT COVID-19 SITUATION IN YOUR SERVICE

WRITTEN PROCEDURES (OR GUIDANCE)

MEASURES IN PLACE (TO AVOID CONTAGION)

IF YOU ANSWERED YES TO ANY OF THE ABOVE:

COMMUNICATION AND COORDINATION

5. RESOURCES

6. EFFECTS ON STAFF

7. PERCEPTION OF THE RISK

8. PREPARING TO OFFER SUPPORT

ADDITIONAL COMMENTS

OPTIONAL:

FINAL INFORMATION

Appendix II. Questionnaire in Arabic

Appendix III.

Appendix IV.

Appendix V.

Appendix VI.

Appendix VII.

Appendix VIII.

Appendix IX.

Appendix X.

Appendix XI.

Appendix XII.

References

ACTIONS

PERMALINK

RESOURCES

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