Quality of Life of Filipino Caregivers of Children in Need of Special Protection: Correlations with their Role Overload and Role Distress

Abstract

Article Info Article History: Received: 28 Apr. 2020 Accepted: 10 Sep. 2020 e-Published: 1 Dec. 2020 Keywords: Quality of life, Caregivers, Child care, Orphanages, Philippines Abstract Introduction: The quality of life (QOL) of the caregivers who attend to children in need of special protection (CNSP) influences their effectiveness in rendering care to their care recipients. Introduction In 2017, the United Nations Children's Fund (UNICEF) reported 140 million children worldwide who were abandoned, orphaned, and neglected.1 Sadly, 123 million of the orphaned and abandoned children came from the deprived, developing, and most under-resourced countries.1 There is an increased vulnerability for children in less developed nations because of poverty, morbidity, and mortality.2 Asia accounts for 61 million orphans worldwide.1 Another report also stated that there are around 150 million street children in different cities worldwide.3 These vulnerable children are among the most physically noticeable of all poor children because they live and work in the streets. [...]the quality of care varies among the caregivers and within different settings and environments.16,17 Previous studies showed that most of the caregivers in CNSP are middleaged women who did not finish college, and from the low social class.18,19 Many caregivers of CNSP often experience a multitude of stressors and distress associated with providing care to their care recipients and the myriad of other hardships of daily life.20 Often, caregivers experience high levels of role overload (RO) and role distress (RD), which can result in negative consequences and may affect their caregiving role. QOL is defined as a good and well-lived life, as reflected in the following domains: physical health, psychological, level of independence, social relations, environment, spirituality, religion, or personal beliefs.36,37 Previous studies found that low level of QOL of caregivers is found to be associated with their work situation, that is caregivers who tolerate a high level of RD, and high level of RO face a higher risk of the low QOL.18,26 Additionally, the measurement of the QOL of caregivers offers vital understanding into the degree to which a condition interferes with daily life activities and depletes psychosocial factors.27 Although caregiving role can be rewarding, care providers experience physical, psychological, and financial stressors which impact their QOL.15 Caregivers are tasked with the essential duty of providing support and encouragement to their care recipient; thus, protecting them from too much work overload and work distress will not compromise their QOL, which can affect the quality of care that they give to their care recipients especially for the case of CNSP.

Headnote

Article Info

Article History:

Received: 28 Apr. 2020

Accepted: 10 Sep. 2020

e-Published: 1 Dec. 2020

Keywords:

Quality of life, Caregivers, Child care, Orphanages, Philippines

Abstract

Introduction: The quality of life (QOL) of the caregivers who attend to children in need of special protection (CNSP) influences their effectiveness in rendering care to their care recipients. This study aimed to determine the QOL of caregivers with their levels of role overload (RO) and role distress (RD).

Methods: A total of 130 caregivers, identified through a convenience sampling technique, from 17 child-caring institutions from the Philippines' National Capital Region (NCR) participated in this descriptive correlational study. The survey method was used to gather the data using a structured self-administered questionnaire. Data were processed and analyzed using Statistica 13.0 and Spearman's rho test.

Results: The study found a significant inverse moderate correlation between the level of QOL of the caregivers and their level of RO. A significant inverse strong correlation was also found between the level of their QOL and their level of RD.

Conclusion: The findings confirm that as the levels of RO and RD of the caregivers decrease, their level of QOL increases. Conversely, their level of QOL decreases as their levels of RO and RD increase. Recommendations were provided to improve the QOL of the caregivers of CNSP in the Philippines.

Introduction

In 2017, the United Nations Children's Fund (UNICEF) reported 140 million children worldwide who were abandoned, orphaned, and neglected.1 Sadly, 123 million of the orphaned and abandoned children came from the deprived, developing, and most under-resourced countries.1 There is an increased vulnerability for children in less developed nations because of poverty, morbidity, and mortality.2 Asia accounts for 61 million orphans worldwide.1 Another report also stated that there are around 150 million street children in different cities worldwide.3 These vulnerable children are among the most physically noticeable of all poor children because they live and work in the streets. These children are not only orphans, but many of them have run away from home because of psychological, physical or sexual abuse, violence, family collapse, socio-economic breakdown, or a natural disaster.1-6

In the Philippines, there are 3.3 million working children7 and 1.8 million abandoned children.8 Around 250,000 of them live in the streets all over the country, and the estimation of 30,000 street children is in Metro Manila, the National Capital Region (NCR) of the Philippines.9 These vulnerable populations are children in need of special protection (CNSP). In the Philippines, CNSP refers to children below 18 years of age and are unable to take care of themselves because of physical and mental disability and those who are victims of abuse, neglect, exploitation, cruelty, discrimination, and violence.10 The Department of Social Welfare and Development (DSWD) is responsible for CNSPs in the country. Aside from the DSWD centers, some institutions are willing to care for these children.11 Many institutions, such as orphanages and non-governmental organizations which started of love by concerned people, have been the most usual form of custody and support for abandoned and orphaned children.12

Their parents or family left these children out of desperation with the hope that they will have a better life. A better life means giving the physiological support needed by a child, such as food and shelter. However, the issue of love and care from a parent or a family is absent. These children long for love and affection from their caregivers in the institution. These caregivers are doing their best to love, protect, and support these children.12-14

CNSP caregivers provide routine care in child-caring centers to meet the holistic health and functional care needs of their care recipients. They engage in many support activities, including monitoring the child's condition, ensuring others know how to deal with the child, working with children to provide appropriate boundaries and reinforcements, giving rewards, and preparing a balanced diet.15 In addition to the medical responsibility of the care providers for the children they are caring for, caregivers with sick care recipients also have to help them keep up with the school's academic demands if the child is studying and support the child in playing with other children. Studies characterized institutional caring by rotational shifts of different care providers, high child to caregiver ratios, and limited social and psychological stimulation. Nevertheless, the quality of care varies among the caregivers and within different settings and environments.16,17 Previous studies showed that most of the caregivers in CNSP are middleaged women who did not finish college, and from the low social class.18,19

Many caregivers of CNSP often experience a multitude of stressors and distress associated with providing care to their care recipients and the myriad of other hardships of daily life.20 Often, caregivers experience high levels of role overload (RO) and role distress (RD), which can result in negative consequences and may affect their caregiving role.

RO happened when caregivers simultaneously commit themselves to several social role positions and tasks. Different role obligations may force a caregiver to allocate resources, such as time, for the consummation and fulfillment of all the roles and duties as a caregiver.21 RO pressures enough time and energy to fulfill various and multiple role commitments.22 It is also defined caregiver RO as a feeling of being exhausted before sleeping at night, having more things to do than they can handle, having no enough time for themselves, and unable to finish what needed to be done.20 In some studies, the level of RO is measured through daily hours of care. When RO increases, caregiver burden is likely to increase. RO influences the caregiver's choices as well as the capacity to provide care resulting in decreased quality of life (QOL) and, subsequently, an erosion of the quality of care to their care recipients. As RO increases, the quality of caring role suffers.23 A high level of RO also contributes to depression and anxiety disorders found in many caregivers. Depressed caregivers who experience a high degree of RO are most likely to have a worse QOL.24,25 Caregivers who tolerate a high level of RO face a higher risk of a low QOL compared to the caregivers who have less RO. This situation is consistent in all QOL domains but with a more significant effect on the physical and psychological health domains.26 Additionally, CNSPs are dependent on their caregivers which can cause perceived burden associated with the daily demands of care, impaired capacity, and reduced QOL.27

RD is defined as the physiological, emotional, societal, and economic issues and problems that can also burden the caregivers.28 It is also characterized by a feeling of difficulty and stress in fulfilling role obligations, commitments, and duties of a caregiver.29 In caregiving, RD can be easily seen as an outcome of a series of stressors and factors. These stressors affect the caregiver's level of RD.23 The tasks were viewed as a prime determinant of the caregiver's RD.30 Studies reported caregivers who experience a higher level of RD to suffer inadequate sleep, ineffective self-care,31 depression, emotional, and mental problems.32,33 An increased level of RD thus negatively impacts the QOL of the caregiver,19,34 and this affects the quality of caregiving role.18 Additionally, RD may wear down the subjective experience of the health of caregivers.35

Caregivers of CNSP need to maintain a good QOL to give quality care to their care recipients. QOL is defined as a good and well-lived life, as reflected in the following domains: physical health, psychological, level of independence, social relations, environment, spirituality, religion, or personal beliefs.36,37 Previous studies found that low level of QOL of caregivers is found to be associated with their work situation, that is caregivers who tolerate a high level of RD, and high level of RO face a higher risk of the low QOL.18,26 Additionally, the measurement of the QOL of caregivers offers vital understanding into the degree to which a condition interferes with daily life activities and depletes psychosocial factors.27 Although caregiving role can be rewarding, care providers experience physical, psychological, and financial stressors which impact their QOL.15 Caregivers are tasked with the essential duty of providing support and encouragement to their care recipient; thus, protecting them from too much work overload and work distress will not compromise their QOL, which can affect the quality of care that they give to their care recipients especially for the case of CNSP. Professionalizing their work as a caregiver is also needed to protect the CNSP. To care and to protect those who provide care and protection to CNSP is a way to uplift caregiving as a profession.

This study primarily aimed to determine the level of QOL of 130 caregivers of CNSP from 17 residential childrearing institutions in 8 cities within the NCR, Philippines. This study also examined the levels of their RO and RD as caregivers of CNSP in residential child-rearing institutions. Overall, the study determined the correlations of the QOL of caregivers of CNSP in residential child-rearing institutions with their levels of RO and RD.

Materials and Methods

This is a cross-sectional study aimed at determining the correlations of the level of RO and level of RD with the level of QOL of caregivers attending to CNSP in childrearing institutions in NCR, Philippines.

From a total of 150 caregivers in the 17 child-rearing institutions, a sample size of 122 was the required sample size under a 99% level of significance and a 5% margin of error. A total of 130 caregivers gave consent and answered the survey questionnaire. Data cleaning was done, and all the 130 accomplished questionnaires were valid and thus included in the data processing.

They were selected through convenience sampling and were selected based on the following criteria: (1) 18 years of age and above, which is the legal maturity age in the Philippines, (2) working as a caregiver in a childrearing institution based in NCR for at least a year to establish familiarity to the role and tasks of a caregiver in a child-rearing institution, and (3) directly attending and providing care and support to CNSP for a minimum of a year. Those who did not qualify in the above-mentioned criteria were prohibited in joining the study.

In gathering the data, a structured questionnaire was constructed, comprised of four sections: demographic characteristics, RO and RD, and QOL. The first part of the questionnaire generated their personal and work-related characteristics, the second part measured their levels ofRO, and the last part measured their level of QOL. To measure their level of RO, an established 13-item RO Scale (ROS) of Reilly38 was used with a Cronbach's alpha value of 0.89.39 Their level of RD was measured based on the established 17-item Caregiving Distress Scale (CDS) of Cousins etal.,40 with Cronbach alpha value of 0.87. Their level of QOL was measured based on the established 26-item World Health Organization (WHO) QOL questionnaire (WHOQOLBREF)41 with a Cronbach alpha value of 0.76.42 All the scales were measured using Likert scale with scales from 1 to 5. Mean scores and standard deviations were generated to identify their levels of RO, RD, and QOL. Permissions were asked from all the authors in using them in this study.

In the data collection, permissions from the administrators of the 17 NCR child-caring institutions were sought. Then, the schedule of visits to the institutions was set. Before the caregiver participated in the study, the researchers thoroughly explained to each one of them the purpose of the study. They were fully informed that participation was voluntary as no incentive will be given to them, and they could withdraw at any stage of the survey with no repercussions. Also, assurance was given that the collected data will be kept confidential and that their identity will be protected. Only after the above process that informed consent was asked of them, which was signed by each of the respondents. During the conduct of the survey, the researchers remained present as the respondents accomplish the questionnaire. When the survey was accomplished, the researchers double-checked the questionnaire to check if there were errors or if the respondents missed any items.

The collected data were processed and analyzed using Statistica 13.0. Descriptive statistics were used, such as frequency, mean, median, and standard deviation in presenting the respondents' profile and their levels of RO, RD, and QOL. The scores for the levels of RO, RD, and QOL were interpreted into three degrees: high (mean score of 3.68-5.00), moderate (mean score of 2.34-3.67), and low (mean score of 1.00-2.33).43 Spearman's rho was used in assessing the correlation of the RO and RD with the QOL. The significance level was set at 95% or P<0.05. The basis of the strength of correlation used an absolute value of four levels: 0.00 to 0.30 for very weak/negligible correlation, 0.30 to 0.50 for weak/low correlation, 0.50 to 0.70 for moderate correlation, 0.70-0.90 for high/strong correlation, 0.90 to 1.00 for very high/strong to perfect correlation.43

Results

Profile of the Caregivers

Of the 130 caregivers who participated in the study, half of them (50%) were of middle age (36-55 years old), about half (47.7%) were single, about three-fifths (58.5%) were non-college graduates, and above the majority of them (56.2%) have 1 to 4 dependents. About two-thirds (63.8%) were working as a caregiver for 1 to 5 years, about threefifths (59.2%) attended 1 to 5 work-related trainings, and more than two-fifths (42.3%) were earning P9,001 to P12,000 ($170 to $230) a month. About three-fifths of them (58.5%) were living in the institution, more than half (51.5%) served as house parents to the CNSP, less than half (47.7%) were assigned in day shift, two-fifths (40%) were rendering 9 to 16 hours of care to their care recipients, another two-fifths (40%) were handling abandoned and orphaned children, and about two-fifths (36.2%) were caring for 6 to 10 care recipients (Table 1).

The Level of Role Overload the Caregivers

The 13-item Reilly's ROS was used to measure if the caregivers experience RO based on three domains, namely duties and responsibilities, energy, and time. Table 2 shows that seven out of the 13 items assessed reflected high work overload, but overall, the caregivers assessed their tasks in the institution (RO) to be at a moderate level with a total mean (SD) score of 3.51 (0.52), with all the domains also rated as moderate or average (duties and responsibilities with x = 3.53, energy with x = 3.53, and time with x = 3.48). Their level of RO was high. They felt that: 1) their duties and responsibilities would require them to prepare a priority list to do their work, 2) they could not meet everyone's expectations in the institution, and 3) they have to cancel their commitments outside to meet work demands. They also felt that they have to overextend their energy level to finish their tasks, and thus they felt that they needed more hours to accomplish their tasks, given too many work tasks/demands.

The Level of Role Distress of the Caregivers

Their RD level was measured using the 17-item Cousins and colleagues' CDS based on five domains, such as social impact, care recipient's demands, personal cost, emotional, and relationship distress. Overall findings showed that they experienced a moderate level of RD with a total mean (SD) score of 2.88 (0.55). All domains generated an average mean score, except for relationship distress, which got a low mean score. Table 3 shows that the respondents strongly agreed that they have less time to visit their family and friends. On the other hand, they reflected low mean scores on items such as caring for care recipients, which made them nervous, felt helpless in caring for care recipients, the relationship with care recipients no longer give them pleasure, and the relationship with the care recipients restrained. The results implied that they care for their care recipients and they like their work. All the other items generated a moderate assessment. While working in the institution may give them less time to their family and friends, they care for their children in the institution, as reflected in their low mean scores on the items above. Overall, the results showed that both the RO and RD levels of caregivers were at a moderate level.

Quality of Life of the Caregivers

Table 4 presents the level of QOL of the caregivers based on four domains, namely: physical health, psychological health, social health, and living condition. Their QOL was measured based on the 26-item WHOQOL-BREF. Their total QOL generated a mean (SD) score of 3.35 (0.52). Results showed that of the four QOL domains, their social health got a high rating with a mean (SD) score of 3.70 (0.64), and all three domains got a moderate rating. Only eight out of the 24 items in the QOL got a high rating.

Their social health condition generated a high mean (SD) score of 3.70 (0.64), with two out of three items, obtained high mean scores, and the other obtained a moderate mean score. The only question that obtained a moderate mean score was the satisfaction of support they got from their friends and colleagues, while their satisfaction with sex and personal relationships got high mean scores. Results implied that their longing for their friends outside of the institution. Their workload in the institution deprived them of having more time with friends. All the other three domains got a moderate rating. They rated physical health conditions moderate with a mean (SD) score of 3.25. (0.49). They reported a low mean score in the satisfaction of sleep, which means they suffer from sleep deprivation. Their psychological health obtained a moderate mean (SD) score of 3.45 (0.78). They reported high mean scores in items such as the extent of feeing life as meaningful, enjoying life, accepting their bodily appearance, and being satisfied with themselves. However, they revealed a low mean score on the item that they do not feel negative, which means that they have adverse feelings such as blue mood, despair, anxiety, and depression. Their living condition also got a moderate mean (SD) score of 3.22 (0.35). Only one out of the eight items obtained a high mean score that they felt safe in their daily life. The rest of the items generated a moderate rating. Overall, the caregivers of CNSP in child-rearing institutions in the NCR only had a moderate level of QOL.

Correlations of the Caregiver's QOL with RO and RD

Overall, findings revealed significant inverse correlations of their levels of RO and RD with their QOL. Table 5 shows that , there was a significant inverse moderate correlation between their level of RO and QOL (r = -0.519, P < 0.01). On the other hand, a significant inverse high/strong correlation was found between their level of distress and their level of QOL (r = -0.782, P < 0.01). These results imply that as their levels of RO and RD decrease, their level of QOL escalates. Furthermore, conversely, the level of their QOL decrease as their level of RO and RD increase. The strong inverse correlations between their level of RO and level of QOL are alarming as they reinforce that their level of QOL decreases, or they suffer more with the increase in RD level.

Looking at the specific domains of QOL, findings also showed significant inverse low correlations between the QOL domains and their level of RO, such as physical health (r = -0.484, P < 0.01), living condition (r = -0.468, P < 0.01), psychological health (r = -0.379, P< 0.01), and social health (r = -0.261, P <0.01). On the correlations between the level of RD and QOL domains, significant inverse moderate correlations were likewise found: the living condition (r = -0.689, P < 0.01), physical health (r = -0.685, P < 0.01), and psychological health domain (r = -0.617, P < 0.01). On the other hand, a significant inverse low to almost moderate correlation was found between QOL social health domain and their RD (r = -0.499, P < 0.01) (Table 5).

Discussion

Caregiving to orphaned and abandoned children is not an easy task. The caregivers need to have a good QOL to carry the load of work and challenges of giving quality care to the children under their care in the institutions. This study shows that the caregivers' QOL was found to have a significant moderate inverse correlation with their level of RO and a strong inverse correlation between their level of QOL and their level of RD. These results suggest that as their RO and RD levels increase, the level of their QOL decreases. Similarly, their QOL increases with decreased RO and RD. More attention needs to be given to their RD as a strong inverse correlation was found between the two variables. Managing their level of RO is essential, but what is more crucial to their QOL is their level of RD. Their high level of RO could increase their level of RD that could have a high negative effect on their level of QOL.

Previous studies regarding the relationship between levels of RO and QOL have proven that caregivers who endure a high level of RO, such as with longer hours of care, and exert more energy face a higher risk of a low level of QOL than the other caregivers who have a low level or no RO at all.26 Also, several caregivers consistently reported the negative consequences of increased RO to their QOL, especially to their mental health domain.44 Thus, an increase in the level of RO makes the level of QOL lower. Additional role obligations added to their role of caregiving can post an extra task to fulfilling role obligations, which eventually can make their level of QOL lower.29 Similarly, a high level of RO contributes to depression and anxiety disorders found in many caregivers. Depressed caregivers who experience a high degree of RO are most likely to have a worse QOL.24,25 Another previous study found out that the demands of high-level RO in caregiving could be responsible for the higher burden among caregivers.45 Too much RO could also harm well-being and leads to a low level of QOL when their health and personal lives suffer as a consequence, and when they cannot perform other essential activities aside from caregiving, such as having time for themselves and visiting their loved ones.46 Therefore, the level of RO is an excellent indicator of the level of QOL based on previous studies and the findings of this study. The results suggested that a high level of RO leads to a low level of QOL among the caregiver. Statistically, this also follows that a low level of RO leads to a higher level of QOL. Previous studies found out that addressing the RO of caregivers can enhance their QOL. Introducing trainings on how to deal with RO situations can prevent a high level of RO among caregivers. Careful scheduling of all activities a caregiver needs to accomplish facilitated productivity, which simultaneously decreased their RO. Also, reducing the number of items on their to-do lists to essential priorities helped reduce their RO level.47,48

Meanwhile, the study results showed that a high level of RD also harms caregivers' QOL, which is proven by previous studies. The different domains of QOL are affected if the level of their RD increases, confirming that their QOL and RD levels are strictly and inversely associated.26 The caregivers who have a higher level of RD may experience a higher risk of a low QOL. Additionally, a high level of RD, covering the caregiver's burden and strain, harms the emotional, social, and physical functions of the caregivers.33,49-51 Also, previous studies reported that most caregivers have symptoms of depression, a negative facet of psychological health because of the high level of RD.33 Caregivers who experience a high level of RD have low psychological and physical health such as high levels of anxiety, symptoms of depression, inadequate sleep, and ineffective self-care and activities of daily living.31,38 They also found out that many caregivers consistently report negative consequences to their level of QOL especially to their mental health domain as a direct result of the high level of RD.44 In relation, the relationship between social health and mental health expressed statistically and inversely significant compared to the level of RD, which means if social and mental health domains are good, the level of RD decreases.19 This is also proven by one study that coping resources such as social support, a facet of social health, maybe an essential factor for improving the QOL of an individual.50 Similar with the psychological health, if psychological interventions, such as psychological counseling, are set up, the level of RD will eventually decrease and may result to an enhanced level of QOL. Some studies have reported using interventions to lower the level of RD and subsequently enhance the level of QOL. Caregivers who undergone stress management and relaxation techniques reported spending less time feeling depressed, guilty, or angry, while instead experiencing more periods of calm and peacefulness.44 Also, managers of institutions who sought ways to help their caregivers managed to improve the level of QOL of caregivers by addressing their problems such as high level of RD.48 This, therefore, means that caregivers who learned to address and manage their low level of RD have improved QOL.

Therefore, an increase in the levels of RO and RD negatively influence the level of QOL of the caregivers and may impair the caregivers' effectiveness in rendering care to their care recipients.26 Due to the vital and indispensable role played by the caregivers; studies proved that RO specifically duties and obligations, energy, and time, and RD specifically social impact, demands of care recipients, personal cost, emotional burden, and relationship distress significantly affect the QOL of caregivers.44,52-56 Thus, managing their tasks to avoid high levels of RO and RD would improve their level of QOL. Therefore, the results of this study corresponded with the findings of the previous related literature.

Conclusion

The RO and RD of the caregivers significantly correlate with the QOL of the caregivers. The study concludes that as their levels of RO and RD increase, their QOL decreases. And conversely, as their levels of RO and RD decrease, their QOL escalates. Thus, their levels of RO and RD significantly influence their level of QOL. Managing their level of RO is important, but what is more crucial to their QOL is their level of RD. Their high level of RD has a high adverse effect on their level of QOL.

The findings ofthe study are essential to professionalizing the work of caregivers. The DSWD should revisit and review the role descriptions of caregivers attending CNSP to appraise their workload level. The management of the child-caring institution should find ways to lessen the RO and RD levels of caregivers to improve their health-related QOL. Hosting and institutionalizing trainings on how to manage their levels of RO and RD are important support mechanisms to the caregivers. Giving them the skills to manage stress (RO) and instituting a peer support system in the institution can avert a high level of RO among caregivers. These caregivers are the primary workers of a child-caring institution; improving their QOL will positively influence the quality of support they give to them under their care and protection.

For further research, the researchers recommend that a qualitative study be pursued to give depth and appreciate the stories of the caregivers attending to CNSP. Also, caregivers in other regions of the country may be studied to see parallelism of their conditions and their levels of RO, RD, and QOL.

Acknowledgments

This study was made possible through the participation of the caregivers and the administrators from the 17 institutions, a sincere appreciation to them for their full cooperation. The authors would also like to express gratitude to De La Salle University and Ford Foundation for the support provided for the completion of the study. Also, a special thanks to the panel members who reviewed the paper to improve its final output. Ethical Issues

This descriptive correlational study was reviewed and approved by the Faculty of the Behavioral Sciences Department of De La Salle University (DLSU) and the Research Ethics Office of DLSU with accession number dlsu.b1387986.

Conflict of Interest

The authors declare no conflict of interest.

Authors' Contributions

ICNR: Conceptualization and formulation, writing of the review of literature, data collection, data analysis and processing, and manuscript writing and revision. MMA: Conceptualization and formulation, writing of the review of literature, data analysis and processing, and manuscript writing and revision.

Sidebar

Research Highlights

What is the current knowledge?

The QOL of the CNSP caregivers influences their effectiveness in rendering care to their care recipients.

What is new here?

The QOL of the CNSP caregivers decreases with the high levels of RO and RD.

References

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